Blood Problems
Low blood cell counts
Low blood cell counts are a common and sometimes serious problem for patients receiving chemotherapy and/or radiation therapy. Targeted and hormonal therapies are less likely to cause this complication. The three basic groups of cells that are affected are the white blood cells, red blood cells and platelets. These cells are produced in the bone marrow and are regularly released into the blood stream as needed by the body. White blood cells and platelets have a shorter lifespan than red blood cells and replicate at a faster rate. Therefore, they are more susceptible to the effects of chemotherapy than red blood cells. Red blood cells have a longer lifespan and can tolerate the insult of chemotherapy longer than white blood cells and platelets. Your physician and nurse will carefully monitor your blood cells throughout treatment using routine lab work called a CBC (complete blood count). Your CBC will alert us to decreases in white blood cells, red blood cells and platelets.
Low red cell count, anemia
Low red blood cells, or anemia, is commonly found in patients with cancer and may be a result of multiple causes. It can be caused by cancer itself, blood loss, iron deficiency, chemotherapy or radiation treatments or a combination of these and other factors.
Red blood cells carry hemoglobin, which attaches to oxygen and carries it to different parts of the body. Drop in red cell number and/or amount of hemoglobin they carry decreases oxygen supply to tissues and organs. Anemia can make you feel tired; if it is severe, you may experience difficulty in thinking, feel dizzy, experience rapid heart beats, shortness of breath or have difficulty staying warm.
Treatment of anemia depends on its cause. If it is a result of acute or chronic bleeding, we will attempt to find its source and stop it. We will also replace blood and/or iron you have lost. If your anemia is related to your chemotherapy/radiation therapy, it can be treated with the use of supportative medications such as Aranesp or Procrit. These are growth factors similar to the ones our own bodies’ produce to boost production of red blood cells. Your doctor will discuss the pros and cons of using these medications with you if the need for them arises. You may read more about these medications in our Supportative care agents section Tab.
Strategies for coping with the anemia and its symptoms:
Eat small, nutritionally balanced meals every 2-3 hours. Include foods that are high in iron such as red meat, and green leafy vegetables.
Be as active as you can. A regular routine of light exercise performed for 15-30 minutes daily can help.
Take short naps. Determine which times of the day you have more energy and use these time periods to perform tasks that require more energy.
It might be beneficial to use supportative medications such as Iron, Aranesp or Procrit as indicated by your physician. You can find additional information about these medications in the section on Supportive Care Agents (Tab to Supportive care agents – Growth Factors)
If red blood cells become very low, you may require a transfusion of red blood cells. Your physician or nurse will discuss this with you in greater detail if it becomes necessary.
Low white cell count, Fever, Infection
White blood cells are responsible for protecting your body from infection. Neutrophils, one of several types of white blood cells, are especially important because they are the body’s first line of defense. Chemotherapy and/or radiation therapy often lead to a decrease in the total number of white blood cells (leukopenia) and neutrophils (neutropenia). Although it varies from therapy to therapy, your white blood cells will generally reach their lowest point (nadir) seven to fourteen days after treatment. At that time white cell counts will begin rising but may not rise all the way up to pre-treatment levels. We will let you know if and when your counts are low and review the things you can do to help lower your risk of infection.
If the risk for infection is high, your physician may recommend the use of supportative medications such as Neulasta or Neupogen. These are growth factors similar to the ones our own bodies’ make to boost production of white blood cells. Your physician or nurse will discuss this with you in more detail if the need arises. You may find additional information regarding these medications in our section on Supportative Medications Tab to Supportive care agents– Growth Factors.
Strategies to decrease a risk for serious infection listed below will also help to protect you during the periods you are at risk:
Frequent hand washing is a must. Many infections are passed from one person to another through touch. So washing your hands before preparing food or eating, after going to the bathroom, after returning home from being out in public areas such as supermarkets, church, or any time your hands come in contact with items used by many people is the best way to cut your risk of infection.
Bath daily. Do not share washcloths or bath towels with other family members.
Maintain good oral care. Brush teeth after every meal and rinse mouth frequently throughout the day to clean mouth of bacteria and food debris.
Protect skin from cuts and burns. Wash any cuts and scrapes with warm soapy water immediately and assess every day for signs of infection.
Wear gloves while working in the garden.
Do not share food utensils with others.
Do not provide direct care for pets and avoid animal excreta (litter box, bird cages, etc).
Avoid ill people and/or large crowds.
When white blood cells are low avoid eating out in fast food restaurants.
Wash fresh fruits and vegetables thoroughly before eating.
Do not use enemas or suppositories without checking with the physician or nurse first.
Use water-soluble lubricant during sex and practice proper hygiene post sex.
Avoid anal intercourse.
Avoid the use of tampons.
Immediately report any signs or symptoms of infection to your physician or nurse. The most common sites of infection in patients’ receiving chemotherapy are skin, mucus membranes (mouth), lung, urinary tract and indwelling devices such as IV catheters.
Signs of infection can include the following:
Temperature 100.4 or higher
Low grade temperature below 100.4 with shaking chills.
Shaking chills without fever
New onset of shortness of breath
New onset of cough with or without sputum
New onset of sore throat
New onset of pain
Pain or burning upon urination
New onset of diarrhea with cramping or fever
New onset of fatigue, somnolence or confusion
Redness, swelling, pain or drainage from a cut or scrape.
Redness, swelling, pain or drainage around a portacath or other intravenous device.
Low platelets
Low Platelet Counts or thrombocytopenia can also occur during chemotherapy and/or radiation therapy, although less frequently than decreases in white blood cells. Platelets are the third primary blood cell type. They are responsible for helping the body to clot blood after an injury. A low platelet count increases your risk for bleeding. We will let you know if your platelets are low and discuss the actions you can take to protect yourself from bleeding.
Please note that bleeding related to certain targeted agents is reviewed separately (Tab to Blood problems: Bleeding)
Strategies for Reducing Your Risk of Bleeding:
Assess your skin daily for the presence of unusual bruising or small pinpoint red dots referred to as petecia. Notify you doctor immediately if observed.
Notify your physician or nurse of any bleeding (nose, gums, eyes, blood in urine, red or black tarry stool)
Use a soft bristle toothbrush for brushing your teeth and avoid the use of dental floss if your platelet count is below 50,000.
When platelet counts are below 50,000 use electric razors instead of a regular razor
Avoid wearing restrictive undergarments
Do not use enemas or suppositories without checking with the doctor or nurse first
Avoid the use of tampons
Avoid having any dental procedures performed while platelet counts are low. Talk with your nurse or physician first.
Use a water-based lubricant before sexual intercourse
Avoid anal intercourse
Avoid activities that have the potential for trauma
Bleeding
Bleeding in patients with cancer can be attributed to multiple mechanisms. It can be caused by tumor itself or by anti-cancer therapies.
Low platelets (Thrombocytopenia)
One of the common causes of bleeding is thrombocytopenia, or low platelets. Platelets play an important role in the body’s ability to clot. Persons receiving standard chemotherapy are particularly susceptible to this side effect. Thrombocytopenia related to cancer treatment is discussed in detail in the section on Low Platelets - tab. Low platelets can also be a result of bone marrow invasion by the tumor. Bone marrow is a soft spongy material located primarily in the iliac crests of the hips, the vertebrae, the sternum and the long bones of the legs. These areas are where our blood cells are produced and then released out into the blood stream for use. Cancer in the bone marrow impacts the body’s ability to produce platelets and can lead to bleeding.
Tumor Invasion
As tumors grow they may grow into nearby blood vessels, rupturing them. Bleeding caused by this mechanism can be slight and undetectable (early-stage colon cancer) or in more advanced cancer, bleeding can be significant and life threatening. The location of the cancer determines the location of the bleeding. For example cancer in the lungs may cause bleeding in the lungs that would cause a person to cough up blood or cancer in the bladder could cause appearance of blood in the urine.
Clotting Factors
Clotting factors are necessary to prevent bleeding. Multiple clotting factors are produced in the liver; when liver is severely affected by cancer or damaged by anti-cancer drugs, clotting factors might not be produced in sufficient quantities, which can lead to bleeding.
Medications with Direct Effects on Bladder Tissue
Certain drugs, such as high dose Cytoxan or Ifosfamide can have a direct effect on bladder tissue. Irritation of the bladder lining can be quite severe and lead to ulcerations of the bladder wall, resulting in potentially severe bleeding.
Medications that affect blood vessel formation
Targeted agents which interfere with formation of blood vessels, for example antibody Avastin, can cause bleeding. The mechanism behind this is not completely understood. Patients are carefully screened for risk factors before being treated with this medication.
Blood clots
Blood Clots could form in the veins or arteries. Normally, clotting is the mechanism used by the body to stop bleeding. The first step in forming a clot is the clumping of platelets which attach themselves to the cut edges of a blood vessel wall, forming a platelet plug. It is strengthened by protein fibers called fibrin which stick together and seal the inside of the wound. Eventually the area of injury heals and the blood clot dissolves after a few days.
This life saving process becomes a problem when excessive clotting results in formation of clots that block arteries or veins and interfere with normal blood flow. This can occur for a variety of reasons. Some cancers, including pancreatic, bowel, lung and ovarian, put persons at a higher risk for blood clots. Anti-cancer therapy could increase the chances for clot formation by killing cancer cells. Dead cells release substances into the blood stream that promote clotting. Some targeted medications, including antibody Avastin, and supportive care agents, like red blood cell growth factors, could also increase the chances for clot development.
The most common sites for these types of clots to occur include the lower legs, the thighs and the pelvis, but they could also occur in the arms or form on the intravenous catheters. Sometimes these clots can break away from the vein wall and move to the heart or lungs. This is known as pulmonary embolism (PE). Blot clots that form in the veins, but travel to the heart or lungs, as well as blood clots forming in the arteries, can be life-threatening.
Other factors that can increase a person’s risk of developing DVTs are:
It is important that you let you physician or nurse know if you experience any of the following:
Pain in the calf or leg muscle
Swelling
Tenderness
Changes in skin color
Changes in skin temperature - skin in the area of the clot may feel warm or hot
Veins in the vicinity of the clot may appear prominent
Common symptoms of a clot that has moved to the lungs or heart include:
New, sudden onset of coughing (with or without blood)
Sudden onset of shortness of breath
Sudden onset of chest pain when taking a deep breath or coughing. Note that pain could also be in the back, shoulder or upper abdomen
Blood clots are diagnosed by clinical presentation and using radiological studies such as ultrasound, CT scans and venography. Treatment of blood clots usually includes use of drugs that decrease activity of clotting factors, such as low-molecular weight heparin and Coumadin.