Sickness (nausea and vomiting)

How might sickness affect me?

Sickness can affect your physical health, for example, leading to dehydration and a lack of nutrients. It can also have an effect on your emotional wellbeing.

Sickness can be a side effect of some lymphoma treatments, including chemotherapy, radiotherapy and some targeted drugs.

You might experience:

• feeling sick (nausea)
• being sick (vomiting)
• retching (dry heaves) - automatic movements of the stomach (abdominal) muscles that happens when you are sick - but without actually being sick.

Speak to your medical team for help to manage sickness. As well as antiemetic medication, there are self-help strategies and other non-drug approaches you can use to help manage sickness.

You might also hear the following words:

• acute sickness – which starts soon after treatment
• delayed sickness – which starts 24 hours after treatment
• anticipatory sickness – which starts before treatment
• breakthrough sickness – which usually starts within 5 days of having treatment
• refractory sickness – which doesn’t improve with medication.

Acute sickness

Acute sickness can start very soon (within minutes or hours) after treatment. It usually goes away within 24 hours of having treatment.

Acute sickness is more common with chemotherapy than with other treatments. However, the likelihood of acute sickness depends on drug factors, such as the specific drugs you’re given, the dose, how often you have treatment, and how you have it, such as by drip (infusion). 

As well as drug factors, there are a number of factors that can also make acute sickness more likely, such as:

• sickness after previous treatments
• a history of sickness (for example motion sickness or pregnancy-related sickness)
• being dehydrated
• not having enough nutrients
• being female
• being under 50 years old.

Speak to your medical team if you are concerned about sickness and would like to ask about anti-sickness medication (antiemetics).

Chemotherapy increases sensitivity to alcohol. You might therefore be more prone to sickness after drinking it. Also, alcohol can slow down the breakdown process of chemotherapy in your body, so the drugs stay in your system for more time than they might otherwise – this can make chemotherapy-related sickness go on for longer.

Charlotte Bloodworth, Lead Haematology Specialist Nurse

Delayed sickness

Delayed (late) sickness starts after 24 hours of having treatment. It is more common with some types of chemotherapy drugs (for example cisplatin, cyclophosphamide, doxorubicin and ifosfamide) given at higher doses on two or more days in a row.

Delayed sickness usually peaks after around 2 to 3 days and goes away within about a week. Taking antiemetics for a few days after treatment can be helpful in preventing or easing sickness.

Anticipatory nausea

Anticipatory nausea happens before (in anticipation of) treatment. It can happen if your brain makes a connection between having treatment and feeling sick. For example, you might start to feel sick just thinking about going to the hospital. The hospital environment, including how it looks and smells could trigger a part of the brain called the vomiting centre. This then leads to sickness. 

Typically, if anticipatory nausea happens, it starts after 3 or 4 cycles of chemotherapy.

Approaches to anticipatory nausea that help some people include behavioural strategies and complementary therapies. Because of the ‘thinking’ (psychological) aspect of anticipatory nausea, anti-sickness (antiemetic) medication usually doesn’t help. 

Speak to your medical team if you experience anticipatory nausea so that they can support you to manage it.

Breakthrough sickness

Breakthrough sickness usually starts within 5 days of treatment, even if you’ve taken an antiemetic to try to prevent it. Usually, making changes to your antiemetic medication can treat breakthrough sickness. For example, your medical team might change the type or dose of your treatment. Or they might add another type of drug to your prescription. 

Refractory sickness

Rarely, people have sickness that doesn’t get better with antiemetics (refractory sickness). Your medical team might refer you to doctors who specialise in controlling symptoms (palliative care).

As well as any medication you are prescribed, you might also find behavioural strategies or complementary therapy helpful.

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Chemotherapy and sickness

Some chemotherapy drugs are more likely to cause sickness than others. Your medical team will talk to you about how likely you are to experience sickness. They base this on your particular treatment and on individual factors. They can also suggest ways of helping to prevent and manage sickness, which might include anti-sickness medication and non-drug treatments.

I was treated with chemotherapy and radiotherapy for Hodgkin lymphoma and experienced nausea and sickness. I sometimes thought this must be how you’re meant to feel, but often support is available and I had medication that helped. Talk to your medical team if you have any symptoms you are struggling with. There is usually something they can do to alleviate the sickness.

Andrea, affected by nausea and vomiting

As a rough guide, we outline the risk based on different types of chemotherapy:

There is a high risk of sickness from the following chemotherapy drugs:

• carmustine 
• cyclophosphamide
• cisplatin
• combinations of drugs (regimens) that contain both cyclophosphamide and doxorubicin.

There is a moderate risk of sickness from the following drugs:

• bendamustine
• carboplatin 
• doxorubicin
• low-dose cyclophosphamide 
• high-dose cytarabine 
• ifosfamide
• oxaliplatin.

There is a low risk of sickness from the following drugs: 

• low-dose cytarabine
• etoposide 
• gemcitabine 
• methotrexate
• mitoxantrone.

There is a very low risk of sickness from the following drugs:

• bleomycin
• fludarabine 
• vinblastine 
• vincristine.

On Macmillan Cancer Support’s online tool, you can search for chemotherapy drugs and find out more about them and their side effects.

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Radiotherapy and sickness

Sickness can happen when radiotherapy triggers signals to the vomiting centre in your brain. Feeling or being sick can start within a few hours to a few days of having radiotherapy. It usually lasts for up to a couple of weeks.

Whether or not you experience sickness as a side effect of radiotherapy depends on factors including:

• which area(s) of your body receive radiation
• the size of the area(s) that radiation goes to
• how much radiation you have (dose) – in general, the larger the dose, the higher the risk of side effects
• having another type of treatment such as chemotherapy or a targeted drug, as well as radiotherapy.

As a rough guide, we outline the risk based on where you receive radiotherapy:

There is a high risk of sickness from radiotherapy given to the following areas:

• stomach
• gastrointestinal tract
• liver
• brain, at a higher dose
• whole body (known as total body irradiation or TBI).

There is a medium risk of sickness from radiotherapy to the following areas:

• upper tummy (abdomen) 
• brain, at a lower dose
• spine.

There is a low risk of sickness from radiotherapy to the following areas: 

• head
• neck
• chest
• pelvis.

There is a very low risk of sickness from radiotherapy to the following areas: 

• a breast or breasts
• arms
• legs.

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Targeted drugs and sickness

In general, targeted drugs give fewer side effects than radiotherapy and chemotherapy.

As a rough guide, we outline the risk based on which targeted drug you receive:

There is a low risk of sickness from the following drugs: 

• belinostat
• brentuximab vedotin 
• bortezomib 
• temsirloimus.

There is a very low risk of sickness from the following drugs:

• rituximab
• nivolumab
• obinutuzumab
• ofatumumab
• pembrolizumab.

On Macmillan Cancer Support’s online tool, you can search for chemotherapy drugs and find out more about them and their side effects.

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Non-drug treatments

As well as antiemetic medication, there are self-help strategies and other non-drug approaches you can use to help manage sickness. We give some examples below. We also have tips to help with eating and drinking if you experience sickness.

Self-help strategies

There are various techniques you could try that might help to manage sickness. These include identifying triggers, distraction, imagery and progressive muscle relaxation (PMR). You might find it helps to get support from a trained professional before you start to use the techniques on your own – ask your clinical nurse specialist if they could help you to access or signpost you.

Identify triggers

Try to recognise any triggers to your nausea. For example, certain foods, smells, activities or surroundings might act as triggers for you. It can help to avoid or limit your contact with these, if this is possible. For example, if a strong-smelling deodorant makes you feel sick, switch to a fragrance-free one. You might also be able to ask friends, family and colleagues not to wear strong fragrances when they’re with you.

Distraction

Think about how you could take your attention away from feeling sick. For example, you could watch a film, listen to music or play a game. Children might find stories helpful, particularly if they’re involved in creating them or they feature in it. 

The mental health charity Mind has suggestions to help with distraction.

Imagery

Imagery can help with distraction and relaxation. Imagine things in as much detail as possible. For example, you might imagine walking along a beach, and the sights and sounds you would experience. You could use imagery to feel calmer before or during treatment, as well as if you feel sick after treatment.

Guided imagery (or guided meditation) involves making use of all of the senses available to you. You imagine being somewhere you’d find calming, such as a forest. You then imagine what you might see, smell taste, hear or touch so that it feels as real as possible. You might also play music or other sounds to help.

The Headspace website has more information about guided imagery. There are also lots of free resources online to help with imagery techniques. For example, Royal Brompton and Harefield hospitals have some audio (MP3) guided visualisations you can listen to.

Progressive muscle relaxation (PMR)

Progressive muscle relaxation (PMR) aims to release tension and bring about relaxation. You do this through tensing and relaxing different muscles. For example, you could focus on tensing the muscles in your legs as you breathe in, hold, and then let this go as you breathe out. Repeat this with other groups of muscles, for example, in your toes, shoulders, jaw and arms. 

You could try using PMR, for example, when you are going for treatment or if you feel sick afterwards.

Cognitive restructuring

Cognitive restructuring is a type of cognitive behavioural therapy (CBT). It aims to make changes to (restructure) distressing thoughts, feelings and beliefs about your treatment. 

CBT can be particularly helpful in managing anticipatory nausea. A trained therapist can support you with cognitive restructuring, adapting your thoughts so that you can respond to them in different ways. The NHS website and the British Association for Behavioural and Cognitive Psychotherapies (BABCP) have more information about CBT.

Complementary therapy

Some people find that complementary therapies help to reduce feelings of sickness. Examples include hypnosis, massage, acupuncture or acupressure (including acupressure bands). Speak to your medical team before trying a complementary therapy so that they can give you advice about what is safe for you and any safety precautions to take.

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Anti-sickness medication (antiemetics)

There are a number of types of antiemetics (medicines that are used to control sickness that work in different ways). 

Before you start treatment, your medical team considers how likely you are to experience sickness. They work out whether to give you antiemetics to prevent sickness and, if so, which ones. To do this, they look at your treatment plan as well as any other factors that might increase your chances of sickness. They work out how much you are likely to need, how frequently, and how to have it.

You might have antiemetics as a tablet (orally), injection, or as a combination of the two. If you are unable to keep any of your medication down, your doctor could prescribe medicine as an injection, a drip or as a tablet that you put into your bottom (a suppository). 

For the highest chances of antiemetics being effective, it’s important to take your medication exactly as it’s prescribed to you. Don’t stop taking it without speaking to a member of your medical team first, even if you no longer feel sick.

If you experience side effects such as diarrhoea or constipation from taking one type of antiemetic, you could ask to try a different one. You might find it helps to keep a diary of when you’re feeling sick. You could show it to your doctor to help them tailor antiemetic medication to you. There are also non-drug treatments that you might want to speak to your medical team about.

Types of antiemetics

There are lots of different types of antiemetics. You might have one or a combination of two or more. 

Examples of antiemetics include:

• dexamethasone 
• serotonin blockers 
• other types of antiemetics.

Dexamethasone

Dexamethasone is a common type of steroid. It can be particularly effective in treating refractory nausea. 

Serotonin blockers 

Serotonin is a hormone your body makes. It has many roles in the body, including affecting digestion.

Serotonin blockers work by blocking messages to the vomiting centre in your brain. 

Other types of antiemetics

Cancer Research UK has information about antiemetics, including other types such as anti-anxiety drugs and antihistamines, which can be used to help manage sickness.

Cannabis

Very rarely, specialist doctors can prescribe medical cannabis. This is on a case-by-case basis, if other treatments aren’t effective, and if it is safe for you. It is not safe to use home-grown or illegally bought cannabis.

What can I do if antiemetics don’t work for me?

Speak to your medical team so that they can adjust your antiemetic medication – if one type doesn’t work for you, another one might. They can also support you to consider any non-drug treatments that might be helpful to you. 

Speak to your medical team about the safety and suitability of any approaches you are thinking of taking to try to help manage your sickness. This includes, for example, complementary therapies or making changes to your diet. 

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How can I eat and drink if I experience sickness?

Talk to your medical team if you experience treatment-related sickness and you are finding it difficult to eat and drink. We give some tips below that you might find helpful.

We have separate information about diet and nutrition that you might also be interested in.

Limit food smells

For some people, even the smell of food could makes them feel sick. You could:

• ask other people to prepare your meals for you
• cook food in a microwave to minimise its smell
• eat your food at room temperature or cold – hot foods tend to give off stronger smells than cooler foods
• avoid or limit foods that have very strong smells.

Meals and snacks

Even if eating is difficult, hunger can make sickness worse. It is also important to get the nutrients you need.

• Plan the best times to eat and drink based on when you generally feel least sick. 
• Eat food you like – however, it can be good to avoid your most favourite foods in case you start to associate them with being sick.
• Quite plain and non-greasy foods can be good choices. For example, toast, crackers, breadsticks, pretzels, rice, pasta, potatoes or noodles.
• If you feel sick when you wake up, eat a cracker or a dry biscuit before you get up.
• Try adding ginger to your diet. For example, ginger beer, ginger tea, ginger biscuits, ginger cake or root ginger. Some people find this helps to ease sickness.
• Try eating five or six small meals a day instead of three large meals. A full plate can feel overwhelming.
• If you feel very full or bloated after eating, avoid lying down too soon after eating.

Drinks

Your body needs water to function well. Good hydration can also help you to cope better with treatment. It’s important to replace lost fluids if you are sick (vomit).

• Drink slowly throughout the day – you could carry a bottle of drink with you. There are also some apps available that are free to download to help you find drinking water supplies to fill up a bottle if you are out and about.
• Choose cool, citrus flavoured, fizzy drinks. These tend to be more soothing than still or hot drinks and can help to settle your stomach.
• Sip drinks slowly through a straw if your treatment affects your sense of taste. This bypasses some of your taste buds.
• Only drink small amounts at mealtimes to avoid feeling too full.

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Frequently asked questions about sickness and lymphoma

Below are some questions people often ask about sickness and lymphoma. Speak to your medical team for advice specific to your situation.

How does lymphoma treatment cause sickness?

Some treatments can activate part of the brain called the chemoreceptor trigger zone (CTZ). The CTZ sends signals to another part of the brain that controls feelings of nausea (feeling sick) and vomiting (being sick). This is known as the vomiting centre.

How likely am I to experience sickness?

Whether or not you experience sickness depends on lots of factors, including:

• where in your body your lymphoma is: sickness is more common if lymphoma affects your digestive tract, liver or central nervous system (brain, nerves and spinal cord)
• your treatment: the type and dose you have
• your age: sickness is more common in people who are under 50
• your sex: females are more likely to experience sickness
• whether you are prone to sickness, for example, if you have experienced travel (motion) sickness or morning sickness during pregnancy
• having experienced sickness during previous rounds of treatment
• other illnesses or health conditions such as diabetes, vertigo and a history of migraines
• other medication you might be taking, for example, sickness can be a side effect of some pain relief medications and antibiotics
• psychological or emotional factors such as feeling anxious, particularly in the case of anticipatory nausea.

How do antiemetics (anti-sickness) medicines work?

Antiemetics work in different ways. For example, they can:

• disrupt the signal pathway to the vomiting centre in your brain
• directly affect your stomach and speed up the movement of food into your bowel, which lowers the likelihood of sickness
• work in combination, with one given to boost the effectiveness of another.

Can medical cannabis help with sickness?

In the UK, cannabis and products made from cannabis (such as cannabidiol or ‘CBD’) are not licensed to treat nausea or vomiting caused by chemotherapy. Home-grown cannabis and cannabis bought illegally contain lots of active chemicals in unpredictable amounts, as well as bacteria and fungus, which can cause chest infections. It is not safe to use instead of medical cannabis. This is because you can’t control the dose you are taking and it could be contaminated with other chemicals. 

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