This week on Thursday Stine begins to climb the first summit – chemotherapy.* Chemotherapy is risky and full of potential side-effects. Most of my time the last two weeks has been spent on primary research to determine what can factually be done to reduce the risk and ameliorate side effects. There is a lot of hype and false marketing so rather than searching through various claims I looked at published data, clinical where possible and pre-clinical if other evidence was lacking.

The biggest way to reduce overall risk was for Stine to get back in shape from the surgery as chemo is both physically and mentally tough. While we could certainly wait longer for her to recover further, the medical staff feels she is ready, and I agree.  We need to take on the remaining cancer as soon as possible. 

Nausea

Next up was dealing with nausea- a very common side effect of FOLFOX. Nausea not only makes patients feel poorly, it impacts their appetite and you can end-up with malnourishment. This can create an ever-worsening cycle during the therapy. There are three approaches that make sense. 

First, she will take an anti-nausea medication- likely Zofran, but she also did well with Scopalamine after her surgery. 

In the second approach to nausea, she will restrict her diet 48hrs prior to the chemo, taking in appx 500-600 calories each day. This should actually end up as a 36 hour fast immediately prior to therapy. There is reasonable clinical data that a short-term fast is not only safe for chemotherapy patients, but that it reduces nausea while protecting the bone marrow (a common side effect is neutropenia) and often improves outcomes (likely by inducing oxidative stress in the cancer cells). One key study in ovarian cancer allowed patients who first fasted to “cross-over” to the control regime of not fasting. 31 of the 34 patients did not cross-over, preferring to stay on the fasting regime. Essentially, this means that 91% of the patients in the study chose to stay on fasting because they saw a positive impact. This paper summarizes a number of studies covering short-term fasting (STF):

“Abundant and convincing preclinical evidence shows that STF can decrease toxicity and simultaneously increase efficacy of a wide variety of chemotherapeutic agents. Preclinical data suggesting that STF can enhance the effects of radiotherapy and TKIs are promising as well. In clinical studies, STF emerges as a promising strategy to enhance the efficacy and tolerability of chemotherapy. It appears safe as an adjunct to chemotherapy in humans, and it may reduce side effects and DNA damage in healthy cells in response to chemotherapy.“

Effects of short-term fasting on Cancer Treatment”, Groot et al, 2019. 

For our third approach in dealing with nausea, we were encouraged by the oncologist to investigate CBD/THC. There is abundant evidence this not only reduces nausea during chemotherapy but that in some cases it may also stimulate a critical tumor suppressor gene (p53). Since CBD/THC is legal in California, we consulted with a practitioner and board certified doctor. Stine does not want the psychoactive ingredients (too bad!) and there are specific compounds that will provide her the anti-nausea benefits (tea and oil).

Lockjaw

Another common side effect of FOLFOX is “lockjaw” where a patients jaw becomes sore while receiving the Oxaliplatin dose.  Here there is not much data, but patients claim that simply chewing gum while receiving the dosage prevents or alleviates the condition. So- Stine will need to chew gum for about 3 hours. I wonder what kind of flavors she will choose?

Neuropathy

Yet another side effect of FOLFOX (yes, FOLFOX is literally a non-specific cell “poison”) is chemotherapy induced peripheral neuropathy- losing the feeling in fingers and toes, and/or becoming sensitive to cold. Symptoms can be a low-level of numbness that subside with time but can also end-up in long-term pain and can progress up the leg and arms.  Here there are far fewer alternatives. There is a medication in Phase III that looks promising (Pledox), but is too far off for us to use. There are also citations the neuropathy risk increases with the number of chemotherapy cycles, so limiting to six cycles may help. Vitamin B12 might also assist, as does the exercise. Since the neuropathy is dose-dependent our first line of defense is to notify the oncologist of any tingling/numbness so that future dosages can be reduced. We will continue to exercise over the cycles, and take vitamin B12. 

Nutrition will of course be a big focus of the chemo plan but we will save that for later.

So, that is a short-list of the side effects, there are of course many more possible and Benjamin, Stine, and I will stay vigilant. While the side effects are certainly not appealing, the risk of not performing the chemotherapy is high. To paraphrase Stine from the first post, chemotherapy is a frog that must be eaten. 

* To be more precise it is chemotherapy plus immunotherapy but for the sake of blogging we will just combine the terms.