Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Anyone listening can imagine hearing the words, “You have cancer.” Those words may bring with them a flood of fears, with all that's flashing through your mind about how your life will change.

When you're confronted with the next step — being told you need chemotherapy, or "let's start hormone therapy" — a whole new set of fears may arise. Fears about how the treatment itself will impact you. Will I be too exhausted to work? Will the nausea keep me in bed? What about my hair, my nerves, my sex life, my sense of self?

If that's where your head is right now, this episode is for you. Today, we'll unpack practical, evidence-based tools to keep you functioning and feeling like yourself while you navigate cancer treatment. We'll also explore how and when to communicate your experiences to your healthcare providers — because surviving cancer isn't enough.

You deserve a good quality of life while you're doing it. First, let me introduce my guest, Dr Elizabeth Cathcart-Rake. Dr Cathcart-Rake is a medical oncologist at Mayo Clinic who specializes in the treatment of breast cancer. Her research is focused on reducing treatment side effects in cancer survivors — anything from neuropathy to fatigue.

For example, she's currently leading a cooperative group trial that aims to reduce chemotherapy-induced peripheral neuropathy to improve quality of life. Welcome to the WebMD Health Discovered Podcast.

Elizabeth J. Cathcart-Rake, MD: Thank you so much for having me.

Pathak: Before we jump into our very important discussion, I'd love to ask about your own health discovery as it relates to the work that you're doing — the research you're doing. What questions, what issues did you see in your own patients that led you down this path?

Cathcart-Rake: That's such a great question. I think we all have this why in us as far as why we get involved. I started my journey as a medical resident at the VA. And so I saw day-to-day the side effects that come from cancer treatments, particularly in the veteran population, and neuropathy was such a huge issue among my patients.

A number of them had a lot of risk factors for neuropathy as well — unfortunately, things like diabetes in the background. And I felt, as a resident, that I didn't have a lot of training as far as how to manage these side effects. I felt like, you know, when I'm an oncologist, these are answers I'm going to be able to have — you know, I'm going to be armed with all of these tools to try to help prevent these things and treat them.

And then as I became a fellow, I continued to have these questions, realizing that there has been some really wonderful pioneering work in prevention and treatment of the side effects of treatment like neuropathy. But also, there's a number of things where we can continue to move the needle forward — help research and help patients live better with side effects from treatment.

And neuropathy is one of those areas. So it continues to keep me motivated to try to help folks feel as good as they can going through some of the treatments that we're recommending. And with the changes in treatments that we have now that help people live longer and live better — you know, we also are coming up with new side effects sometimes as well. So this is an ever-growing field. Our job is to try to help patients as much as we can.

Pathak: So can you talk a little bit about some of the nuances of what you can expect with these different treatment regimens?

You mentioned that there's a shift in the type of therapeutic options that we have as well. So can you talk us through some of the big categories and some of the side effects that you might think of as often associated with those treatment categories?

Cathcart-Rake: Yeah, absolutely. So traditionally, we think about cancer treatment as being chemotherapy. And this is often where folks' minds go, understandably, when they think about cancer treatment. Chemotherapy, we talk about, is killing both the good cells and the bad cells in the body.

Fatigue is one of the biggest side effects of chemotherapy, as well as things like nausea and vomiting, infection risk, numbness and tingling — that neuropathy word that you heard me use earlier. Alopecia — so hair loss.

And as you brought up very thoughtfully, patients often will come in and talk with us about their most feared side effect. And I actually really welcome that in clinic. You know, I have folks who come in and think about chemotherapy and they imagine themselves being at home and just vomiting all day for weeks on end.

It's really helpful for me to know what those preconceived notions are so I can help say, “Oh gosh, this is not a regimen that causes a lot of nausea,” or “This is one that does — but let's do all these things to help prevent that.” I try to take that approach. Same thing, for instance, with alopecia.

So chemotherapy is one bucket. In the breast cancer space, I think about endocrine therapy — you know, which is really anti-hormonal therapies. Those have side effects that are more like hot flashes and night sweats and things like that. That can be not just for breast cancer, though — that’s for prostate cancer as well.

Then we think about targeted therapies — so therapies that are directly targeted toward a specific aspect of the cancer, kind of like a lock and key — you know, turn that cancer off. They have a really wide range of side effects.

We think about skin side effects — so rashes, we often see a little bit more in those. Sometimes folks have some nausea with those, but it’s maybe more like a reflux-type feeling or a sick-stomach-type feeling — maybe a little different than a chemotherapy side effect.

And then we have the bucket of medicines called immunotherapies, which really are using the body's immune system to kind of ramp up and notice that the cancer is not supposed to be there in the body and fight off the cancer as well.

And that's a whole different bucket of side effects. Those are our immune-related toxicities — that are just overactivation of the immune system. And that's — we often refer to as the “-itises,” you know: pneumonitis, adrenalitis, hypophysitis — which is just inflammation. So you can have inflammation in a number of different areas in the body that may cause side effects associated with that part of the body.

So pneumonitis is the lungs, and you have inflammation in the lungs, and you could have shortness of breath or cough. So there's a number of different side effects depending on what kind of medicines you have.

And then, this list of types of medicines is growing — which again, is wonderful in the cancer therapeutics world — but poses new challenges as far as being able to identify side effects.

There’s a group of medicines now — the antibody-drug conjugates — and those are kind of chemotherapy-like, where we're actually able to deliver chemotherapy more targeted to the cancer cell. And it's kind of a mix then of chemo and targeted therapy.

And those medicines may have their own side effects as well. So we may see some more traditional chemotherapy side effects, but we might see some things like pneumonitis, for instance.

Pathak: What really struck me as you were talking is that there’s such a broad array of treatment options — and there may be multiple treatment options that are going to be used at once.

What really also struck me is when you said that you want to know what your patient is most concerned about as it relates to those side effects so that you can help them talk through those concerns.

That really is just such an important, important point, because I think often patients are, again, struggling with the big “C” — that word — and they just feel like, well, they have to undergo this treatment regimen in order to address that.

And then all of these side effects are then just secondary, and they're just going to have to potentially push through or deal with these side effects.

So how do you start this conversation? How do you advise your patients to start this conversation? Whether their concern is about a physical side effect, their mental health, the emotional toll that this diagnosis is taking on them, sexual side effects, financial well-being — there's a whole array of how someone might be feeling.

So how do you suggest someone kicks off this conversation?

Cathcart-Rake: So it's individualized. There's not one right or wrong way to do this. I think maybe the only wrong way to do this is not to talk about it, because it's so important to have an open line of communication with your treatment team. You know, you mentioned so much, and I think that's because this is such a significant conversation that we have, and that it can't be all accomplished in one visit.

And so I think that's the first takeaway — that I wouldn't expect to have all your questions listed and all of them perfectly answered, everything addressed in that first visit. I would try to take that first visit to get just a general kind of overview: understanding of the cancer, understanding of the treatment options (if there are options), or the treatment recommendation. And then make sure there's a follow-up visit scheduled in short order, or at the very least, a way to communicate with your team to kind of regroup, answer questions, and talk more in detail about side effects. Because this is just too much to tackle, I think, for any person, including an oncologist, in one visit.

And then I think prioritization is really helpful as well — making sure the clinician and the treatment team know what the patient is most concerned about is incredibly important. 'Cause that's a really good starting point. Talking about side effects, and breaking up side effects into smaller categories.

So, what's most likely? What do most patients experience in the midst of this? Then what's uncommon, but really serious? And then is there anything else that I should be aware of? So I think kind of breaking it up into these buckets: what's a general expectation? How am I gonna feel? Can I work? What are the most common side effects — that’s one bucket. And then the second bucket being: what's rare, but what do I need to know just because I might see that out there — that’s this rare but serious side effect. And then are there any other considerations that just in experience, a clinician may know to be able to share.

Pathak: There are two things that stand out to me in what you just said. Number one is that this is going to be an ongoing process. So expectation management around just knowing: Who is on your team? How do you connect with them as questions come up? And recognizing in yourself — some of us are better at asking questions and some of us don't say anything and then process afterward and may feel like, "This is going to be burdensome for the person I'm with, so I don't want to ask this question."

So really kind of interrogating yourself and how you generally interact, and then maybe figuring out a way of making sure that your questions get addressed over time. And then I love your framework — really makes so much sense for triaging the questions that you have around a particular treatment.

Let's move on to some of these very common side effects, or at least the side effects that patients are commonly concerned about. You mentioned nausea and vomiting as frequent side effects, and that there are treatment options that might be available to people, where if this might be the predominant side effect of the regimen that they're going to be on.

So can you talk us through how you talk to your patients about that and what the potential treatment options are?

Cathcart-Rake: Yeah. I do think there are folks that seem to be a little more prone to nausea, and some folks are a little less prone. It's always hard to know that, but I'd say patients typically know themselves really well. I've had folks come to me and say, "I get really nauseous," or, "I have migraines and I get nausea with that. I just seem to be somebody where that's a more common thing."

And in folks like that, it may not necessarily mean I adjust their medicines, but I may up front and certainly just want to have very close follow-up of that nausea moving forward after we start treatment.

The other thing is, with anybody, I think one of the most important things is for folks to have a plan A, B, and C. And this is when you call. Many of our treatments do cause some nausea, especially the chemotherapies. But if somebody is vomiting — that's actually pretty rare — and I want to know about it.

I think that's different from cancer type to cancer type, cancer center to cancer center. But I will always give folks the recommendation of, you know, if you're feeling a little nauseous and your medicines are managing it, that's fine — keep moving forward. But don't ever hesitate to reach out. If you're vomiting, actively vomiting in spite of what we're doing, I want to know about it.

So having that framework I think can be really helpful. I try to give folks a sense of how much nausea they'll have, but again, that's hard to predict. I think the most important thing is giving a plan if they do have nausea — and especially vomiting.

You know, we give pre-medicines before any of, especially the IV chemotherapies, are given. And so if it's a medicine that's given in the chemotherapy unit or the infusion unit, they will often have medicines before that even starts — sometimes even some oral medicines. And then they'll have medicines to take at the first sign of nausea or vomiting.

And often, the earlier that these medicines are taken, the more effective. So I always recommend that folks don't hold out on taking them. Don't try to tough it out. You know, if you feel like you're getting nauseous, just take them. And there's often kind of a group of different types of medicines that we use that work in different ways. Some patients may find one more helpful than another.

There's one, for instance, that seems to really help with nausea but may cause a headache, for instance, or may cause some constipation. And so that may be a really good choice for somebody with diarrhea — it may be less of a good choice for somebody who is prone to headaches.

There's another medicine that can really help with sleep as well as nausea. So just trying to find the right fit of a medicine with the other medicines somebody’s on, and kind of the risk factors that somebody has, is really important.

Pathak: Then sort of moving on to the other major impact that you were talking about, which is fatigue. Can you talk us through how you address fatigue in your patients? That seems like a tough one.

Cathcart-Rake: That is such a tough one. You know, this is one of those things that is just really challenging to treat with a pill because there are so many things that factor into fatigue and everyone experiences it differently. And it's really just a side effect of chemo that we just don't have good pill medicines for.

It can just be a challenge. I think trying to set as best expectations as possible about how this will go is important. And the reason I say that is just, you know, having met patients throughout my career, a number of folks are afraid or don't want to ask for help.

You know, they're used to being the caregiver for everyone around them, and then they face this cancer diagnosis and they very much want and expect — understandably — to continue to be able to do all of those things, such that they don't ask for help. And it can just be even more challenging to manage.

And I think just having some expectations of: life — this is a life shift. And that's super hard. There's nothing that makes that piece easier. But just to try to surround yourself and make a list of the things that need to be done, and then ask people to help with the list — you know, that type of thing — to help navigate maybe a shift in relationships that comes with fatigue.

As far as fatigue management, what we have the most data for is this strategy called energy conservation, which is really trying to save up your energy for things that are really meaningful and either need to be done or bring someone joy throughout the day. And then rest when you need to.

Part of that is trying to keep as much of a usual schedule as possible, again, with the thought that things do change significantly. Trying to wake up at the same time each day, trying to kind of work in some expected activities during the day — albeit maybe small. And then also doing some sort of activity.

That may be different for different folks based on what you're coming in doing. You know, we know that things like yoga and tai chi, even sitting in a chair, can really help with fatigue — and sometimes some of the joint pains and muscle pains that come with some of our treatments.

So strategies like that can be really helpful. You know, we've been looking into things like acupressure and acupuncture as well, to try to help with some symptoms. Those management strategies that don't involve a pill, I think, can be really beneficial. We're really interested here in studying ginseng. So we actually have a clinical trial open looking at ginseng for different groups of folks dealing with cancer treatments. So there is a lot of interest in new options for fatigue, but that's usually what I share with folks and I hope folks find to be helpful.

Pathak: It's really helpful and really interesting because it feels almost counterintuitive, maybe, as a patient, to feel like you've got to schedule in some time for physical activity — whatever that means to you. I think it's really important, what you've mentioned about finding joy in your day and maintaining as close to a schedule as you possibly can.

So the balance really of listening to your body when you need to conserve energy, but also thinking about physical activity as your treatment as well. So just like you would get up to take your medicine at a certain time, you'd think about maybe potentially doing some sort of physical activity as medicine to keep yourself moving in some ways.

I think that the literature there is getting stronger.

Cathcart-Rake: Absolutely. And you said that just beautifully. I love the way you described that. That's absolutely correct.

Pathak: So then, moving on to peripheral neuropathy. As part of your research, can you talk to us a little bit about what it means to have neuropathy? Explain that a little bit, and then what are some of the options for managing it?

Cathcart-Rake: Neuropathy is often described as numbness or tingling of the fingers and toes, but sometimes it can be burning pain. Sometimes it's just changes in circulation. And so folks go out in the cold and they don't feel that it's as cold, or they feel more cold, but they're less able to feel the floor and actually realize when they're stepping on something or getting into trouble with their extremities because their nerves aren't picking up on signals as well. So there's a wide range of how this is described.

Neuropathy comes from a number of different chemotherapy agents. We've also started seeing it with some of these new, more targeted therapies or these antibody-drug conjugates as well. And so we're trying to learn more about the way neuropathy is experienced with those too.

As far as treatment—gosh, I am excited to be able to share, hopefully in the future, that we have a wide array of treatments and preventive options out there. I do think some of these things are coming. There is a medicine that has been shown to decrease the symptoms of burning pain, particularly associated with chemotherapy. That's a medicine called duloxetine. You know, we've had some mixed results from other medicines that help treat nerve pain, like gabapentin, where I've had a number of folks report a benefit. The trials have been somewhat mixed there.

We've also seen some mixed results from studies looking at acupuncture for neuropathy. I'm very interested in strategies—things like exercise—and also in these more complementary medicine strategies like acupuncture and something called scrambler therapy, which is kind of like a fancy TENS unit. That helps try to retrain the electrical impulses in the fingers and toes.

We certainly need more data on many of these things, but there's an array of things that we’ll talk about and that we hope to have more information on as we move forward.

As far as prevention of neuropathy—that's also critically important. As you very kindly mentioned starting out here, I am very thankful to be the PI on a trial looking at a medicine to help prevent peripheral neuropathy with paclitaxel, one of our chemotherapy agents. Very excited about the potential for this medicine.

But there are also studies ongoing looking at something called cryocompression—so strategies to try to decrease the chemotherapy flow to the fingertips and the toe tips to try to prevent neuropathy. That's building on the strategy called cryotherapy, which is actually ice.

So many folks will hear about ice gloves and booties while the chemotherapy is infusing, to try to prevent neuropathy. This is kind of taking that a step further and actually using a device to compress the hands and the feet in addition to the cold, to try to minimize neuropathy as well.

So there's a number of different strategies that we're excited about that might help with neuropathy prevention or treatment. It's just trying to get more data and try to build our database of options for folks.
Pathak: That's really interesting because you know the other question I was going to ask you about—where I know cooling has some benefits—is hair loss and hair thinning. So can you talk to us a little bit about strategies to address those risks?
Cathcart-Rake: Absolutely, yes. We see hair loss and hair thinning certainly with traditional chemotherapies, but also with some of the newer agents and some of the targeted therapies even. We're seeing some significant hair thinning too. So that warrants a lot of further questions to your clinician, but also some management strategies.

During chemotherapy, cold capping—which is just a cold cap that's actually fitted to your head—can help with hair loss and hair thinning related to chemotherapy. The absolute benefit of it differs from chemotherapy agent to chemotherapy agent, and actually depends on somebody's hair texture to begin with and the duration of the cooling.

But we do see significant benefits to that. And that can be purchased, sometimes with the support or help of an infusion center. Folks can also get information about it online or even purchase it themselves online. There’s the Rapunzel Project and HeretoStay.org that have a number of good resources for folks. That's definitely an option.

And then there's a lot of interest in medicines to be able to help and treat hair loss and hair thinning from targeted therapies—things like minoxidil, which is in a topical form, but there's also interest in looking into a pill form for that as well. A trial of that is well open.

So there are options, no matter what folks are thinking about or going through. If hair loss or hair thinning is a potential, it's just about trying to weed through what might make the most sense.

Pathak: And then I wanted to ask you about one that I wasn't familiar with, but I hear is more common than people recognize—nasal vestibulitis. Can you talk to us a little bit about that side effect?

Cathcart-Rake: You know, this is a side effect that is really significant. I think this is one of the things that I've published on that I've had the most patient engagement on because it's not talked about much.

And it's one of those things that I think kind of gets poo-pooed in an unfair way. Folks can have some discomfort in their nose—dryness, crusting, scabbing, even runny nose—and it's related to the chemotherapy. We've seen it especially with taxanes, although I've seen it in practice related to other agents as well.

It's just one of those side effects that, on top of everything else, can be such a problem in terms of quality of life. It just builds, you know—it builds over time.

We actually did a natural history study. We saw over 70% of folks on taxanes got this side effect. And then there's actually a nasal spray that works. It seems like saline spray may help, but there's a rose geranium and sesame oil nasal spray that can be compounded that decreases symptoms too.

It's one of those little-known side effects that I do think treating and being proactive about can really help someone live better in the midst of everything they're going through.
Pathak: This has been really informative. I really want to thank you so much because I think a lot of what we talked about are concerns that so many patients I know—friends I know—that are recently diagnosed or are potentially going to be going through this treatment are really concerned about, but also don't necessarily talk to their oncologists or their teams about.

We didn't cover everything—there are, as we talked about in the beginning, sexual health side effects, financial, mental health—so many things. And I think if nothing else, I hope people take away that all of this should be addressed with your team, even if it has to happen slowly over time.

Cathcart-Rake: Absolutely. And I completely agree. I hope that's the biggest takeaway—if you're concerned about something, bring it up. I think the sexual health side effects especially could be its own episode, and I'd love to go into that too, because that's so critical. I hope folks feel comfortable bringing it up, and our job is to try to help.

Pathak: Are there any resources that you want to make sure our listeners are aware of, so that they can go there to educate themselves more?

Cathcart-Rake: There's a number of really great websites out there. They're put out by the major cancer centers. I am from Mayo, so the Mayo Clinic resources I do think are nice as far as side effects.

You know—Cleveland Clinic, Sloan Kettering, and MD Anderson, among many others—have really solid resources out there. The American Society of Clinical Oncology has really nice resources, as does the American Cancer Society. And there’s a number of very specific supportive care materials for folks through those organizations that can be really tailored.

Pathak: Thank you. And any final thoughts on something I didn’t ask you about that you want to make sure we share with our audience?

Cathcart-Rake: Gosh, it’s just been such a pleasure to get a chance to talk with you. I think the best take-home point you made is: please be proactive in bringing up any questions or concerns. Don’t hesitate to have a few touch points with your clinical teams to make sure that your needs are heard, your wishes are met, and your questions are answered as you get started.

Pathak: Thank you so much for being with us today.

My key takeaways from this discussion are that cancer care isn’t just about the treatments you’ll undergo to treat the cancer itself—it’s about preserving the quality of life that happens between appointments.

Today, we heard practical ways to navigate some of the side effects of treatment, but the overarching prescription is communication. The conversation around treatment side effects will rarely fit into a single office visit. So build a relationship with your oncology team.

Identify the symptoms you fear most, the symptoms that are most likely, and the symptoms that are the most dangerous. Set expectations early and schedule follow-up visits to revisit new concerns.

It’s also important to use reputable resources and bring what you learn back to your clinicians.

With ever-expanding therapies and trials aimed at prevention, living well during and after treatment is no longer a luxury—it’s an essential part of cancer care.

Speak up. Stay curious. And let your cancer team know exactly what better looks like for you.

To find out more information about Dr Elizabeth Cathcart-Rake and her work, make sure to check out our show notes.

Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform.

If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected].

This is Dr Neha Pathak for the WebMD Health Discovered Podcast.