Glucocorticoids are often prescribed during a course of chemotherapy and radiation because

Highlights

•

Corticosteroids have multiple indications that recently increase in immuno-oncology.

Corticosteroids have miscellaneous adverse events and should be used with caution.

Corticosteroids do not impact the efficacy of immunotherapy in metastatic patients.

Corticosteroids use may compromise the efficacy of immunotherapy in adjuvant setting.

Prolonged corticosteroid use should be accompanied by ad hoc anti-infectious prophylaxis.

Abstract

Corticosteroids are among the most prescribed drugs in oncology. The indications range from cancer-related indications for refractory symptoms, anti-cancer effects mainly in hematology, supportive measures for cancer-specific treatments and more recently immune-related adverse events induced by modern immunotherapies. In oncological emergencies, corticosteroids are common first-line treatments because of their rapid effect and wide variety of actions. In the last 5 years, with the advance of immune checkpoint inhibitors, corticosteroids are becoming routinely used to manage immune-related adverse effects. Preclinical studies suggested that corticosteroid-induced immunosuppression might dampen the activity of immunotherapies. Prospective clinical studies show that corticosteroid use is a prognostic marker for the cancer outcome in metastatic setting but does not significantly alter the patient's response to immunotherapies per se. Here, we review the state of the art on corticosteroid use in oncology, with a focus on the drugs' potential impact on immunotherapy activity. The comprehensive pharmacological characteristics of corticosteroid drugs, clinical indications, modality of administration and associated precautions for use are discussed in this article.

Keywords

Corticosteroid

Cancer

Immunotherapy

Immune-related adverse event

T-cell lymphocyte

© 2020 Elsevier Ltd. All rights reserved.

Steroids are naturally made by our bodies in small amounts. They help to control many functions including the immune system, reducing inflammation and blood pressure.

Man-made steroids can also be a treatment for many different conditions and diseases. The information on this page is about steroids used in cancer treatment.

The type of steroids you might have as part of your cancer treatment are usually a type called corticosteroids. These are man-made versions of the hormones produced by the adrenal glands just above the kidneys.

Steroids used in cancer treatment include:

• prednisolone
• methylprednisolone
• dexamethasone
• hydrocortisone

What steroids do

Steroids help control many body functions including:

• how your body uses food to produce energy (metabolism)
• keeping the balance of salt and water in your body
• regulating blood pressure
• reducing allergies and inflammation
• controlling mood and behaviour

Why are steroids used in cancer treatment?

There are a number of reasons you might have steroids as part of your cancer treatment.

They can:

• treat the cancer itself
• reduce inflammation
• reduce your body’s immune response, for example after a bone marrow transplant
• help reduce sickness when having chemotherapy
• improve your appetite

You might have them:

• when you are first diagnosed
• before and after surgery
• before and after radiotherapy
• before, during and after chemotherapy treatment
• for an advanced cancer

How you have steroids

The most common ways of taking steroids during cancer treatment are as:

• tablets or liquid (take them after a meal or with milk as they can irritate your stomach)
• an injection into a vein (intravenous)

Make sure you take your steroids according to the instructions your doctor or pharmacist gives you. Take the right dose, not more or less. And don’t stop taking them without talking to your specialist first.

When you have steroids

The dose and length of steroid treatment is different depending on why you're having steroids. 

You might need to take them:

• every other day
• once a day
• several times a day

You should have a steroid card to carry with you all the time if you take steroids for more than 3 weeks. Your doctor or pharmacist might also suggest you wear a medical alert bracelet. This is in case you need treatment in an emergency. It tells the healthcare team you are taking steroids.

Always let your dentist know you're taking steroids.

Stopping steroid treatment

Take your steroids exactly as your health professional has told you.

When you take steroid tablets, the higher amounts in your bloodstream stop your body from making its own supply. Stopping them suddenly can cause serious symptoms such as:

• pale, cold, clammy skin
• sweating
• fast, shallow breathing
• dizziness
• feeling or being sick
• diarrhoea

Never just stop taking your tablets. Cut them down gradually with help and guidance from your doctor or pharmacist.

Tests

You have blood tests before and during your treatment. They check your levels of blood cells and other substances in the blood. They also check how well your liver and kidneys are working.

Side effects

We haven't listed all the side effects. You may get some of them, but it is very unlikely that you will have all of them. You might have some of the side effects at the same time.

How often and how severe the side effects are can vary from person to person. We’re unable to give an idea of the frequency of these side effects because it depends on:

• what other treatment you are having - for example, your side effects could be worse if you are also having other drugs or radiotherapy
• the aim of the steroid treatment (for example to treat your cancer or to help with symptoms)
• if you’re taking steroids short or longer term
• the dose of steroids

When to contact your team

Your doctor or nurse will go through the possible side effects. They will monitor you closely during treatment and check how you are at your appointments. Contact your advice line as soon as possible if:

• you have severe side effects
• your side effects aren’t getting any better
• your side effects are getting worse

Early treatment can help manage side effects better.

You might have one or more of these side effects. They include:

Increased risk of infection

Steroids can hide or change the signs and symptoms of some infections. They might also make it harder for your body to deal with an infection. This means infections are more difficult to diagnose at an early stage.

Symptoms of an infection include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection.

Mood changes

You might feel more anxious and emotional than usual when you take steroids. You may also feel tired and sad for a while after you stop taking them.

Up to 6 out of 100 people (6%) experience serious mental health problems when they take steroids. This includes depression. Let your doctor know if you notice any changes in your emotional or psychological wellbeing. Let your doctor know if you or any family members have ever had depression or manic depression (bipolar disorder).

Rarely, steroids can cause a reaction called steroid induced psychosis. People can become excited, confused and imagine things that aren’t real. This can be frightening, but it goes away when you stop taking the steroids.

Changes in blood sugar levels

You might have regular blood and urine tests to check this. Some people develop diabetes. You might need to have blood sugar lowering treatment. But your sugar levels usually go back to normal shortly after you stop taking steroids.

If you have diabetes already, you might need to check your blood sugar levels more often than usual.

Increased appetite and weight gain

Steroids can increase your appetite. Feeling hungrier can make it difficult to keep your weight down. Your appetite will go back to normal when you stop steroids - but some people need to diet to lose the extra weight.

Talk to your nurse or your dietitian about how to safely control your weight.

Fluid build up

A build up of fluid may cause swelling in your arms, hands, ankles, legs, face and other parts of the body. Contact your doctor if this happens to you.

Difficulty sleeping

It can help to change a few things about when and where you sleep. Try to go to bed and get up at the same time each day and spend some time relaxing before you go to bed. Some light exercise each day may also help.

Try and take your steroids in the morning or around lunchtime.

Indigestion or heartburn

Take your tablets after a meal or with milk as they can irritate your stomach.

Steroids can cause ulcers in the stomach or top part of the small bowel (duodenum).

Tell your doctor or nurse if you have:

• a gnawing or burning pain in your tummy (abdomen)
• indigestion
• heartburn

Changes to your face and appearance (Cushing's syndrome)

You might develop:

• a swollen or puffy face
• stretch marks
• acne
• increased facial hair

You might put on weight around your tummy (abdomen).

This can be quite upsetting. Talk to your doctor or nurse about any of these side effects.

High blood pressure

Tell your doctor or nurse if you have headaches, nosebleeds, blurred or double vision or shortness of breath. Your nurse will check your blood pressure regularly.

Eye problems

You might have eye problems including:

• clouding of the lens of the eye (cataracts)
• glaucoma (damage to an eyesight nerve)
• eye infections
• problems with your vision, such as blurred vision due to increased pressure on the eyesight nerve

Let your doctor or nurse know if you have any problems with your eyes.

Skin changes

Skin changes might include:

• rashes
• skin thinning
• bruising

Wounds might take longer to heal than usual.

Weaker bones

You might have weaker bones due to bone loss (osteoporosis).

Dizziness and loss of balance (vertigo)

You might feel dizzy and you may feel as though the room is spinning. This is vertigo. Let your doctor or nurse know if this happens.

Increased numbers of white blood cells

Steroids can increase the number of white blood cells in your blood. Your doctor might see this on a full blood count test.

Hair changes

You might have more body hair than usual. Your head hair may thin. This is usually not noticeable by other people but can be upsetting.

Heart problems

Steroids can cause severe heart problems if you have had a recent heart attack.

Muscle wasting

Your legs may feel weaker and walking or climbing stairs may be more difficult. You may have aching muscles for a short while after stopping treatment.

Allergic reaction

You might have an allergic reaction to steroids, causing a skin rash, itching, swelling of the lips, face or throat, breathing difficulties, fever and chills. Tell your nurse or doctor immediately if at any time you feel odd or strange.

Headaches

Tell your doctor or nurse if you keep getting headaches. They can give you painkillers to help.

Growth problems in children

Steroids might cause growth problems in babies, children and teenagers. Your child’s doctor will look at the benefits and risks of prescribing high doses of steroids for your child

Low levels of potassium in your blood

Let your doctor or nurse know if you have cramping in your arm or leg muscles, tingling or numbness, palpitations (feeling your heart beat irregularly), or if you feel faint.

A low level of potassium in the blood is called hypokalaemia. You might have blood tests during cancer treatment to check for this. 

Burning or tingling around your bottom

You might have a burning or tingling sensation around your bottom during a steroid injection into a vein (intravenous). It usually goes once the injection finishes. Your nurse will give the injection slowly to try and prevent this.

Epilepsy becoming worse

If you have epilepsy this could become worse when taking steroids.

Blood clots

Blood clots can develop in the deep veins of your body, usually the leg. This is called deep vein thrombosis (DVT). A blood clot can be very serious if it travels to your lungs (pulmonary embolism), although this isn’t common.

Symptoms of a blood clot include:

•    pain, redness and swelling around the area where the clot is and may feel warm to touch
•    breathlessness
•    pain in your chest or upper back – dial 999 if you have chest pain
•    coughing up blood

Tell your doctor immediately or go to A&E if you have any symptoms of a blood clot.

Inflammation of the pancreas

This drug can cause inflammation of the pancreas (pancreatitis). Tell your doctor straight away if you have sudden and severe pain in your tummy (abdomen).

Changes to your periods

Women might have irregular periods, or they stop altogether (amenorrhoea).

Liver changes

You might have liver changes that are usually mild and unlikely to cause symptoms. They usually go back to normal when treatment finishes. You have regular blood tests to check for any changes in the way your liver is working.

Coping with side effects

We have more information about side effects and tips on how to cope with them.

What else do I need to know?

Chicken pox and shingles

Keep away from people who have chicken pox or shingles whilst taking steroids if you have never had these illnesses. They could make you very ill.

If you do come into contact with someone who has them, tell your doctor or nurse straight away.

Other medicines, food and drink

Cancer drugs can interact with some other medicines and herbal products. Tell your doctor or pharmacist about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies.

Pregnancy and contraception

This treatment might harm a baby developing in the womb. Talk to your doctor or nurse about effective contraception before starting your cancer treatment.

Breastfeeding

There is evidence that steroid drugs may come through into your breast milk. Talk about breastfeeding with your doctor. You can make a decision together based on the benefits to you and the possible risks to your baby.

Treatment for other conditions

Always tell other doctors, nurses, pharmacists or dentists that you’re having this treatment if you need treatment for anything else, including teeth problems.

Immunisations

Don’t have immunisations with live vaccines while you’re having treatment and for up to 12 months afterwards. The length of time depends on the treatment you are having. Ask your doctor or pharmacist how long you should avoid live vaccinations.

In the UK, live vaccines include rubella, mumps, measles, BCG, yellow fever and the shingles vaccine (Zostavax).

You might be able to have other vaccinations if you have had:

• small doses of steroids for a short period of time (less than 2 weeks)
• local steroid treatment, such as eye drops or creams

Avoid close contact with people who’ve recently had live vaccines taken by mouth (oral vaccines) such as oral polio or the typhoid vaccine.

This also includes the rotavirus vaccine given to babies. The virus is in the baby’s poo for up to 2 weeks and could make you ill. So, avoid changing their nappies for 2 weeks after their vaccination if possible. Or wear disposable gloves and wash your hands well afterwards.

You should also avoid close contact with children who have had the flu vaccine nasal spray if your immune system is severely weakened. 

More information about this treatment

For further information about this treatment go to the electronic Medicines Compendium (eMC) website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.

iWantGreatCare lets patients leave feedback on their experience of taking a particular drug. The feedback is from individual patients. It is not information, or specialist medical advice, from Cancer Research UK.

This page is due for review. We will update this as soon as possible.