Evaluation on Symptoms and Self-Treatment due to Radiotherapy

and Chemotherapy Based on Different Cancer Stage

Yesiana Dwi Wahyu Werdani

Faculty of Nursing, Widya Mandala Catholic University Surabaya,Surabaya,Indonesia

Keywords: Radiotherapy, Chemotherapy, Cancer Stage, Self-treatment.

Abstract: Radiotherapy and chemotherapy is modality therapy in cancer patients to minimize metastatic, but it causes

disruption of the overall organ system and decrease in various body functions. It can interfere the daily

needs fulfilled, and the patient become discouraged and worsened their condition. This study was to identify

the symptoms and self-treatment due to radiotherapy and chemotherapy based on the different cancer stage.

This was mixed method design and sequential explanatory approach. Samples were 30 cancer patients taken

by purposive sampling at Indonesian Cancer Foundation East Java Branch. The instrument was a

questionnaire. Result showed the most symptoms complained by all patients in various stages was fatigue.

Pain, hair loss and constipation were dominated in cancer stage 4, nausea-vomiting and insomnia were

dominated in cancer stage 3. All patients did the self-treatment. The majority self-treatment of fatigue was

yoga exercise. Pain and nausea-vomiting were treated by combination of medication and relaxation.

Insomnia was treated by mild massage. Constipation was treated by consuming the high fiber foods.

Nobody treat the hair loss complaints. Radiotherapy and chemotherapy affect the disturbance of the

stimulation hormones and metabolism that cause several of physical symptoms. Self-treatment by the

patient could reduce the symptoms effectively.

1 BACKGROUND

Cancer is tumor cells which has the ability to

replicate rapidly and invade the normal body tissues.

(Bunz, 2008). Cancer can metastatic to all of organs

depending on the stage of cancer. Prevention of

metastatic can be done through radiotherapy and

chemotherapy. It is expected to has a longer

survival. In prior studies of women with breast

cancer post-chemotherapy found that the survival

rates of patients increased reaching 5 years (92.1%)

and 10 years (81.9%)(Rossi et al., 2015). The

effectiveness of radiotherapy and chemotherapy in

prolonging survival was followed by various effects

on physical conditions. It will lead to disruption of

the patient's daily activities and if it lasts longer can

worsen the quality of life of the patient. In the prior

studies mentioned the various physical effects post-

chemotherapy and radiotherapy separately. No

research identify these effect and the beneficial

treatment by patient to reduce it based on the cancer

stage.

In 2013 based on the basic health research stated

that the prevalence of cancer in Indonesia reached

1.4 per mil with the highest areas of Yogyakarta (4.1

‰), Central Java (2.1 ‰), Bali (2 ‰), Bengkulu and

DKI Jakarta respectively (1.9 ‰), while in East Java

reaches 1.6 ‰(HRDI, 2013).

Research on 100 cancer patients found that the

majority effects of chemotherapy is a weakness 95%

and fatigue 90%(Shahbaz Aslam et al., 2014).

Another research reported that 15 patients performed

radiotherapy, majority complained were totally

exhausted, pain like skin burning and itching(Schnur

et al., 2009). Radiotherapy and chemotherapy trigger

the occurrence of oxidative stress not only in the

target tissue, but also on healthy tissue. It causes the

toxicity and organ dysfunction(Gilliam and St. Clair,

2011). Exposure to oxidative stress on radiotherapy

and chemotherapy to the muscles can cause

weakness and progressively increase the occurrence

of fatigue(Powers and Jackson, 2008). Oxidative

stress can lead to apoptosis, metabolic disorders,

neuroinflammation, metabolic disturbances and

neuronal failure(Areti et al., 2014). Target cell

damage due to radiation on the tissues can cause

DNA damage(Baskar et al., 2014).

150

Werdani, Y.

Evaluation on Symptoms and Self-Treatment due to Radiotherapy and Chemotherapy Based on Different Cancer Stage.

DOI: 10.5220/0008321901500156

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 150-156

ISBN: 978-989-758-336-0

Therefore the physical symptoms due to

chemotherapy and radiotherapy is very important to

be recognized by patients earlier and empower

patients to reduce symptoms independently is

essential to improve the patient's adaptation process.

This study was to identify the physical symptoms

and self-treatment due to radiotherapy and

chemotherapy based on the cancer stage.

2 METHODS

This was mixed method design and sequential

explanatory approach. Sample was cancer patients

with radiotherapy and chemotherapy program at

Indonesian Cancer Foundation East Java Branch

which amounted to 30 people, taken by purposive

sampling technique.

The questionnaire as an instrument was made by

researchers based on theories about the effects of

chemotherapy and radiotherapy. It consists of

closed-ended questions that describe a wide range of

physical complaints in post-chemotherapy and

radiotherapy. The instrument has been tested the

validity and reliability test, the result of the

correlation coefficient was 0.872 and cronbach’s

alpha result was 0.923. It means that the instrument

is valid and reliable.

All participants were given an explanation of the

purposes, benefits and risks of this study, and who

agreed to sign a voluntary and non-compulsory

informed consent sheet.

After the participants filling out the

questionnaire, it continued with interviewed about

the self-treatment to reduce the symptoms. After the

data collected, it was compare among the symptoms

and self-treatment based on cancer stage and

calculate the percentage.

3 RESULTS

Below is the general and particular data of

participants about physical symptom and self-

treatment.

Table 1 shown the majority participants were

female (73.3%) with average of age 41 – 50 years

old (40%). The most type of cancer was breast

cancer (30%), based on cancer stage was III (40%)

and majority time of diagnosed with cancer was 1 -

< 2 years (40%).

Figure. 1: The symptoms due to radiotherapy and

chemotherapy based on cancer stage

Graph as shown in fig. 1 that found six

symtopms due to radiotherapy and chemotherapy,

but fatigue was found in all of stage of cancer. In

stage 1 no symtomp about hair loss and constipation.

In stage 2 – 4 all symtomps was found. Pain, hair

loss and constipation symptoms were dominated in

cancer stage 4, whereas nausea/ vomiting and

insomnia were dominated in cancer stage 3.

0% 50% 100%

Fatigue

Pain

Nause/Vomiting

Insomnia

Hair Loss

Constipation

Stage 1 Stage 2 Stage 3 Stage 4

Table 1. General Data of Participants at Indonesian

Cancer Foundation East Java Branch, 2017.

General

Data

Categories

Frequency

(Person)

Percentage

(%)

Age

25 – 30 years

31 – 40 years

13.3

41 – 50 years

51 – 60 years

> 60 years

6.7

Sex

Female

73.3

Male

26.7

Type of

cancer

Breast

Cervix

Nasopharing

26.7

Colon

6.7

Ovary

6.7

Lung

3.3

Lymphoma

Hodgkin

3.3

Rectum

3.3

Cancer

stage

13.3

III

26.7

Time of

diagnosed

with

cancer

< 1 years

36.7

1 - < 2 years

2 - < 3 years

6.7

> 3 years

16.6

Evaluation on Symptoms and Self-Treatment due to Radiotherapy and Chemotherapy Based on Different Cancer Stage

151

Table 2 shown that in fatigue symptom identified

two details characteristics. The first was weak and

lack of energy, it was dominated in cancer stage 1

and the second fatigue disturbing of daily activity

fulfilling was dominated in cancer stage 4. In Pain

symptom participant felt hand, feet and back cramps

was dominated in cancer stage 3 and abdominal &

back lancinating was dominated in cancer stage 4.

Participants felt nausea when smell of food and

sometimes followed by vomiting was dominated in

cancer stage 1 and 2. Nausea feel anytime

Table 3 shown that participants got trouble

getting started sleeping & woke up early were

dominated by cancer stage 3, and woke up at night

and could not sleep anymore were dominated in

cancer stage 4. In hair loss symptom the most

moderate hair loss was dominated in cancer stage 3

and severe hair loss (alopecia) was dominated in

cancer stage 4. In constipation symptom all of stage

of cancer felt straining during defecation and hard

lump of faeces except cancer stage 1.

Table 4 shown that in fatigue symptoms,

participants relieve it by resting was dominated in

cancer stage 4, but yoga exercise was dominated in

cancer stage 1. In pain symptom the majority of

cancer stage 3 relieve by analgesic drug consume,

but treatment by combination of analgesic drug &

relaxation (deep breathing and distraction) were

dominated by cancer stage 4. Majority participants

in cancer stage 4 relieve nausea/ vomiting by

antiemetic drug, but in cancer stage 1 and 2 relieve

by combination of antiemetic drug & relaxation

(deep breathing).

Table 5 shown that mild massage on head, back,

hand and feet were dominated in cancer stage 1 and

2 to relieve insomnia, whereas cancer stage 4 relieve

insomnia by sleeping pills. In symptom of hair loss

the majority of participants in cancer stage 2 do no

treatment, and using hair tonic to stimulate the hair

growing were used by cancer stage 3. In symptoms

of constipation participants in cancer stage 2 – 3 was

relieved by high fiber foods consuming such as

vegetables, fruits and drink amount of water.

4 DISCUSSION

4.1 Symptoms and its Characteristics

The most symptoms after chemotherapy and

radiotherapy was fatigue, it occurred in all patients

with various stages of cancer. The details

characteristic identified were weakness, lack of

energy and fatigue disturbing of daily activity. The

participants have limitations in the activity and cause

the high levels of dependence on others. One of

research on 100 cancer patients reported that

weakness (95%) and fatigue (90%) after

chemotherapy (Shahbaz Aslam et al., 2014). Fatigue

(cancer related fatigue) is a subjective complaint

against the onset of physical fatigue. Post

radiotherapy or chemotherapy majority of

respondents got severe fatigue(Kummer et al.,

2013),(Bock et al., 2014),(Werdani, 2017).

Chemotherapy, surgery, and radiotherapy can lead to

increased plasma cytokines, especially TNF-α, IL-

Table 2: Description of details characteristic symptoms due to radiotherapy and chemotherapy based on cancer stage.

Stage of

Cancer

Fatigue

Pain

Nausea

Weakness

& lack of

energy

(%)

Fatigue disturbing

of daily activity

(%)

Hand, feet &

back cramps

(%)

Abdominal &

back

lancinating

(%)

When smell of food

sometimes followed by

vomiting (%)

Any time sometimes

followed by vomiting

Stage 1

100

Stage 2

66,7

33,3

100

Stage 3

Stage 4

100

28,6

71,4

14,3

85,7

Table 3: Description of details characteristic of symptom due to radiotherapy and chemotherapy based on cancer stage.

Stage of

Cancer

Fatigue

Pain

Nausea/ Vomiting

Resting

(%)

Yoga

Exercise

(%)

Analgesic

drug (%)

Combination of

analgesic drug &

relaxation (%)

Antiemetic

drug (%)

Combination of

antiemetic drug &

relaxation (%)

Stage 1

100

Stage 2

33.3

66.4

100

Stage 3

33,3

66,7

Stage 4

62,5

37,5

42,9

57,1

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1β, and IL-6. TNF-α has been shown to cause

changes in neurotransmission of the central nervous

system leading to behavioral changes such as

lethargy and anorexia(Ryan et al., 2007).

Pain symptom was identified by two

characteristics, hand feet and back cramps and

abdominal & back lancinating. This complaint is felt

by the participants every day and more severe during

the activity. Pathophysiology of cancer pain involves

somatic, visceral and neuropathy. Somatic pain is

usually superficial and arises from the skin, soft

tissue and musculoskeletal tissue. Visceral pain is

dull originating from internal organs. Neuropathic

pain arises from the structure of the somatosensory

system such as receptors, peripheral nerves,

autonomic nerves and central nervous

system(Mishra et al., 2009). Another research

reported that 13% of breast cancer patients

complained of moderate to severe pain (rating> 4) at

early of radiotherapy and 23% reported moderate to

severe pain after radiotherapy(Parks et al., 2017).

Persistent pain also felt in breast cancer patients

after 5-7 years post-chemotherapy(Mejdahl et al.,

2013).

Details characteristic of nausea/vomiting were

smelling food and at any time and it sometimes

followed vomiting, it cause reduce nutritional intake

and body weight. Participants only able to spend half

the portion of the meal. Vomiting is a reflex

triggered by a toxic substance, such as a

chemotherapy agent, which causes damage to the

gastric mucosa and the small intestine, thus

stimulating the vagal afferent interacting with the

central nervous system, and generating an emetic

response(Hesketh, 2008). Neurotransmitters that

affect the emetic response are serotonin, dopamine,

acetylcholine, and γ-aminobutyric acid (GABA),

histamine, endorphins, and cannabinoids(Navari,

2009). Cancer patients in another research stated that

the effects of chemotherapy led to nausea of 77%,

vomiting 75%(Shahbaz Aslam et al., 2014).

Insomnia characterized by trouble getting started

sleeping & woke up early and woke up at night and

could not sleep anymore. It causes respondents often

feel tired throughout the day. Radiation and

chemotherapy are both reported to produce sleep

disturbances(Liu and Ancoli-Israel, 2008). In cancer

patients, circadian rhythm disturbance is caused by

endocrine changes (such as cortisol, melatonin,

prolactin), metabolic processes (such as temperature

and circulation levels of proteins), and the immune

system (such as leukocyte and neutrophil levels)(Liu

and Ancoli-Israel, 2008). Sleep disturbances and

increased daytime drowsiness occur in adult and

child of various types of cancer including acute

lymphocytic leukemia, central nervous system

tumor, Hodgkin's lymphoma, soft tissue sarcoma,

and bone tumor(Mulrooney et al., 2004).

The symptoms of hair loss is suffered in stage 4

of cancer with degrees of hair loss vary, but it does

not make the patient feel ashamed. Research

conducted on Caucasian cancer patient reported that

post-chemotherapy cause hair loss and alopecia on a

moderate scale

(Kluger et al., 2012).

Constipation is suffered in stage 4 of cancer.

Majority of patients told that difficulty defecation

with the fastest frequency of defecation is 1 week

once times with stiff consistency of the feces.

Table 4. Description of details self-treatment to reduce the symptoms.

Stage of

Cancer

Fatigue

Pain

Nausea/ Vomiting

Resting

(%)

Yoga

Exercise

(%)

Analgesic

drug (%)

Combination of

analgesic drug &

relaxation (%)

Antiemetic

drug (%)

Combination of

antiemetic drug &

relaxation (%)

Stage 1

100

Stage 2

33.3

66.4

100

Stage 3

33,3

66,7

Stage 4

62,5

37,5

42,9

57,1

Table 5. Description of details self treatment to reduce the symptoms.

Stage of

Cancer

Insomnia

Hair Loss

Constipation

Mild massage

(%)

Sleeping pills

(%)

No Treatment

(%)

Using hair tonic

(%)

High fiber food

consuming (%)

Stage 1

100

Stage 2

100

Stage 3

66,7

33,3

42,9

57,1

100

Stage 4

100

Evaluation on Symptoms and Self-Treatment due to Radiotherapy and Chemotherapy Based on Different Cancer Stage

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Constipation often occurs 50-87% in patients with

advanced cancer(Abernethy, Wheeler and Zafar,

2009). Constipation is the third most common

symptom in patients receiving cytotoxic

chemotherapy with an overall prevalence of 16%,

with 5% being severe and 11% moderate(Anthony,

2010). Chemotherapy and radiation drugs affect the

contractile physic activity that contribute to colonic

motor activity and peristaltic reflexes (Kuizenga et

al., 2015).

4.2 Self-treatment to Reduce the

Symptoms

The majority of patients who suffered fatigue cope

with resting (reduced daily activities and use the

time to lie down, while some light activity such as

reading, making handwork is done by sitting). But

there is a small percentage of patients who overcome

fatigue by doing yoga exercise, because they have

understood the steps of yoga through social media

and training from local cancer organization where

they come from. In prior studies reported that the

activity of yoga for 12 weeks can reduce fatigue

significantly(Bower, Garet and Sternlieb, 2011).

In pain symptoms, the majority of patients

overcome by taking analgesic drug from the

physician and combined with the deep breathing

relaxation and distraction technique. It has learned

from health care workers in the hospital. But

sometimes the pain is still felt in moderate to mild

scale. Meditation, progressive relaxation, rhythmic

respiration, therapeutic touch, transcutaneous

electrical nerve stimulation (TENS), hypnosis, music

therapy, acupressure are among the non-invasive

methods of reducing pain in cancer patients(Woolf,

2011). Non-opioid analgesic drugs are the first step

to reduce cancer pain, but if the pain is not well

controlled then strong opioids such as morphine can

be given(PDQ Supportive and Palliative Care

Editorial Board, 2002).

In Nausea/ vomiting symptoms, the majority of

patients cope with a combination of antiemetic drug

and deep breathing relaxation techniques. In the

prior studies reported that providing a relaxation

intervention with music for 25 minutes is effective

Figure 2: The Patterns of Symptoms and Self Treatment due to Radiotherapy and Chemotherapy Based on Different

Cancer Stage

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

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in reducing the intensity of nausea and vomiting in

cancer patients(Arakawa, 1997).

In insomnia symptom are overcome by the

majority of respondents with deep relaxation

techniques such as meditation and mild massage on

the head/ hands/ feet/ back performed by family

caregiver. Medical massage therapy interventions on

cancer patients showed significant differences in

sleep quality scores before and after intervention in

the treatment group(Kashani and Kashani, 2014).

Massage therapy can increase different levels of

relaxation in a person's body and can improve sleep

habits(Reza et al., 2010).

In hair loss symptom, the majority of patients

doing nothing of treatment, but there is a small

percentage of patients who use hair tonic to cool the

head and stimulate hair growth. Scalp cooling

especially in the frontal, superior and occipital areas

of the head can reduce hair loss during

chemotherapy(Ghaffari M et al., 2015).

In constipation symptoms overcome by

increasing the high fiber foods consuming such as

fruits, vegetables, and many waters, it help them

alleviate perceived complaints. Dietary fiber intake

increases the frequency of defecation and improves

fecal consistency, which is especially useful for

patients who are constipated (Yang et al., 2012).

Figure 2 shown that side effect of cancer therapy

(radiotherapy and chemotherapy) cause the

complicated symptoms and its details. Many self-

treatment done by patients to reduce the symptoms.

5 CONCLUSIONS

Radiotherapy and chemotherapy in cancer patients

can lead to the physical symptoms that disrupt the

balance of individual physiological basic needs

fulfilled. Every stage of cancer has different details

characteristic of symptoms. The Patients did the

self-treatment to reduce the symptoms and every

stage of cancer has different ways to overcome it.

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