How Do We: Assess Treatment (Chemotherapy, Targeted Therapy) Side Effects?

Undeniably, cancer treatments, whether with chemotherapy or targeted therapy, might cause some side effects.

Might occur, not must occur. A lot of time now, pre-medication is incorporated into treatment/ chemotherapy regimes to prevent side effects from happening at all.

Incidence of side effects or it’s severity increases for patients with poor nutritional status, poor hydration or those mixing treatment with alternative/ herbal substances.

Common side effects such as lethargy, nausea, vomiting, diarrhoea, hair loss, low haemoglobin, platelet level, low total white blood count.

Life threatening side effect is febrile neutropenia, when white blood count is so low/ negligible and patient contracted simple infections. The body unable to defend itself and end up spreading to whole body via bloodstream (sepsis). The mortality rate is about 15-30%.

It’s generally accepted that 1% of patients undergoing treatment will end up with life-threatening febrile neutropenia and all efforts must not be spared to save patient as it’s treatment-related. We do not give up just because patient is stage 4 – active resuscitation.


Severity of side effects/ adverse events from treatment (chemotherapy, targeted therapy, etc.) are graded 1-5, based on Common Terminology Criteria for Adverse Events (CTCAE v4.03).

  • Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated.
  • Grade 2: Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental ADL (preparing meals, shopping for groceries or clothes, using the telephone, managing money, etc)
  • Grade 3: Severe or medically significant but not immediately life-threatening; hospitalization; disabling; limiting self-care ADL (bathing, dressing and undressing, feeding self, using the toilet, taking medications, and not bedridden).
  • Grade 4: Life-threatening consequences; urgent intervention indicated.
  • Grade 5: Death related to AE.

That is why you were asked how many times vomiting or diarrhoea and other side effects during consultation. Be precise as different grading will have different implications and treatments.

Examples of gastrointestinal toxicities, especially diarrhoea and vomiting
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Toxicity management guideline

How does grading of side effect affect treatment? In general:

  • If side effect is grade 1, we can give some supportive medications for vomiting, diarrhoea, etc. to be taken if it occur.
  • If side effect is grade 2, increase vigilant is needed so that patient won’t end up at higher grade or get admitted due to treatment. I tend to ask patient to take the supportive medications regularly and for longer duration. Patient treatment also may need dose reduction, longer break or prophylactic treatment (GCSF to prevent white blood cells from dropping too low).
  • If side effect is grade 3, all the considerations as for grade 2, plus consideration to reduce dose further or stop treatment need to be considered and discuss with patient.
  • For grade 4, treatment will be stopped as harm outweighs the benefits too much to risk life.

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