Chemotherapy Treatment and Your Blood Counts This booklet has been developed to help you better understand the chemotherapy treatment you are about to receive. Here at Moffitt, we firmly believe that we can avoid unnecessary fear and anxiety through a better understanding of what is happening to you and why. Your doctor or nurse will review this information with you and answer any questions you may have. Chemotherapy Treatment: There are four major forms of cancer treatment, which are used alone or in combination with each other to remove or destroy cancer cells. These treatments include: 1. 2. 3. 4. Surgery Radiation Chemotherapy Biotherapy The following discusses chemotherapy in the treatment of cancer. Through studies, we have learned that chemotherapy drugs affect certain types of cancer. We have also learned that chemotherapy drugs have side effects. Not all chemotherapy drugs have the same side effects, and the severity of those side effects is different with each drug and dosage. The drug information handout given to you will explain the typical or expected side effects of the drugs you will be taking. An important fact to remember is that chemotherapy affects each person differently. There is no way to predict how you as an individual will react. It is also important to remember that when side effects do occur, it does not mean that your cancer is worse or growing. The severity of side effects does not necessarily relate to the effect chemotherapy has on your cancer. Chemotherapy is the treatment of choice for some forms of cancer. Its purpose is to destroy unhealthy cells. The goal is to rid the body and the bone marrow of the unhealthy cells. In doing this, however, good cells as well as bad cells are destroyed. Chemotherapy drugs do not have the ability to seek and destroy only unhealthy cells. Due to this cellular destruction, your immune system, which helps fight infection, may not work as well as it normally would. The Immune System: Normally, our bodies have a built-in system of defense for fighting infection. These infection fighters are called white blood cells and are made in the bone marrow. They travel through the blood stream attaching themselves to germs and destroying them. There are many types of germs, or microorganisms, around us at all time. These can be in the form of: • Bacteria • Viruses • Fungi Page 1 of 7 • Yeasts We come into contact with germs through: • objects we touch • the air • our food and water • other people We cannot escape them, yet not all germs can hurt us. Some germs live in certain parts of our body and serve a purpose without causing us to be sick or infected. For example, we have a germ that normally lives in our intestinal tract and which helps us digest food. However, if that germ invades our urinary tract, frequently through improper hygiene, we can develop infection. This is when our white blood cells, or infection fighters, go to work to destroy the intruding organism and restore a sense of balance. Your Blood Counts: About 7 to 14 days after receiving your chemotherapy treatment, your blood counts may begin to fall. Nadir is the word that we use to define the point in time when your blood cell counts are at their lowest. The timing and the severity of the fall in your blood counts depend on: • the chemotherapy drugs and the dosages used for your treatment • your general state of health • your nutritional state Not all chemotherapy drugs wipe out your blood counts. However, in some forms of cancer, like leukemia, we expect a severe fall in the blood cell counts. When we look at our blood cell counts, we look at three main types of cells, each with a specific job to do. • white blood cells or WBCs • red blood cells or RBCs • platelets White Blood Cells (WBCs) The main functions of white blood cells, or leukocytes, are to fight infection; defend the body by destroying foreign organisms; and to produce, transport, and/or distribute antibodies throughout the immune system. Simply stated, they are the infection fighters. However, there are different types of white blood cells. All white blood cells function as a part of the immune system, but not all white blood cells fight active infection. The true infection fighters are the neutrophils, also called segs or polys, and they are normally the most abundant type of white blood cell. After chemotherapy, the number of neutrophils may be lowered through destruction and/or the inability of the bone marrow to make them. If your neutrophils fall below an acceptable level, you would be at high risk for infection, or neutropenic. You would then require special precautions, called neutropenic precautions, to help you avoid developing an infection. These Page 2 of 7 precautions are described later in this booklet. Because a fever is usually the first sign of an infection, you should call your doctor if your temperature is at or above 100.5oF, or if you have shaking chills. This is not the time to retreat to your bed armed with a box of tissues and a bowl of chicken soup. Infection in a person with a low white blood cell count is a very serious and potentially life threatening situation. CALL YOUR DOCTOR! Red Blood Cells (RBCs) The main function of red blood cells, or erythrocytes, is to carry oxygen from the lungs to the body tissues and to carry carbon dioxide from the body tissues to the lungs. This process is achieved by means of the hemoglobin in the red blood cells. Hemoglobin is the main component of red blood cells. After receiving chemotherapy, your red blood cells and hemoglobin may be decreased through destruction and/or the inability of the bone marrow to make these cells. You may look pale, feel overly tired and weak, and may even become short of breath. The word to describe how you may feel is anemic. These symptoms may occur because the hemoglobin that carries the oxygen needed for your tissues, organs, and muscles has been depleted. If your hemoglobin falls too low, blood transfusions may be necessary. Vitamins and iron supplements may not make you feel better and should only be taken with your doctor’s advice. Platelets Platelets, or thrombocytes, are the smallest of the formed elements in the blood and are vital for blood clotting. A decrease in the amount of platelets in the blood due to destruction and/or the inability of the bone marrow to make them can lead to bleeding. After chemotherapy, you may notice that you have a tendency to bruise more easily, or a minor cut may take much longer to stop bleeding. You may see tiny, pin-like red dots on your ankles, lower legs and arms. These red dots are called petechiae. You may also notice that your gums may bleed after brushing your teeth. Chances are you have thrombocytopenia, or a low platelet count. A severely low platelet count is a serious and potentially life-threatening situation because bleeding can also occur in your vital organs. CALL YOUR DOCTOR! Play it safe: It is not unusual, especially for leukemia patients, to have a fall in all three blood counts: WBCs, RBCs, and platelets. When all three cell counts fall below an acceptable level, we call this pancytopenia. Ask your doctor or nurse when you can expect your blood counts to be low so you can be prepared. The following is a list of things you can do to help weather the low blood count storm: ! When your white cell count is low, or expected to be low, resist infections by avoiding crowds and people you know who have a cold or flu. Do not do any gardening or clean the cat box, birdcage, or fish tank. Page 3 of 7 ! Since fever is usually the first sign of infection, you should take your temperature every day between 4:00 p.m. and 8:00 p.m. Temperatures have a tendency to go up in the evening. Also take your temperature at any time you feel feverish or develop shaking chills. Call your doctor if your temperature is at or above, 100.5° F. ! Get enough rest and eat plenty of nutritious food to avoid being overly tired and weak, which can occur from a low red cell count. ! Practice safety measures by wearing protective items when needed (i.e. oven mitts) to avoid the bleeding or bruising that can occur from a low platelet count. Also, wear shoes or slippers when out of bed, use an electric razor, and avoid rough exercise, trauma, and falls. Do not take any aspirin or products containing aspirin unless prescribed by your doctor. Aspirin can increase the chances of bleeding. ! Get in the habit of performing good hygiene and mouth care. Salt water and salt and baking soda mixtures are excellent forms of mouth rinses and should be used after every meal and before sleep. Avoid commercial mouthwashes because many contain alcohol, which can dry your mouth. Use a soft-bristled toothbrush to avoid gum bleeding and, unless you have practiced it on a daily basis, do not floss. Use ointment on your lips to prevent chapping and cracking. ! Do not use enemas, rectal suppositories, or rectally inserted medications for hemorrhoid problems. Rectal bleeding and infections may occur. ! Drink plenty of fluids, at least 2 quarts a day, unless you have been instructed otherwise. When should I call my doctor? You should call your doctor if you experience any of the following signs or symptoms: • shaking chills and fever • unusual pain anywhere • severe diarrhea or constipation • bloody urine or stool (bowel movement) • shortness of breath • severe weakness • severe nausea and/or vomiting • bleeding or bruising • rash or other allergic reactions • a cut or sore that will not heal • flu-like symptoms, cough or sore throat • burning or pain when urinating (passing your water) Neutropenic precautions: A low white cell count with fever may require hospitalization and a course of intravenous Page 4 of 7 antibiotics. While in the hospital, the staff will place you on neutropenic precautions to protect you from possible infections. The following measures will be instituted: 1. Always wash your hands thoroughly before and after going to the bathroom/using the bedside commode and before and after eating/drinking. All staff members and visitors will thoroughly wash their hands before entering your room. 2. No live flowers or plants will be allowed in your room. Stagnant water and dirt carry germs that can infect you. 3. You may eat fresh fruits and vegetables as long as they are not bruised, aged or brown. They must be washed for 30-60 seconds under running water before eating them. This includes thick-skinned fruits that are peeled before eaten, like bananas and oranges. For more information please refer to the Moffitt publication Diet Guidelines for Patients with Decreased Immunity. 4. Do not eat raw fish or meat. They can carry germs. 5. The door to your room will be kept closed at all times. Visitors or other patients passing by your room may have a cold, flu, or infection that may enter your room through the air. 6. You will have to stay in your room. If you must leave the room, it will be necessary for you to wear a mask to avoid possible airborne germs. (Masks should be changed every 30 minutes). Avoid other patients walking on the nursing unit. It is better to go outside the building if possible. 7. Your family and friends will be instructed to limit their visits. Children are permitted to visit at Moffitt Cancer Center, but any child (or adult) who has been immunized (had vaccinations) within the last 10 days, cannot visit you. Also children frequently carry infections that may not slow them down but can infect you. Please use caution about visitors. Nursing care: Besides the measures to protect you from infection, your nurses will also: ! Check the inside of your mouth for lesions and infections, and provide you with oral rinses to be used after each meal and before sleep. If you have mouth ulcers, thrush, or difficulty swallowing, your doctor will order special medications and special rinses. ! Inspect your rectal area for lesions, tears, bleeding, and hemorrhoids. Your doctor may order external medications, special washes, and sitz baths if necessary. Rectal temperatures, enemas, rectal medications and manipulations will not be performed due to the risk of infection and bleeding. ! Check your vital signs (blood pressure, pulse, temperature) every 4 hours - more often if necessary. ! Observe your IV (intravenous) site closely for tenderness, redness and bleeding. Your Page 5 of 7 IV will be changed every 3 days to avoid possible infection and inflammation of the vein. However, if a problem arises, your IV will be changed when necessary. Other procedures will be followed if you have a Port-a-Cath, Hickman or Groshong catheter in place. ! Administer medications. Antibiotics ordered by your doctor are the first line of defense against germs. Frequently, two or three different types of antibiotics are ordered to cover different types of germs and these are usually given IV. It is vital that you receive your antibiotics at the scheduled times to maintain a certain blood level. Therefore, it is not unusual for your nurse to administer platelets and blood transfusions in between scheduled antibiotics. ! Draw daily blood work to check the status of your blood counts. When ordered by your doctor, blood is also drawn to check the blood levels of certain antibiotics. The purpose of these drug levels is to make sure that you are receiving the necessary dosage of the antibiotics, not too much and not too little. If you have a Port-a-Cath, Hickman, or Groshong catheter, the nurses will draw your blood through it. However, blood for some types of blood tests cannot be drawn through these lines, and it will be necessary for the lab to take blood from your arm. Although we do all we can to protect you, it is not uncommon for you to still develop an infection. We discussed before how we have germs in certain parts of our body. They are there normally and serve a purpose. The reason that these normal germs do not Arise up in a person with normal blood counts and cause infections is because the white blood cells keep them at a controllable level. When chemotherapy depletes the white blood cells, these normal germs can overgrow and cause us to infect ourselves. When your temperature rises above an acceptable level, your doctor may order blood to be drawn for blood cultures. The purpose of these cultures is to find out what germs, if any, are causing the fever and chills so the best antibiotic for killing that germ is ordered. The bright side: By now, the burning question in your mind is probably, “will my blood counts ever return to normal?” Depending on the type of cancer that you have, the chemotherapy drugs given to you, and the dosage of those chemotherapy drugs, your blood counts usually begin to rise a week to 10 days after nadir. Remember, nadir is the time when your blood counts are at their lowest. Those with leukemia may have a longer period of neutropenia, or low blood cell count. Infections are harder to prevent in leukemia patients and the treatments for infections are more involved. The important thing to remember is that no two people are alike, and chemotherapy will not affect everyone in the same way. Therefore, the time it takes for your bone marrow to recuperate and begin making the normal levels of white cells, red cells and platelets, depends on you and time. Newly developed medications to promote bone marrow production of certain blood cells can be used for some patients. Check with your doctor or nurse to see if these medications are right for you. Page 6 of 7 Conclusion: This booklet has been developed to help you understand what is happening to you as a result of chemotherapy. It still may not give you all the answers, so please use the following space to jot down any questions you may have for your doctor or nurse. The telephone numbers of your doctors and nurses are also listed below: Outpatient treatment room nurse: _______________________ Program/clinic phone number: ________________________ After hours phone number: ___________________________ Notes: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Produced by the Patient Education Department 1/ 2012. H. LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTE, AN NCI COMPREHENSIVE CANCER CENTER – TAMPA, FL. 1888-MOFFITT © 2012 H. LEE MOFFITT CANCER CENTER AND RESEARCH INSTITUTE, INC. All rights reserved Page 7 of 7