Managing Chemo Side Effects Before, During, and After Treatment

Marisa Weiss, MD: Hello, everyone. I'm Dr. Marisa Weiss. Thank you all for joining us to talk about preparing for and managing side effects from chemotherapy. We understand the fear, the pain, and the emotional toll of side effects, which can directly affect your everyday quality of life. It can be overwhelming. We hope that by knowing what to expect and getting ideas about how to reduce potential side effects, that you will feel more in control before, during, and after treatment.

For 25 years, Breastcancer.org's mission has been to give you trusted information, actionable guidance, and the confidence that you need to make the best decisions possible on your medical care together with your team. With that in mind, our editorial team created new and expanded resources about chemo side effects that go deep into the topics you need to know. We'll share these resources throughout the webinar and provide you with email links. Everything as you know at Breastcancer.org is available at no cost.

As you're listening to the webinar, it's important to remember that if you're one of the many people taking a combination of therapies like immunotherapy or anti-HER2 therapy along with chemotherapy, you may have a variety of side effects from these different types of treatments. If you're looking for more information, we do have in-depth articles, podcast episodes, and videos on Breastcancer.org that help explain what to know about other types of treatment for breast cancer alone or in combination with chemotherapy.

First, I want to thank our generous sponsors for making this event possible. AstraZeneca, Gilead, Lilly, and Pfizer. Thank you so much for supporting Breastcancer.org.

We are honored to be joined by a group of brilliant, inspired, and dedicated speakers that are really here because they do such a great job and we're thrilled to have them.

First, we'll hear from Cara Sapida. Cara is an award-winning reporter based in her hometown of Pittsburgh. She's also a mother of two, an author, and a breast cancer survivor. Cara was diagnosed with an aggressive type of breast cancer at the height of the COVID pandemic lockdown. She shared her story on social media week by week, and we're thrilled that she's here today to share with us.

Dr. Maryam Lustberg is the director of the Center for Breast Cancer at Smilow Cancer Hospital and Yale Cancer Center and the chief of Breast Medical Oncology. She's also an associate professor of Medicine. Dr. Lustberg's Research focuses on improving the long-term outcomes for patients with breast cancer who have developed side effects associated with treatment. She has received numerous awards for her dedication as an oncologist and as a mentor.

Dr. Aditya Bardia is the director of Translational Research Integration at the Jonsson Comprehensive Cancer Center and a professor at the David Geffen School of Medicine, both at UCLA. As a physician-scientist, he has led the development of new targeted cancer therapies including for metastatic breast cancer and blood-based biomarkers. He's also been internationally recognized for his research achievements and mentorship.

LaShae Rolle is a PhD candidate and cancer researcher at the University of Miami and a breast cancer survivor. She was diagnosed with a rare form of breast cancer at age 26. Now, her professional goals and personal expertise and experience have aligned. She's speaking out to help others get the information and support that they need.

Later in the program, we'll hear from Ashley Patrick, doctor of Pharmacy at Walgreens, who will share tips she commonly is asked about by her customers experiencing side effects from cancer treatments.

Thank you all for being here. If this is the first time you're learning about how chemotherapy medicines can affect our bodies, I wanted to share some facts to know before getting into the complexities of treatment. For starters, the goal of chemotherapy is to stop and destroy breast cancer cells. Chemotherapy can be used for all stages of breast cancer depending on each person's unique circumstances. Not everyone, of course, diagnosed with breast cancer will get chemotherapy, but if your doctor is recommending it, there are a variety of factors that go into which medicines to take, and if they're taken before or after surgery.

From this list, I also want to call out that side effects are different for each person. Having or not having certain reactions isn't an indication of how well the medicine is working. So many people think like, "No pain. No gain." But really medicines today can work really effectively, hopefully without side effects or minimal side effects. We really lean on the physical exams, blood tests, and imaging, the x-ray tests that would show us how you're responding to treatment.

In a survey that we led at Breastcancer.org, we asked people if the long-term side effects of treatment were explained before treatment was started. With only about 28% saying, "Yes, definitely," the answers are an important reminder that people need to ask their doctors to explain both the short and long-term side effects, and to do your own research to feel most informed. It can go a long way to ask your doctor again about possible long-term side effects after your treatment is done. Because up front, it's really hard to remember everything and ask everything, but all along the way, the reason why you keep meeting with your doctor is to have this ongoing dialogue. You really deserve a survivorship care plan to help you live your best life, and that includes knowing what to expect as a result of the treatment that you received. We'll be talking more about this in a bit.

But before we get into the practical tips and solutions for managing side effects, I just wanted to share a beautiful sentiment or quote from a member of the Breastcancer.org community with her advice. She said, "Be kind to yourself. You didn't cause this to happen. Take time out of each day to try to do something you love. Try to go for walks, and I guess the most important thing that has got me through this... laughing. Our time is too short here whether we are healthy or not so don't sweat the little things and hug and tell the ones you love, that you love them."

Now, it's my great pleasure to introduce Cara Sapida who will be moderating our panel discussion. But first, I wanted to ask Cara a bit more about her personal story. Welcome, Cara.

Cara Sapida: Hi. Thank you so much for having me.

Marisa Weiss, MD: We're thrilled to have you. I know you were diagnosed with a stage 2, triple-negative breast cancer at a young age when there was a lot going on in your personal life and in the world. Can you tell us what happened and how you found the strength that you needed to get through it all?

Cara Sapida: Sure. I was diagnosed at the height of the pandemic. It was June, right when the world in Allegheny County outside of Pittsburgh, here where I live shut down, and I had just separated from my husband. So I had a two-year-old and a four-year-old and found out that I had this aggressive form of breast cancer and I would have to start chemo right away. And there wasn't even a church open in the whole town. I mean, everything was shut down. So my options were stay home or go to chemo. That was it. And everybody was afraid to visit. It was a very lonely time period.

And to be honest, I got a little emotional listening to you because I would have loved a program like this, a webinar. I had so many questions. I couldn't get enough answers. And because there was so much going on in the world at the time, I think that my questions just got lost in the shuffle. I would've been the first in line to sign up for something like this, and it just didn't exist. And I think that maybe if you look at reframing things, and one blessing that came out of that time period is there are more webinars like this now. So you don't just have your little local meeting with a dozen women who live locally, but you can connect with women all over the world like this here today with you, so I'm grateful for it.

Marisa Weiss, MD: Well, thank you. I mean, going through breast cancer, it can be so lonely. I'm a survivor myself. But particularly, during the pandemic, when people were socially isolated, it was an even worse, rough ride. And I know you had a lot of treatment. You had chemotherapy, right, and a double mastectomy.

Cara Sapida: Yes.

Marisa Weiss, MD: Did you experience any side effects from the chemo? And if so, what helped you through it?

Cara Sapida: I did. I had Taxol, I had carboplatin, I had an immunotherapy, and then I had AC. And so Taxol was a walk in the park for me, but I really struggled with carbo and AC. I was very, very nauseous. And I think that the steroids helped a lot. I think that what helped the most was learning that you can have a few hard days knowing that good days were coming, and that you can build back that strength. And that, honestly, once I really started focusing on how even if I was so nauseous and even if I was throwing up and even if the Zofran was only mildly helping me or fluids were only mildly helping me, it's only a few days of that. And then your body starts building strength, and eventually, you're just going to get through it.

Marisa Weiss, MD: Wow. It's amazing that all those life changes you went through at the same time as all this. Your hair now, is this your... Were you able to keep your hair? Is this your new hair?

Cara Sapida: My hair is very, very curly, and I almost felt like a fraud being here today because I just got it colored, so she straightened it. And I was like, "Oh, I have curls. I would love to show everybody my curls." But I was very bald and I did not do any kind of cold capping. I just embraced being bald.

Marisa Weiss, MD: Wow.

Cara Sapida: This is four and a half years of growth.

Marisa Weiss, MD: Wow. Well, you look amazing, and we're so grateful that you shared your story. And I know you published a book about your story. That must have been therapeutic. And it started, didn't it, with Instagram posts?

Cara Sapida: Yes. So I had these posts. And every week, I would let people know what that week of chemo was like. And I was shocked by how many women from around the world were reading and commenting and connecting with me. And I realized that this unites us in a way that I'd never experienced anything before. And so I took those blog posts, I turned them into a book called Not the Breast Year of My Life. And it is laced with a lot of humor. I know you just said that humor helped you get through it. It helps me get through it to this day. I think if we don't laugh about it, we'll just cry about it. And one of the things that I... When I'm speaking to women and I talk about that time period and how hard it was losing my hair, I like to say that my son, when we shaved it off, he walked over to me, and he was four, and he said, "You are still beautiful."

Marisa Weiss, MD: My gosh.

Cara Sapida: I choked up, and my daughter said, "Yes, like a beautiful hamster."

Marisa Weiss, MD: Oh my gosh. Wow.

Cara Sapida: And that made me laugh. This beautiful hamster. And I thought, "Yes, Lila. I am a beautiful hamster."

Marisa Weiss, MD: Wow, wow, wow. Well, and we want them to say what's on their mind and not filter it.

Cara Sapida: Don't hold back.

Marisa Weiss, MD: Well, thank you so much Cara for sharing your story. Now, I'm going to hand it over to you to help us all learn a lot more about how to stay healthy and get through the rough patches so that we can get out on the other side. Thank you so much.

Cara Sapida: Thank you so much, and thank you for finding this beautiful organization. So I'm going to take over, and I want everybody that's listening to know that we went through all of your questions, and there is a number of really important questions. And as I was reading them, I was thinking, "Gosh, I would have loved to know the answers to these." And even to this day, I'm looking forward to hearing what our great doctors have in store for us. And I hope that it helps you. And if you're at home, feel free to write your question here, and we'll try to get to them as well. 

So it is my pleasure to welcome Dr. Aditya Bardia and Dr. Maryam Lustberg. And we're going to start with Dr. Lustberg. And I want to start by asking, "Which breast cancer chemo medicines are known to have the most difficult side effects?" This is the number one question we've received, and I want to know if it's AC or maybe it's something else, but I'm looking forward to finding out.

Maryam Lustberg, MD, MPH: Thank you so much, Cara, for this wonderful question, and thank you for the audience for joining in. So I wish I could tell you there was one chemo regimen that's known to be harshest, but it's very much an individual experience and no one person will have the same experience. But in general, when we use multiple chemotherapy agents, typically in combination with either HER2 monoclonal antibodies or with immunotherapies, anytime you have multiple agents that are synergizing together, known to have better anti-tumor efficacy, we often also see that the toxicities can often synergize as well.

And when we use multiple agents, fatigue seems to be the most commonly reported side effects, but other toxicities can certainly be pronounced as well, including nausea, diarrhea, and mucositis. Another important factor that determines how harsh a treatment ends up being is actually the duration of the treatment. We have some regimens that tend to go for four cycles. Others go for six. Others maybe ongoing for patients with more advanced breast cancer. So I think the longer the treatment, the harsher that it can feel to many patients. You mentioned AC, and it's been notoriously known for being one of our hardest regimens in lay literature. It used to be called the Red Devil. But I do want to say, not to say that it's easy now, but we've made so many advances in terms of our anti-emetic pre-medications so I think many patients can tolerate the AC regimen much better due to the advances in supportive care that we have.

Cara Sapida: That's great to know. Do you think that there are certain health factors or conditions that make someone more likely to experience debilitating side effects?

Maryam Lustberg, MD, MPH: I think so. I think we're still learning about different individual factors. It would be ideal in the future and we're working toward this where I can look at a patient and do a quick test and really know what your toxicity experience might be. We're not there yet. But in terms of what we see in general if you have a lot of other chronic health conditions, this can also make it harder for you to tolerate the chemotherapy regimen. In medicine, we talk about what is your performance status. Are you able to walk a mile and walk a flight of stairs without getting too tired? So just how fit you're actually has direct associations in terms of how tolerable a regimen might be.

And then, there are other factors, things that maybe we don't immediately think about that go beyond the individual, where we live, who we live with, how much support and social support and resources that we have. What we term the social determinants of health, can actually have a direct impact on how you're able to tolerate chemotherapy.

Generally, the more connected you are, the more support systems you have, patients tend to do better with chemotherapy. We also know that the extremes of age, whether you're very young or much older, that can sometimes make it much harder to tolerate chemo. The younger patients are thrust into this early menopause because of chemotherapy, and that can further synergize in a negative way, the toxicities of chemotherapy.

And older patients, again, we don't have an age cut off for treatment, but generally, an older age can potentially increase the risk of these toxicities and make you more vulnerable. But we really do look at each patient as an individual. And then other conditions that I just want to make sure to point out is that sometimes underrepresented minorities may not have as good at resources or may not feel as welcomed within our healthcare systems. Breast cancer can impact so many different groups, and so I do want to acknowledge that the transgender community dealing with breast cancer, all these groups may find it harder to sometimes find resources and support, and that can also sometimes make the experience of chemotherapy much, much harder.

Cara Sapida: That is so interesting. I think that is why it is so important to share everything with your oncologist, including what your social situation is at home in addition to your side effects. I'm going to turn out to Dr. Bardia. I know many people aren't just having chemotherapy, but they're having immunotherapy, hormone therapy at the same time. And if you're experiencing side effects, how do you know as a doctor which of the medicines might be causing it so that you can treat the right thing?

Aditya Bardia, MD, MPH, FASCO: Well, that's a very good question. When multiple drugs are used, the question becomes, if someone is experiencing a side effect, out of the various drugs, which one is contributing to that side effect? Often, it's based on the type of side effects because we know certain drugs are associated with certain specific side effects. And you had mentioned your experience with the anthracyclines and paclitaxel. Paclitaxel generally causes more neuropathy. The anthracyclines can cause a lot of fatigue and tiredness, so it's based on the type of side effect profile. Sometimes you can say that this is likely the culprit.

Immunotherapy tends to have a different side effect profile. The way the current immunotherapy agents work, the ones that are used in breast cancer, is that they allow the activated immune system to attack cancer. So if the immune system is activated, these immunotherapy agents take the breaks away so then the immune system can attack cancer.

The side effects come from if those breaks are also removed from normal cells, so then the immune system can also impact the normal cells. And the common side effects include diarrhea, which can be, when it affects the intestinal tract, we do blood work because sometimes some of the hormonal levels can become abnormal with the immunotherapy agents. Sometimes the liver gets impacted. These are not very common side effects, but when a patient is on these drugs, these are some of the things we monitor.

And if we are seeing that say the liver enzymes or the liver function is becoming normal, we do feel that it could be coming from the immunotherapy agents. And similarly, with hormonal therapies, the side effect profile is different. So based on the type of side effect profile, we can usually say that it's likely this drug as opposed to something else. But sometimes we are stumped. Sometimes it's very difficult to know what's happening. It could be either this drug or that drug. And one approach that's taken is to, if it's severe, stop both the drugs. If it's not severe, stop one and monitor closely. And if things improve, it was likely that drug. Otherwise, it's the other one.

Cara Sapida: I want to read a question that came in. We actually received a few questions similar to this one about continuing to work through treatment. Of course, it depends on the type of job and the kind of treatments you're going through. But typically, I'll send this to Dr. Lustberg, what should people expect? Should they plan to work through it? Should they... For me, I will just say I took that time off. It was during the pandemic and there was such fear of my immune system already being compromised and catching COVID in 2020. What do you tell people?

Maryam Lustberg, MD, MPH: Yeah. Yeah, this is such an important question. And I think my message to the audience is that as your oncology team, we're here to support you and be supportive of your goals. For some of my patients, it's really important for them to have the time off and really be able to focus on themselves and their family. And I'm happy to support them in that goal. There are others who really want to have some return to work, and it's something that helps keep their mind off the toxicities and it's a very individual decision.

In terms of what to expect, I think the best way to know what your own personal needs are, to go through at least one cycle of treatment and kind of see when your bad days are, when your good days are. Because as much as I can try to predict it for each individual patient based on the chemotherapy, there is a tremendous amount of variability.

But in general, I would say... My biggest advice to patients is at least go through one cycle of chemo so you have a better sense of what to expect. But talking more in general, if you are receiving intravenous chemotherapy, the day of treatment, I always recommend taking that day off. It's exceedingly difficult to come in for an infusion treatment, and then return to work. You don't want to do that to yourself.

And then on the other days, I think it's possible with many regimens if you want it to work in those subsequent days after chemotherapy. Symptoms for many chemo regimens tend to peak around days 8 to 10 when the nadir is happening when the white count is dropping. So, again, lots of variability, but many patients think that that first week of chemo tends to be harder on them, but what we generally see on average is that it's usually that second week when counts are dropping when some of them are common complications including fevers, infections, diarrhea, mouth sores, and fatigue tend to peak. So listen to your body, and I think the right answer will become apparent.

Cara Sapida: I forgot about the mouth sores. Whoo. Thank you for that. That is interesting. I think it's different for every person. I know that the steroids, for example, could make you feel great the next day, and you might think you can take on the world. You could go to work. You can do all the things. When they wear off the following day, it's rough, very difficult. We have another audience question about when to ask your doctor about taking a lower-than-standard dose of chemo. I'll give this one to Dr. Bardia. I know that a lot of people ask if they can lower their dose of chemo in an effort to have fewer side effects. Is that as effective? How do you determine that?

Aditya Bardia, MD, MPH, FASCO: Absolutely. That's a very good question. I would look at this as less about low or high dose, but more about the right dose. Dr. Lustberg was also involved with an initiative with the PCDI, the Patient-Centered Dosing Initiative, which was started by a patient advocate, the late Anne Loeser. And the idea was can we find the right dose for a patient? If you look at studies, we consistently see that even in patients who have a dose reduction, their efficacy is not compromised. And so the idea is, "Why do we need the maximum tolerated dose? Can we actually focus more on the optimal biological dose or the right dose for a patient?" So for an individual patient, I would say discuss with your doctor when something is prescribed. Discuss, "Is this the best dose? Are there other dosing options available?"

And ultimately, the dose needs to be tailored based on not only the disease, but also the patient's individual circumstance in terms of what their wishes are, what their home situation is, the support is, all of these have an impact because a drug at a certain dose maybe can cause more diarrhea, and if you lower the dose, there'll be less diarrhea and that could have a major impact for a patient's quality of life. So discussing the preferences and having an open discussion about the dose is very important when we talk about therapies.

Cara Sapida: I know that a lot of the questions that we received had questions about specific reactions that you might have to chemo and how to prepare and how to manage. Dr. Lustberg, I know you talked about when diarrhea might hit, when extreme fatigue might hit, especially after those steroids were off. What about hair loss? A lot of people want to know, "Can you tell me when my hair is going to fall out?"

Maryam Lustberg, MD, MPH: Of course, yeah. This is such an important quality of life issue, and in talking to so many patients over the years, I think, the experience of losing your hair and looking in the mirror can make things feel so much more real and traumatic as patients are going through it. So, in general, and again, differences in chemo regimens. But what we see loss of scalp hair tends to happen, some shedding tends to happen during the first cycle, but most patients are able to keep their hairstyle during that first cycle.

It's typically by cycle number two, within a day of receiving dose number two, where there is an accelerated loss of hair, which can be quite distressing. So if you're in the shower, you're going to see hair coming out in clumps or you're going to wake up on your pillow with a lot of hair. So scalp hair tends to happen by cycle two. Eyebrows and eyelashes tend to be a little bit later in many of our cycles. So many patients think, "Oh, it's not going to happen to me". But then it's near the tail end of many of our chemo regimens that we see the lashes and eyebrows, unfortunately, coming off.

Cara Sapida: When I was going through, and I knew my days were numbered with having hair, and my son would get a little lint roller and he would roll my pillow every morning to get the hair, and it was like a little job for a four-year-old, and he didn't know what was going through me, the internal turmoil. But I always tell women not to feel apologetic that it is such a harrowing experience to lose all of your hair in such a few short weeks. And this isn't one of the questions that's up next, but I know that a lot of women almost feel like a guilt like, "I'm sorry, but this is really hard for me." You don't even have to be sorry. It's hard. It's so hard, and there's so much happening all at once that they're like, "I know I shouldn't be focusing on the hair, but I think that it is okay to give women this pass. You're allowed to feel the weight of this loss in addition to all the other losses that come with a breast cancer diagnosis and all the loneliness and everything else that goes with it."

Maryam Lustberg, MD, MPH: Absolutely. And multiple studies have confirmed exactly what you're relating, that there is a tremendous effect on quality of life and sense of self. And so, no, hair loss is absolutely a huge stressor, and we can certainly talk about potential mitigators of it in subsequent questions.

Cara Sapida: Another really important question just came in for Dr. Bardia. There's a lot of people that experience serious fatigue, forgetfulness, concentration issues, are there studies on approaches like meditation, exercise, music, anything that can help, and how long after treatment ends do you think that people feel that fog in that chemo brain finally lift a little bit and start to disappear?

Aditya Bardia, MD, MPH, FASCO: Absolutely this is a side effect that can be seen with chemotherapy and can also be seen with hormonal therapies like aromatase inhibitors and tamoxifen, and that could include difficulty with concentration, memory loss, as well as just not being able to focus like you used to before.

In terms of how long it lasts, usually, it's present... So if you talk about chemotherapy, it's usually present a few months after chemo. But for some patients, it can be present up to a year, two years later as well. So the key is A, recognition that this is probably from the treatments that someone has received. And then B, in terms of intervention, things like meditation can be helpful. Brain exercises those can be helpful as well. But if it's severe, if it's impacting the quality of life, it is something important to discuss with your primary oncologist and getting additional help if needed.

The visits with a primary oncologist, say after surgery, are not just related to cancer recurrence or how the cancer is doing in terms of if a patient has metastatic disease and talking about the scans, but also talking about these side effects, talking about the memory loss, talking about nausea, talking about fatigue, these are all important things to discuss during the visit with an oncologist.

Cara Sapida: We have another hair question for Dr. Lustberg. Does scalp cooling prevent hair loss when taking certain chemo medicines, and when does the hair start to grow back for people had their hair thin or fall out? So I know that a lot of people do the cold caps and sometimes they lose some. Sometimes they end up shaving their heads in the end anyways. What is your recommendation there?

Maryam Lustberg, MD, MPH: Yes. Yes. So scalp cooling, we have a good body of data across multiple sites with different scalp-cooling procedures that it can help mitigate hair loss. Some hair will fall out, but still a majority, by that I mean about 70% of patients, are able to maintain their usual hairstyle. There may be areas where the cooling of the cap didn't have direct contact with the scalp in a complete way, so there may be a patchy area that may have lost more hair than others.

It's most effective with taxane-based therapy. So that's where the 70 to 75% odds are based on. It is less effective with anthracyclines. This is not to say that you shouldn't do it if you're receiving anthracyclines, regimens like AC, but we do have data consistently showing that it can be much harder to maintain the scalp air with scalp cooling with AC-like regimens. For patients who are very committed to doing this, starting with the taxane first, and then going on to the AC portion is something that we have done.

And there are also studies looking at some of our newer treatments such as antibody-drug conjugates, and whether scalp cooling is effective for those newer drugs. Typically, regrowth starts within four to six weeks of completion of chemo, and within six to eight months, there is variability here. I think most patients can have a short pixie-type hairstyle if they didn't use scalp cooling. If they did use scalp cooling and it was just a patch that needed to grow in, then certainly, it's a much shorter duration.

I did want to just quickly highlight that apart from chemotherapy, some of our endocrine therapy agents are also associated with hair thinning, and maybe we don't always do a good job of explaining this to our patients. It's typically not a total scalp hair loss like chemo, but many patients are surprised that this was not explained to them. So, about a third of patients on drugs like aromatase inhibitors may have thinning of the hair in the temple area, for example, or feel that their hair is drier and less thick since starting endocrine therapy. So obviously, scalp cooling is not an option for endocrine therapies, but I think there are certain medications that could be prescribed to help manage the endocrine therapy hair loss, including low-dose oral minoxidil.

Cara Sapida: A lot of women submitted questions about neuropathy, and I think that kind of goes hand in hand with the cold capping. Women want to know about ice gloves.

Maryam Lustberg, MD, MPH: Yes. Yes, important question. So, neuropathy is very common. It's most common with our taxane-based regimens and a little bit with our platinum taxane regimens as well, less so with our AC regimens. So yes, there are a body of data suggesting in smaller studies that cooling or cooling with compression or even compression alone can be helpful in terms of reducing the chance of numbness or tingling that we see in these neuropathy conditions.

The definitive study is a Phase III study called Ice Compress, which is being conducted as part of a national cooperative group NCI study, and they're testing in a randomized fashion combining cooling with compression versus compression alone versus a very low compression that is probably not going to... It's more like a standard control arm. So that's study is ongoing, and if patients have an opportunity to enroll, I think it's a really good option.

But if it's not available or if you've already started chemotherapy and you're worried about neuropathy, generally, I think purchasing your own cooling gloves and socks is not unreasonable. The only drawback may be there is a small chance of frostbite. So if things are feeling uncomfortable, making sure to take off your gloves or socks and inspect the area. But it's something that I think, yes, we do need Phase III data, but I think there is enough Phase II data that I think patients could make their own educated decision about pursuing this during chemotherapy.

Other things are movement, physical activity, essentially, anything that's increasing blood flow. We actually have a series of important studies and larger studies are being planned where exercise and movement can actually be helpful both in the prevention of neuropathy as well as treatment of neuropathy, so keeping that in mind. And then most importantly, reporting your symptoms as they're occurring is really important.

Cara Sapida: I hear that all the time about the exercise and movement. I probably did get frostbite. That explains a lot. But I didn't get neuropathy. Okay, our next question is about what to eat. Obviously, we got a lot of questions about this. I'm going to give this one to Dr. Bardia. This question is, "In terms of what you should eat and shouldn't eat, just stay strong during chemo and for weight management, what are your recommendations? And can diet also help with side effects?" And I know that... I remember when I was very, very sick. They said you have to flush everything out of your system. So if you cannot get your chemo drugs out because your diet is not helping in that regard, maybe that's why you are not feeling so well. I would've loved to ask you this back then, so please help me.

Aditya Bardia, MD, MPH, FASCO: Yes. Yes. Now, food is medicine as they say, and I think diet is an important component. With chemotherapy, sometimes patients have side effects like nausea or they're feeling tired. So the first principle is, eat what you can to ensure that your nutrition is maintained. That you are getting enough nutrition in terms of calories. You're keeping yourself hydrated. And if that means that there are certain foods that you're gravitating more towards, that's okay during chemotherapy because the most important thing is to ensure that your calorie needs are being met, and you're keeping yourself hydrated.

After the chemotherapy is done, when you are on endocrine therapy survivorship, that's a different discussion in terms of what to avoid and what to take and what not to take. Studies have consistently shown in breast cancer that fruits and vegetables are a good idea. So generally, we say, five or more servings of fruits and vegetables and some form of physical activity, moderate physical activity, especially in the survivorship setting is helpful for health in general and potentially could help related to breast cancer prevention of recurrence as well. But again, I would emphasize. During chemotherapy, the key is just ensuring that you're keeping your nutrition and keeping yourself hydrated.

Cara Sapida: All right. This question is for both of you. An audience member wants to know, "What complementary therapies are proven to help with chemo-induced side effects, and are there any other tips or lesser-known ideas to try?"

Maryam Lustberg, MD, MPH: I think we have a number of wonderful resources, including a very tight collaboration between the American Society of Clinical Oncology, ASCO, as well as the Society of Integrative Oncology known as SIO. So I think, for patients who are interested, they have wonderful patient-facing information as well as the official guidelines. But essentially, they have worked very closely together to look at the evidence for some of these complementary therapies.

Their latest recommendations are the evidence is strongest for music therapy, meditation, stress management, and yoga. These are the most important complementary approaches for anxiety and stress reduction. Meditation and yoga were also shown in multiple studies to improve the quality of life in those with a cancer diagnosis.

In terms of acupuncture, we have really strong data that it can be helpful for reducing chemotherapy-induced nausea and vomiting, and this is actually endorsed by the National Institute of Health. Studies are ongoing about the benefits of acupuncture for chemotherapy-induced neuropathy. So I said the level of evidence is not as strong there, but studies are ongoing. So these are some of the key recommendations from these joint guidelines.

Caution is absolutely recommended regarding supplements because many of the supplements can actually interact in a negative way with chemotherapy. So, definitely, be careful before initiating any supplement to make sure that your primary oncology team and pharmacy team are doing cross-checks for any unwanted interaction between supplements. And back to what Dr. Bardia was saying, really, instead of ingesting a lot of supplements, focusing on whole foods and unprocessed foods rather than going toward supplements, which may have additional interactions, is generally our recommendation.

Cara Sapida: Did you want to add anything to that, Dr. Bardia?

Aditya Bardia, MD, MPH, FASCO: Dr. Lustberg summarized it very nicely. She provided the recommendations in terms of... based on evidence. I don't have much to add. I'll just make two quick points. One is regarding supplements. Absolutely, you have to be very careful. Studies have shown that if you're taking high doses of vitamins during chemotherapy, that can actually be harmful. We are often okay with things that are neutral or can be beneficial, but we always want to avoid things that can be harmful. So that would be one example. And other supplements like black cohosh that can have estrogen. So if you have hormone receptor-positive breast cancer and you're taking some of these phytoestrogens, that can actually be harmful.

And the second point I would make is regarding these different therapies. Massage also can be helpful if a patient is having acute pain, especially if it's musculoskeletal in nature, so that's something to consider. And exercise, yoga that can help with fatigue as well. So do consider these things, but just with supplements, you have to be careful.

Cara Sapida: All right, Dr. Bardia, I have another question for you. And I just want to say to anybody tuning in right now, we have 1,300 people from around the world taking part in this, and I know there's a lot of questions and this one I think is important. This comes from an audience member with metastatic breast cancer and she says she's been Stage 4 for nine years. "How can I best cope with this lengthy marathon?"

Aditya Bardia, MD, MPH, FASCO: That's a good question. First of all, I'm glad that... And hope you're doing well on your treatments, that you've had this disease for nine years, and more and more we are seeing this in breast cancer, in hormone receptor-positive breast cancer, HER2 positive breast cancer as well. With these therapies, it's almost becoming like a chronic disease where you can control the disease for years, and that's where the quality of life becomes very important. The side effects of these drugs become very important. That's where the discussion about the dose and treatment holidays, those become very important as well. So the way I would view this would be more like take it a day at a time. Think of this more as a chronic disease. And it's okay to ask your physician about taking a break from treatment if needed, talking about the side effects related to the drugs.

Cara Sapida: All right, Dr. Lustberg, this one's for you. And it's about having a good solid support system. How can patients communicate their needs to their family, their friends, their spouses who might not understand what they're going through? I know that it is very difficult for many of us to ask for help. After I published my book, a few husbands messaged that they appreciated just having this little road map so that they didn't have to ask the questions. They just knew, "I know how you're feeling today X, Y, and Z." but I think many times we don't want to ask for help. What is your advice there?

Maryam Lustberg, MD, MPH: Yeah, so true. And I think, as you mentioned, family and friends may not always get it right because they haven't gone through this before, more than likely. And so not to put more burden on the patient who's also going through so much. I think if you can maybe identify both what you need emotionally. I think for many patients, they want to be listened to and not instantly offered solutions or be told that, "I know what you're going through," when the other person certainly does not. So maybe being clear about what your needs are emotionally.

And then the second thing is, there are probably tangible things that would help you. It might help you to have somebody help you with your groceries or fix your dinner or give you a ride to treatment. Families and friends love tangible solutions. So if you can make a list of practical things that they can do to help you, you'll make their day, but also, it's a help to you obviously.

I also wanted to kind of highlight peer support. I think the right type of peer support with other fellow patients can be incredible. I think it has to be the right group. It has to be the right type of peer support. When it can go wrong, sometimes it can elevate anxiety. But if the group of tight-knit folks that are supportive, I think, those folks really get what you're going through, and it can be a really incredible source of support.

And for some patients who feel comfortable with certain social media circles, there is a tremendous amount of support on social media. But again, you have to really tease out the good advice from the bad advice and know that ultimately vetting things through your primary oncology team is really important.

Cara Sapida: I think it's helpful to lean into that community that exists out there many women that have walked through it and want to help. I agree with you. I think it's important to hand your family and friends the tools to help you. Help them help you. I also think that I speak for a lot of women that when we're in the thick of it, empathy helps, and sympathy hurts. And it's a gray area. It's very hard to get that right. And so sometimes people don't know what to say because they don't want to say the wrong thing.

But I agree with you. Just telling them, "You can help me if you could just have DoorDash on Wednesday, that would really be great because my treatment is Tuesday or something like that." And they're like, "Yes, I can do this for you."

Okay. Our next question is more about helping people. The mental health aspect of a breast cancer diagnosis. A lot of it comes with fear, anxiety, depression, and they can have lasting side effects in addition to just physical side effects. Dr. Bardia, what do you tell people who are looking for mental health support?

Aditya Bardia, MD, MPH, FASCO: That's where family members, friends can be quite helpful in terms of providing that support system. Definitely, the oncologist, many centers have additional help in terms of providing... Be it a social worker or be it additional team members who can provide help related to these things. So it's very important to discuss with your primary team to see if the hospital or the clinic has those resources that could be tapped in.

The other thing I would suggest is a support group. Sometimes that can be very helpful when you have people who've had a similar conditions where you can share your thoughts, your feelings, your ideas. That can be pretty powerful as well.

Cara Sapida: One of our last questions, Dr. Lustberg, I think this is a really important one. Most of the people joining us today want to talk about side effects with their doctors. Sometimes they find it difficult. They struggle with the doctor patient relationship. What is the best way to speak up and be heard?

Maryam Lustberg, MD, MPH: I hope we can collectively come together today and really agree that it's critical for each patient to feel that their cancer team is listening to them and taking their concerns seriously. I think we all share that value. We all know it's important. And if it's not happening for whatever reason, it may take a few tries to find a team that's right for you. And I know that may be easier said than done. And maybe they need a second chance. Maybe you can tell them, "I don't feel heard," or, "I don't feel that my symptoms are being taken seriously." But if that is not doing it, I think it's really important for you to feel heard and to find that therapeutic relationship with your cancer team.

Cara Sapida: All right. We have time for two more questions. Dr. Bardia, what do you recommend for people who are experiencing nausea and vomiting, making it hard to even leave the house? I was one of those people just clawing at the pillows. What can you do?

Aditya Bardia, MD, MPH, FASCO: Chemotherapy-induced nausea, vomiting is one of the most distressing side effects of treatment when we think about chemo, the bad name chemo has. Nausea, vomiting definitely contributes to that. I think the key is to plan ahead and that's where, again, the team comes in. The patient should never be in a position where they don't have anti-nausea medications at home. The nausea usually occurs during chemo, a couple of days after chemotherapy. That is chemotherapy-induced. Which is different from nausea that can occur a week later or 10 days later, what we would call delayed nausea. The management of these two different type of chemotherapy-induced nausea, vomiting is different. And so it's important that the patient has the right medications.

But if you are in a situation where you're having severe nausea, vomiting, obviously, call your physician's office. You might need hydration because with the vomiting, you're losing fluids. With chemotherapy, that already causes a dehydrated state, so it becomes important to ensure you can be hydrated and you have the medications you can take to control this.

Cara Sapida: Do you have a large percentage of patients who need that hydration you think?

Aditya Bardia, MD, MPH, FASCO: It depends on how proactive the team is. These days, we have a number of good anti-nausea medications you can use to prevent nausea from chemotherapy. We talk about a three-drug anti-nausea regimen, so that is something that should be considered with chemotherapy. But yes, you can be in a situation where a patient is dehydrated. So often, we also recommend having even a video visit. Say you're getting chemotherapy a week later, having a video visit with your treating team so they can review side effects. And if there are problems including nausea, they can give you medications.

Cara Sapida: All right. Lastly, before we go, what message of encouragement do you each have for people who are about to start chemo? Maybe they're in treatment now or maybe they're dealing with long-term effects after treatment.

Maryam Lustberg, MD, MPH: I would say that you are already here and seeking information, and I think that proactiveness will absolutely serve you well. There is a lot of information, solutions, interventions, and support out there. And I think it's possible to do well. It's possible to manage side effects. It may not work the first try, but we have a lot of different tricks that we can try. So ask and complain. I tell my patients to complain. We want to hear about your symptoms.

Cara Sapida: Great.

Aditya Bardia, MD, MPH, FASCO: I fully agree. I fully agree with what Dr. Lustberg was saying. I think the key is to bring to the attention if you're having any problems, any side effects. And I come back to what you were saying earlier, which is, you should not feel guilty that you are having a certain side effect. This is because of the treatment. It's the treatment's fault if you are having hair loss or nausea. So bring it to the attention of your treating provider and know that a lot of these symptoms will get better. The hair loss, the nausea will get better. So it is kind of a marathon, but as long as you have the support and ask your treating providers for additional support if needed, you can get through this.

Cara Sapida: Thank you. Thank you both so much for your expertise. Thank you for being here, answering all of these questions. I'll speak for everybody. We're very grateful. Thank you both so much. And now, I'd like to welcome our next speaker who has an incredible story to share. Thank you for being here.

Thank you so much for being here. I would love to start with your diagnosis. Can you tell me how you discovered you had breast cancer?

LaShae Rolle, MPH, CPH: I found out that I had breast cancer, basically, I was going for a woman's health exam. And I had noticed that I had a lump that got bigger in the past. And so I decided I would bring it up when I did my yearly exam. And at first, the practitioner did not even do the breast exam. She did a pap smear, everything else, and she asked me if I had any other concerns. And I mentioned that. And she initially thought that it was likely fibrous tissue because again, at the time, I was 26 years old. I'm currently 27. But she still let me know that it would be important for me to still go and get an ultrasound and mammogram. So I went, and I got that done. And the second that they put the ultrasound wand on my breasts, they were like, "Ooh, how long have you had all those masses?"

Cara Sapida: Oh.

LaShae Rolle, MPH, CPH: And yeah, went downhill from there. So that's pretty much how I found out.

Cara Sapida: I felt that in my heart. So you're 26 years old. Nobody wants to hear that. Ooh. I know fertility preservation was something very important to you. Can you talk to us about that? How did your healthcare team help you through that?

LaShae Rolle, MPH, CPH: Yeah. So initially, once I was diagnosed and I went to the surgical oncologist. That was my first step after having surgery. She mentioned that later down the road if I may need chemotherapy, it can increase my chances of becoming infertile because you are pushed into early menopause. And so then she mentioned that they have oncofertility at my cancer center, Sylvester Comprehensive Cancer Center. And I immediately got an appointment. I went there. And it was actually a very smooth process because they work with the Livestrong Foundation, and I was able to get a grant and get pretty much 80% or more, around 80% off that total cost. And I was able to preserve 24 eggs.

And it was very important to me because as a young woman, 26, not married, still in school, not really... My life is just beginning. It was a lot to think about. If I wanted to have kids, if I didn't want to have kids, and I knew I wanted to have kids immediately, especially when it was at the forefront. And so it was very important for me and I'm very happy that I was at a cancer center that was able to provide that for me and connect me. And it all has been working out so far.

Cara Sapida: What about your side effects? What did you experience?

LaShae Rolle, MPH, CPH: In terms of side effects, I'm going to preface this by letting y'all know what I was on. So I was on Taxotere and cyclophosphamide for cycles for chemo. And the major symptom side effect that I had was fatigue. It was bad. And then I had some diarrhea and a bit of stomach pain. And then, obviously, I had hair loss as y'all can see.

Cara Sapida: Great. It looks good.

LaShae Rolle, MPH, CPH: Oh yeah, yeah. Thank you.

Cara Sapida: You carry it well.

LaShae Rolle, MPH, CPH: But yeah, those were the main side effects that I had. And yeah, I do share the same sentiments that everyone here has said about hair loss and how it was distressing. It was very hard for me. And I did do the cold capping and all that stuff.

Cara Sapida: So you tried the cold capping, but in the end you just shaved it?

LaShae Rolle, MPH, CPH: No, near the beginning. So, for me, it didn't work at all. And again, this is a case by case basis. That's one of the things I learned. Because I now have a lot of friends who were diagnosed with cancer. I joined the AYA support group. But for me, yeah. So the oncology nurses told me when I came back from my second round of chemo, they were like, "You have lost more hair than the patients I have who don't do the cold capping." So I had, what looked like when I shaved it, the day after cycle two, it looked like a world map. It was thinning there in the middle].

Cara Sapida: Patchy, yeah, a world map.

LaShae Rolle, MPH, CPH: Literally, I have a picture of that, and I'm like, "It looks like a world map. This is North America. This is..." Yeah.

Cara Sapida: I had that world map when it came in. What about, how has strength and fitness helped you in your recovery?

LaShae Rolle, MPH, CPH: Oh, strength and fitness has helped me a lot. So during my rounds of chemo and even before all the treatment, I would work out because I was a power lifter. I still am a power lifter. And so, even less than 24 hours after my first cycle of chemo, I squatted, bench pressed, deadlifted, the whole thing. That helped me a lot. While I don't think everyone should power lift. The research that I'm doing for my PhD right now is on how lifestyle interventions like diet and exercise can help with the side effects of chemo during treatment and after treatment. And so I was like, "I'm going to practice what we're preaching in my lab." And I think it really did help me. When I would finish working out, I'd feel less fatigued. Even though you'd think I'd be tired, I didn't have as much pain or anything like that. And as we speak right now, I'm feeling great. I'm still going through radiation. I had my seventh round of radiation today.

Cara Sapida: How are you feeling?

LaShae Rolle, MPH, CPH: But I'm still doing everything. Feeling good. I mean, I'm here,

Cara Sapida: You're here. We have a doctor here in Pittsburgh I recently interviewed who is doing a trial, a study on how heavy lifting can help you get through chemo treatment. And so it's similar to what you're saying, which I would've never thought to do that. I started boxing, so I just wanted to let out my aggression and punch things. But I think incorporating heavy lifting is interesting and smart.

LaShae Rolle, MPH, CPH: Yeah, it's helped me a lot. I mean, because one of the things I think generally, even besides from chemo in life, is when you feel empowered, it helps you get through these tough situations. And so seeing me, somebody diagnosed with cancer, going and getting chemotherapy, being able to lift over 400 pounds the day after chemo, it's insane.

Cara Sapida: Amazing. Yes.

LaShae Rolle, MPH, CPH: It's like almost when you have a fake it to make it mentality, how can I not feel the-

Cara Sapida: Yes, it's the fake it to make it as well as the you don't know how strong you are until you have no choice but to be that strong. But I also never resonated with feeling like a warrior, like people call you. But when I was punching things and I could see myself punching in the mirror, and then I was like, "Oh, I'm such a warrior." And so you're right. You have to find the strength within you.

LaShae Rolle, MPH, CPH: Yeah. It's crazy. When you get a diagnosis like this, I really think that's when you truly find out just how strong you are.

Cara Sapida: How strong you are.

LaShae Rolle, MPH, CPH: Because all of that strength comes out.

Cara Sapida: I could talk to you about this for hours. I also think you gain a mental strength that you didn't know you had. That's almost like you get in the breast cancer community. You come through it even stronger.

LaShae Rolle, MPH, CPH: Yes, definitely.

Cara Sapida: I have a couple more questions for you before we let you go. How has going through breast cancer motivated you in your work on health disparities and did the focus of that research you were doing change at all?

LaShae Rolle, MPH, CPH: Yeah, it's really inspired me. So from the get-go, I've always wanted to do disparity work, and that's what my whole goal was, always to help those who are from marginalized and minority populations. And after going through this, it's actually opened my eyes to a community I didn't know was facing a lot of disparities in AYAs. And so it's changed in the fact that I'm now very aware of the fact that AYAs go through such unique experiences because we're basically coming out of pediatric care into adult care. And then, you're not looking for cancer in people who are in their 20s and 30s and things of that nature. And so it's basically like you're almost alone.

And when we talk about community, when I go to the cancer center, people are like, "Are you the patient? Why are you here?" And so it's like you're very alone in that sense. And so just understanding that we might want for fertility preservation in some way too. So we have specific and unique care needs that sometimes can be overlooked, and so as a result, it's made me really want to help in a way people who are just like me, literally.

Cara Sapida: I think it's so important to speak out like you're doing today, going on today's show and showing the world that you can get breast cancer in your mid-20s. It is critical to speak out and share your story. What advice do you have for women of color, people of color who are watching this who might not feel like their voices are being heard when it comes to reporting issues from treatment or talking to their doctors?

LaShae Rolle, MPH, CPH: I would say just keep fighting and keep advocating for yourself because I hear from a lot of my friends that their physician or whoever was their practitioner told them that it was impossible for them to get cancer, and it turned out that they had cancer. Just keep fighting for that mammogram. Keep fighting for that ultrasound. It doesn't matter. At the end of the day, what I say is that you as the patient, you're the one who's going to suffer all of the effects of not being seen or not getting tested. So you have to fight for yourself. People are there to help you. I love my care team. They have been great. But for those who do not have that same experience, you just got to fight for yourself and be a big advocate for yourself.

Cara Sapida: You are a shining light. Thank you so much. Thank you for being here.

LaShae Rolle, MPH, CPH: No problem. And also if y'all would like to follow my journey.

Cara Sapida: I'm going to follow you as soon as we hang up.

LaShae Rolle, MPH, CPH: @strongaftercancer. Thank you.

Cara Sapida: Strongaftercancer. Okay. Thank you so much. Thanks for being here. And it is now my pleasure to introduce a message from Ashley Patrick from Walgreens. Walgreens stores can be an invaluable resource for side effect management, especially at their 75 oncology-specialized pharmacies which are across the country.

Ashley Patrick, PharmD: Hi, everyone. It is so great to be here with you. Helping Walgreens customers navigate side effects from cancer treatment is something we are fully dedicated to 24/7. Through the care of our pharmacists, the products we offer, and the support we provide on the phone, web chat or in person, we are here for you.

I want to share three common chemo side effects we help people alleviate every day. First, we will discuss dry skin. Cancer treatment may cause skin changes. To help alleviate some of these skin changes, keep it simple. Shower or bathe in warm water. Pat rather than rub skin dry, and apply moisturizing cream to damp skin. Avoid loofahs and bath scrubs, soaps, detergents, and moisturizers with skin irritants, including fragrances or dyes. Instead, use gentle fragrance-free soaps, lotions, and laundry detergent. You can also look for products that can help relieve discomfort and help soften the skin such as salicylic acid, urea, or lactic acid.

Keep in mind that creams or ointments are often thicker and can be more hydrating than lotions. Specifically, I recommend Cicaplast by Lipikar, or Lipikar by La Roche-Posay. These products are dermatologist-tested, fragrance-free, and clinically proven to be suitable for patients undergoing chemotherapy and radiation. La Roche-Posay products are carried at our many Walgreens locations nationwide.

Our Feel More Like You services feature pharmacists and beauty and wellness consultants who are specially trained to help people better manage internal and visible side effects from cancer treatment. This service is free and is available at select Walgreens stores.

Next, we'll move on to mouth sores. Cancer treatment may result in mouth sores or painful red or white patches caused by a weakened immune system. To combat this, I recommend using a DIY mouthwash you can put together at home consisting of one teaspoon of salt, one teaspoon of baking soda, and one quart of water.

It is also important to maintain good dental hygiene and brush your teeth at least twice a day with a soft nylon toothbrush or foam mouth swab. Use a non-abrasive toothpaste that contains fluoride and avoid any hydrogen peroxide-containing products.

Lastly, constipation and diarrhea. Constipation may be caused by cancer treatment, change in diet, pain medication, or decreased physical activity. I recommend staying as active as possible. A short walk may help address and prevent constipation. Also, aim to have 8 to 10 glasses of liquid per day, including warm liquids like coffee, hot tea, or warm prune juice. And be sure to add foods rich in fiber to your diet, such as bran, whole grain breads, cereal, fresh fruits and vegetables, beans, and nuts.

Now, pertaining to diarrhea, chemotherapy can affect cells lining the intestine, which may prevent water absorption and lead to diarrhea lasting up to three weeks after treatment ends. I recommend following the BRAT diet which stands for bananas, rice, applesauce, and toast. Having five to six small meals per day can be extremely helpful. And like what is recommended for constipation, maintain high fluid intake each day. It is also helpful to avoid acidic drinks, carbonated drinks, even if they are clear, hot or spicy foods, high fiber, greasy or fatty foods, raw fruits and vegetables, caffeine, and milk products if they make diarrhea worse.

Of course, there are also several over-The-counter medications used to provide relief of the common chemo side effects, but it's important to speak with your doctor or pharmacist before starting any new medication to ensure it is safe for you and your current therapy regimen. Whether you're dealing with these specific issues or other side effects, know that you're not alone. Our trained pharmacists are here to help you manage side effects at every stage of treatment. Visit Walgreens.com to learn more about our expert care products and services or visit your local Walgreens to speak with one of our pharmacists and beauty and wellness consultants. We're here for you. Thanks so much.

Marisa Weiss, MD: Well, thank you so much, Ashley, for sharing those really helpful tips. It's amazing that your corner drug store, Walgreens has all these experts there that are giving you out medicines or that's the place that you go for all kinds of remedies, and they have a lot of expertise and smarts to share with you, so thank you, thank you.

Before we go, I want to summarize some of the important information that was shared today. We'll also send you email links with articles and interviews. First about chemo medicines and all that and treatment plans. There are different chemo medicines and combinations of therapies that may be recommended for you, which can result in a variety of possible side effects. As you've heard, there's only one of each individual, and the treatment plan for you is unique to your situation. You can find more in-depth information about 20 types of chemotherapies at Breastcancer.org/treatment/chemotherapy/medicines.

Before starting treatment, ask your doctor about how your healthcare team will help you cope with potential short-term side effects like the nausea, constipation, diarrhea, mouth sores, hair loss, dry skin, and early start of menopause, changes in your immune system, sexual health issues like vaginal dryness, weight changes, and more. It's better to know what to expect than to all of a sudden experience it and not know how to deal with it. It's important to note that some short-term side effects could potentially last longer and become more long-term for some people. As I mentioned earlier, we want to emphasize the need for discussions and talk to your doctor about the short-term and the long-term side effects. The long-term ones like loss of fertility, losing some bone density, bone strength, the lung issues, the neuropathy, the pain in the hands, numbness, tingling hands and feet, and the mental health conditions like anxiety. It's also important to discuss whether you're at elevated risk for other types of cancers and to be monitored for that.

Before starting chemo. There are a number of things you can ask your healthcare team about how best to prepare to minimize side effects, including getting over-the-counter prescription pre-medications for some of the short-term side effects that can be expected. You might ask about scalp cooling to reduce hair loss, and frozen gloves, the cold gloves and socks to lower the risk of peripheral neuropathy, as well as the nail changes that you can get from intravenous chemotherapy.

And if you're considering having children biologically after completing treatment, it's also important to discuss fertility preservation, and possibly see a specialist to help you before chemo starts. Now, a diagnosis of breast cancer usually feels like an emergency, but really, it's an urgency and there is time to meet with those doctors, but you do need to get in fast and get your oncologist to call the fertility docs and get in there so you can have this conversation.

There are also steps that you can take at home before starting chemo to prepare for what's to come, like putting together a bag to bring with you that has comfort items. Talking with your employer about your options for flexibility at work, taking time off in case you're not feeling well enough if you can work from home, shifting hours, ask people if they want to contribute... Your coworkers, if they want to contribute some of their sick leave to you as an example. And you want to create a journal where you actually write down what side effects you're experiencing, and when they happen, how do they feel, when they start, what makes them go away, what makes them worse, so that you can learn from your own experience. You can also go to Breastcancer.org's community because people will share a lot of information with you about what helped them, what hurt them, and what were the solutions that made a difference.

All this journaling and just really documenting what's going on in your life can help you when you go to your doctor to explain what you're experiencing and they can hopefully help you better to find solutions. Consider starting medication by downloading one of the... Meditation rather, sorry. Consider starting meditation, using the power of your mind to help you get through it. There are a lot of apps that may help you learn how to do meditation. Of course, it's a practice, so with anything in life like meditation, practicing helps you do better. And we've heard a lot about exercise as medicine. Continue or start to move. Getting moving like 10 minutes in the morning, get up, go to the bathroom, brush your teeth. 10 minutes of exercise basically helps you physically and mentally stay well. It gets your motors going, it keeps your metabolism up. It trains your body that this is the start of the day. It's time to rock it out, and it can help with the things like fatigue and aches and pains and other side effects of chemo.

Think about exercise as mandatory. It's no longer optional. It really can make a huge difference in staying well, getting to and sticking to a healthy weight, feeling better about yourself, and building back your energy, your metabolism, all that. It's all really important. And I highly recommend you check out Breastcancer.org's community forums for valuable tips and tricks on what's worked for others. People are there to share their experience, and a lot of times, their experience can help you. So if you get advice from people who have been there, done that, walk the path before you, it's a big help. And we'll email you links to you after the webinar as well.

To help you find relief and gain strength through exercise. We're excited to launch a new five-part video series with short guided workshops and workouts for all levels that you can modify and do at your own pace. Find the one that you like, repeat it, line them all up, get more exercise there, change it up, make it interesting, do it with a friend, find people at Breastcancer.org that might be doing it also. These videos, these exercise videos were led by an expert in cancer medicine. That person is Sami Mansfield and they're all available at Breastcancer.org/videos. And tomorrow at 2:00 PM Eastern Time, you can ask Sami your exercise questions and join her for a workout on Zoom with the Breastcancer.org community members.

I want to give a special thanks again to our fabulous speakers for sharing their precious time, amazing expertise, wisdom, and personal stories. And a big thank you to every one of you for joining us. We really are grateful to have this important role in your life, to be part of what helps you get through all this and beyond your treatment, back to a life that you find enjoyable, meaningful, and long and healthy. 

We'll email you with a link to the recording as well as a link to the articles and videos that we talked about on the program today. We wish you much comfort, strength, and support as you navigate your treatment and navigate through any lingering side effects that you may be experiencing. We wish you all to take care of yourselves. Thank you so much for joining us.

Q: Any update on management of hand-foot syndrome due to capecitabine?

A from Dr. Maryam Lustberg: Yes, diclofenac available over the counter is a wonderful option in addition to good moisturizer and avoiding harsh irritants. For symptomatic hand-foot syndrome, dose modifications should be discussed with your oncologist including reduction of dose and/or one week on, one week off regimen.

A from Jen Uscher: Read more about research on using diclofenac to treat hand-foot syndrome and about other ways of preventing and managing the condition. Also, learn about how to talk with your treatment team about changing your chemo dose.

Q: Can you talk about the use of compression gloves/socks during infusion to try to prevent/reduce neuropathy?

A from Dr. Maryam Lustberg: A prospective national study on cryocompression is ongoing due to these promising data referenced here: https://www.swog.org/clinical-trials/s2205

A from Jen Uscher: Compression (wearing tight gloves and socks) and cooling (icing the hands and feet) during chemo infusions may prevent or reduce neuropathy. Compression and cooling can be used alone or together. Read more about research on cooling and compression and what you need to know if you’re considering using cooling gloves and socks or compression therapy during chemo.

Q: Is there anything the patient can do to keep their blood counts up during chemo?

A from Dr. Maryam Lustberg: Depending on the type of chemotherapy and schedule, growth factor injections may be used to maintain white blood cell counts. In other situations, [chemo] dose modifications are advisable, particularly if there are other toxicities happening. There is no special diet or supplement that helps keep counts up because these are directly due to bone marrow suppression effects of chemo.

Q: Are there exercises to do before chemo, during, or after?

A from Jen Uscher: Yes. Here are some specific approaches to exercise that are recommended and backed by research. For example, the American Cancer Society publishes recommendations on physical activity during and after cancer treatment. Getting regular exercise, when you’re feeling up for it, has many benefits for your physical and mental health. Learn more about exercise and breast cancer and about how exercise during chemo can reduce side effects.

Q: I developed a rash on my scalp after my second round of chemo. Any recommendations to avoid this? I think it was folliculitis.

A from Dr. Maryam Lustberg: Yes it is possible to have follicle inflammation due to hair loss from chemotherapy. Depending on appearance, it may improve with gentle cleansing and moisturizer. If there is evidence of more active infection, it is important to seek help for topical or oral antibiotics. Hard to say what is needed without visualization.

Q: How can I be proactive after my immunotherapy treatment? My liver tests have been going high.

A from Dr. Maryam Lustberg: If your liver function tests are going up on immunotherapy, it's important to have a discussion about the possibility that this may be coming from immunotherapy. Depending on the levels, immunotherapy may need to be held and steroid therapy or other immunosuppressive therapies may be needed. Please share this concern with your oncologist.

Q: I survived my early triple-negative breast cancer treatment in 2021-2022 at the age of 75. Because I tested positive for the BRCA1 and BRCA2 gene mutations, I had a lumpectomy, chemo, and radiation. At that point, I opted not to do the bilateral mastectomy. However, because of the gene mutations, I am at high risk for a recurrence. I am now exploring the better option of chemo again or the bilateral mastectomy. Feedback?

A from Dr. Marisa Weiss: The role of bilateral mastectomies is to reduce the risk of recurrence in the affected breast and to reduce the risk of a new, unrelated cancer in either breast in the future. The risk of future breast cancers is higher in people who have BRCA1 or BRCA2. For people who choose breast preservation therapy in the setting of a high-risk inherited gene, it's important to be watched carefully — every 6 months with 3D digital mammography in alternation with a breast MRI.

Q: Still having hot flashes and bone pain after chemo completed 2 months ago, when will this go away?

A from Jen Uscher: Those side effects can potentially last for months or longer. Sometimes there are instances in which they can be caused — or made worse — by other treatments you might be receiving, as well. It’s worth talking with your oncologist (if you haven’t already) about options for easing your side effects.

Q: How much time would be needed during the treatment. How long could it go?

A from Dr. Marisa Weiss: Each person's treatment plan is so unique to his or her situation — so it's impossible to generalize. Ask your team for an overall plan so you can know what to expect — and how to live your life around it

Q: I work in childcare. Should I take a leave from work?

A from Dr. Maryam Lustberg: It really depends. If you are worried about bugs and viruses from children during flu/covid season, this is something to consider. It also depends on your type of chemotherapy and other health conditions. I view this as a case-by-case situation with my patients and we decide together.

Q: Have any patients experienced eyesight issues from chemotherapy? My wife was on a TCHP treatment and started experiencing blurry vision after Round 3 of 6. Her last round was on Aug 29 and she started experiencing blurry vision 2 weeks later. We're not sure if this is because of chemo agents still in her body from the last round.

A from Jen Uscher: Some chemo medicines can potentially cause blurry vision. Other medicines used to treat breast cancer can also cause vision changes. Your wife might want to consider seeing an ophthalmologist and talking with her oncologist about options for easing this side effect.

Q: What happened to the chemo treatment that is worn for a constant dose? My Dad had this and the side effects were more minimal.

A from Dr. Maryam Lustberg: Continuous infusion chemos are not typically used in breast cancer.

Q: I have lasting side effects from my chemo treatment, especially peripheral neuropathy, mostly in my feet. Combined with increasing arthritis, I have trouble with mobility. I do exercise, but is there anything else that can help?

A from Dr. Marisa Weiss: The medicine that's been most associated with a good response is duloxetine or Cymbalta. There was a recent clinical trial that looked at CBD from hemp that contains some THC (Ananda Health Full Spectrum CBD) that helps with numbness and tingling from neuropathy — but without a clear impact on "pain."

Q: Is there anything else to take besides Claritin to help with joint pain from the Neulasta shot? The Claritin doesn't seem to provide much relief.

A from Jen Uscher: You may want to try Zyrtec, Pepcid, or an NSAID such as ibuprofen or naproxen — or some combination of those medicines — if your oncologist says it’s safe for you. Also, you may want to ask your oncologist whether you can try a corticosteroid such as prednisone. In addition, some people have reported that getting acupuncture within a few days after the Neulasta shot can help.

Q: Triple-negative. Age 68. Chemo with Taxotere and Cytoxan with Neulasta. Developed tachycardia during 3rd cycle of chemo. Is this a common side effect? Now taking Metoprolol for tachycardia. Does it resolve or is this a lasting side effect? Thank you.

A from Dr. Maryam Lustberg: It is not typical and I would encourage additional cardiology workup for other causes.

Q: I suffered from hair loss and thinning after chemo and Femara treatment. I have tried Minoxidil, and laser cap treatment, but no help for hair thinning on the top even though my hair did grow. Shall I try the PRP treatment for hair growing?

A from Dr. Marisa Weiss: Minoxidil 5% solution (not the foam), applied twice daily, can help many people, over time. If it doesn't help you, ask a dermatologist for other solutions, including PRP. You can also get creative with hair extensions to get more fullness.

Q: What about Doxil in terms of the nadir… can the fact that it is coated make the nadir later? Also if we have to be on prednisone for side effects, can that cause dizziness?

A from Dr. Maryam Lustberg: It depends if Doxil is given every 3 weeks or every 4 weeks. The nadir is typically in the midpoint of the cycle. Steroids may be associated with dizziness if you are feeling dehydrated or if blood sugar is becoming elevated. Drink plenty of fluids.

Q: If my hair and eyebrows are growing back 6 weeks after last chemo, is it likely my eyelashes will grow back too?

A from Jen Uscher: For most people, eyelash regrowth starts several months after the end of chemo treatment. Read more about managing eyelash loss.

Q: Does chemo affect your immune system worse than hormone therapy?

A from Dr. Marisa Weiss: Chemo can have an impact on your immune cells, whereas hormonal therapy is much less likely to affect your immune system.

Q: Is there a way to treat chemo induced neuropathy? The medications lyrica and cymbalta are not helping me.

A from Jen Uscher: If medications aren’t working well for you, consider meeting with a rehab medicine doctor, physical therapist, occupational therapist, or chiropractor who specializes in neuropathy. They may use a variety of other strategies for reducing neuropathy symptoms, such as nerve stimulation techniques, exercises, massage, and acupuncture.

Q: B6 and Gabapentin were key to my improvements with neuropathy.

A from Dr. Maryam Lustberg: I am very glad this worked for you. There are individual differences. However, large studies have not shown benefit from these for most patients.

Q: What can help the return of healthy hair after chemo?

A from Jen Uscher: If your oncologist says it’s safe for you, you might want to consider medicines like Minoxidil and supplements like Nutrafol. Read more about managing hair loss from chemotherapy.

Q: Chemo gave me brain fog but nothing compares to the loss of memory and severe lack of cognitive power, taking hormone blocker Arimidex. It has made it impossible to work. I had to take medical leave after chemotherapy. Is there any hope for better medication than Tomoflex [Tamoxifen] and Arimidex? Thank you.

A from Dr. Marisa Weiss: Work with your team to figure out what is causing your cognitive issues. Sometimes chemo induced brain fog only happens after chemo is over — exactly when the hormonal therapy starts. If you and your team determine that your cognitive issues are due to your hormonal therapy, then they may try various options to see which one you tolerate the best.

Q: Can you suggest any online exercise/weight workouts that are good for survivors to do online?

A from Jen Uscher: Breastcancer.org has a new series of exercise videos featuring cancer exercise specialist Sami Mansfield. The exercise routines are focused on reducing specific side effects such as anxiety, fatigue, joint pain, and more.

Q: I completed chemo and targeted therapy a year ago. Now I’m on hormone therapy. The side effects continue: fatigue, aches, bone pain, nerve pain, headache, neuropathy is lessened but not gone. All tests check out I am recovering "normal" - just have to be patient and "be kind to yourself." It does impact quality and enjoyment of life.

A from Dr. Marisa Weiss: You probably have a combination of lingering side effects from the chemo that you had, along with side effects from ongoing hormonal therapy. Exercise seems to make a huge difference! When you get up in the morning, 10 minutes of exercise can help get your motors going, reduce aches/pains, help your energy, mental health and sense of wellbeing. Wishing you the best!

A from Jen Uscher: Read more tips about easing chemotherapy side effects and hormonal therapy side effects.

Q: Does anyone have experience with Reiki to help with side effects of chemo? My mother-in-law suggested it, but I don't know a lot about it.

A from Jen Uscher: Check out our article and podcast about the benefits of Reiki for people who’ve had breast cancer.

Q: For neuropathy post-chemo, what about hot wax baths?

A from Dr. Marisa Weiss: Hot wax can be too hot! You can burn yourself — especially if your ability to sense temperature may be altered because of the neuropathy.

Q: What, if anything, can be done for neuropathy in my feet? I am taking gabapentin which really does not work. The chemo also left me with a weakness in my right leg. Exercise does not seem to help. Any suggestions?

A from Dr. Marisa Weiss: Duloxetine has been proven to be more effective than gabapentin. See other responses re: the use of CBD products from a clinical trial.

Q: During chemo I had two episodes of cold spells where I couldn't warm up to the extreme of shivering, even with layers of clothing, socks and hats - the only thing that helped was a heated blanket. What would cause such a temperature drop?

A from Dr. Marisa Weiss: Cold spells are so unique to each individual. If chemo threw you into an early menopause, you can have both cold spells and hot flashes. Plus, treatment can confuse your temperature control center...making you feel extra cold and extra hot, at unpredictable times.

Q: PICC or a Port. Is this an individual choice or based on the medication stream, etc?

A from Dr. Maryam Lustberg: Generally PICCs are in the extremity and are used for shorter term use. Ports are preferred for longer term use

Q: What to use on your scalp after you have shaved your hair off? For caucasian pale skin? Oil? Cream?

A from Jen Uscher: It’s typically recommended to only use very mild/gentle shampoos, moisturizers, and conditioners on your scalp after you shave off all your hair. Some people like using organic coconut oil as a moisturizer and to ease any irritation. Also, it’s a good idea to wear sunscreen on your scalp if you’re going to be spending time in the sun without a hat.

Q: It’s been 3 years since my 74 year old mother started chemotherapy. She is still suffering with neuropathy, brain fog, and exhaustion. All are significant. What things can she start doing to improve her quality of life?

A from Dr. Maryam Lustberg: I am sorry your mom is going through all this. Search your area to see if there is a geriatric oncology specialist or a survivorship clinic to better assess her symptoms. You can also ask for resources from her oncologist.