Before Shruti could begin her next round of chemotherapy, an unusual request came from her oncologist: would she be open to talking to someone else about her experience with chemotherapy? She wondered whom her doctor wanted her to meet. At 31, she was one of the youngest people receiving cancer chemotherapy, which she was only getting used to. The last few months had been a whirlwind. She had been holidaying in Maldives when she felt a lump in her breast on self-examination. She pushed it to the back of her mind and did not think much about it till she met a surgeon who wanted to admit her immediately for surgery the next day. Fearing the worst, she and her husband went for a second opinion when their fears were confirmed: this was cancer of the breast. Being the youngest in the family, everyone was supportive and rallied behind her, still in shock that cancer could happen to someone so young. Shruti decided early on not to let the cancer get the better of her. She refused to let it touch her spirit and refused to use a wheelchair to the operation theatre and instead walked in.
Post-surgery was hard for her supportive family; her sister could not hold back her tears as she saw drains where Shruti’s breast used to be. Shruti desperately tried to get all the information she could gather regarding the side effects of chemotherapy. When she Googled about it, the information was endless and overwhelming.
One of the unexpected side effects of chemotherapy was the pain that she felt in her scalp when her hair started falling off. She shaved off her head and her fears of how it would change her were quickly dispelled by her husband, whose first words to her were: ‘You look beautiful’, and her nephew, who thought she looked ‘really cool!’
With time, her hair grew back but what took time to get better was the metallic taste in her mouth, also known by its scientific name: dysgeusia. Dysgeusia is defined variably as ‘an abnormal or impaired sense of taste, an unpleasant alteration of taste sensation, or a distortion or perversion of the sense of taste’ and can be described as a bitter, metallic, salty, or unpleasant taste. This is closely linked to the sense of smell as both can be distorted during cancer therapy. Things can taste too salty, sugary or downright bitter. The taste changes can be measured by testing the five basic tastes: sweet, bitter, sour, salty, and umami (the savouriness of protein-rich foods) with taste strips or an instrument called electrogustometer (that’s a mouthful!!).
However, the exact mechanism by which these changes occur is unknown. Possible causes include destruction of sensory receptor cells, change in the structure of the cells, and disruption of the nerve pathways in the tongue. Normal human taste bud cells turn over every 10 days and the lifespan of receptor cells in the nasal tract is about one week. These are impacted by radiation therapy and some chemotherapy agents which target and kill cells with high turnover rates. Bitter and metallic sensations can also result from the use of chemotherapeutic drugs which have compounds that are bitter and can enter the mouth through blood vessels in the posterior of the tongue—or odour receptor cells. Approximately half of patients undergoing chemotherapy only can experience dysgeusia while 66.5 per cent of patients on radiotherapy alone and 76 per cent of patients who received combined RT and CT experienced changes.
While there is no specific therapy that improves outcomes, the following strategies might help improve quality of life during and after therapy:
•• It is important to drink plenty of liquids. Try using herbs or fruits to flavour water.
•• Oral hygiene is very important. Brush your teeth and tongue after every meal and seek dental care before therapy, especially radiation for head and neck cancer.
•• Freeze fresh fruits (grapes, watermelons or oranges) and snack on them.
•• If you have a bad taste in the mouth, try sugar-free gum, mints or lemon drops.
•• If you have a metallic taste in your mouth, avoid metallic silverware and eat in glass cups and plates and use plastic cutlery.
•• Try eating foods cold or at room temperature.
•• If foods taste salty or bitter, try added sweeteners like honey. If they taste too sweet, increase salty or tart flavours by adding lemon juice, vinegar, salt, and try adding citrusy foods to your overall diet.
•• If food tastes bland, marinate foods to improve their flavour or add spices.
•• If red meat starts tasting strange, switch to other high-protein foods such as chicken, eggs or fish.
•• Strong smells can be intolerable, so try and cover beverages with a cap and sip through a straw to avoid the smell. Shruti struggled with strong smells and food tasted too sugary.
To counter this she switched to tangy foods. Golgappas and papdi chaat were her favourite comfort foods and she ate light meals and snacked a lot during chemotherapy. It was in the middle of one of these sessions when she met Neeti and a sisterhood blossomed.
Neeti is one of those people who can light up any room she walks into. She has a carefree, positive vibe about her and is always ready with a quick smile. Just like Shruti, she was only 31 when she felt a lump in her breast. Dismissing it as nothing, she slept over it and did not seek medical advice for two months. When she did go to a doctor, she had a sense of dread that this was not normal, which was confirmed when she was diagnosed with cancer. Her main memory of her surgery is how she and her husband were lay on the hospital bed watching How I Met Your Mother, oblivious to the world and the upcoming surgery, just holding on to each other.
After the surgery came the chemotherapy, which she dreaded as her only previous exposure to it was the portrayal of cancer patients as emaciated and sick people in Bollywood movies, most of whom do not make it. (Just like Rajesh Khanna in Anand. If you have always wondered ‘lymphosarcoma’ of the intestine does not exist, it is a combination of two different cancers: lymphoma and sarcoma.)
Complicating matters, she was a very sickly child and was very nauseated during pregnancy. Unfortunately, her prediction turned out to be accurate and nausea hit her hard.
Nausea and vomiting are triggered when impulses from a zone in the brain called the chemoreceptor trigger zone, and the throat and gut send a signal to the vomiting centre in the brain that something is not right. In response, the centre sends a signal to different areas in the body including the stomach, salivary centre, and nerves, resulting in vomiting. Cancer therapy causes vomiting by activating neurotransmitters. A neurotransmitter is a type of chemical messenger which transmits signals from one neuron (nerve cell) to another ‘target’ neuron, muscle cell, or gland cell. Subsequently, their receptors located in the chemoreceptor trigger zone, the gut and the vomiting centre are also triggered.
Factors that can increase the risk for nausea and vomiting include being female, younger than 50 years of age, a history of morning sickness with past pregnancy, constipation, and if one has a tumor in the gastrointestinal tract, liver, or brain. Neeti met a number of these criteria and was at high risk for chemotherapy-induced nausea and vomiting.
The nausea and vomiting can be classified into different types: acute, that happens within 24 hours after treatment starts; and delayed, which happens more than 24 hours after chemotherapy.
Patients might also get anticipatory nausea and vomiting which can occur if a patient has had nausea and vomiting after an earlier chemotherapy session. This usually begins after the third or fourth treatment and is triggered by any reminder of previous times whenthey got sick—like the smells, sights, and sounds of the treatment room. In my practice, I have had several patients who get nauseous just from entering the chemotherapy suite or from the night before, anticipating chemotherapy the next day. Over the past decades, there has been an improvement in the control of therapy-related vomiting with the advent of several new medicines targeting active neurotransmitters in the brain and in the gut. However, there are also non-pharmacologic therapies like self-hypnosis that can potentially be of help.
Although severe vomiting needs medication, a few nutritional remedies may come in handy for patients with queasiness accompanied by little or no vomiting:
•• Eat five to six small meals a day and avoid keeping the stomach completely empty.
•• Avoid greasy and high-fat foods and consume cool, light foods which may also help reduce nauseous feelings.
•• Try sipping on water and other clear, cold liquids. Sip slowly. Try popsicles.
•• Avoid strong food odours and try to remain outside the kitchen during food preparation if possible.
•• Try natural ginger tea or ginger candy. The major pharmacological activity of ginger appears to be attributed to gingerols and shogaols, biologically active secondary metabolites of ginger rhizome. Various laboratory-based and clinical studies have also shown ginger to possess antivomiting effects; however, the exact mechanism for antiemeticeffect is not known.
Neeti had a hard time during chemotherapy but stuck it out with the love and support of her family. She tried licking a lime with salt on it to help with her nausea. Khichdi was her go-to food. The chemotherapy impacted her olfactory senses and she can no longer bear the smell of hand sanitizer. But with all struggles in life comes a silver lining: Shruti and Neeti stayed friends during and after their chemotherapy and still meet regularly. They have joined forces to help other women diagnosed with breast cancer. The Sisterhood is alive, well and thriving.
Excerpted with permission from Food Matters: The Role Your Diet Plays In The Fight Against Cancer by Dr Shubham Pant, published in India by HarperCollins Publishers (193 pages; ₹299)