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Blood Counts

Blood Counts

Question
An OncoLink visitor asks questions about blood counts (Neutropenia, Thrombocytopenia, Anemia).


Answer
Why does chemotherapy affect my blood counts?

Chemotherapy kills both cancerous cells and other normal cells in your body. The normal cells in your body that are most at risk for being killed by chemotherapy are those that are growing at a fast rate. Because your body is constantly producing blood cells, these cells are often destroyed by chemotherapy. It's important that you understand the different types of blood cells and what each type does.

There are three different kinds of blood cells:

  • red blood cells, which are often called RBC's
  • white blood cells or WBC's
  • platelets
Each type of blood cell has a special function. The primary job of red blood cells is to carry oxygen to all the cells of your body. White blood cells are important in preventing and fighting off infections. Platelets play a big part in stopping bleeding.

What is Neutropenia?

Neutropenia refers to a low level of white blood cells. Since chemotherapy kills both cancerous cells and other normal cells that grow at a fast rate, white blood cells are often destroyed.

Since white blood cells play an important role in preventing infection, any time your white blood cell count drops, you are at higher risk of getting infection. What's more, since these cells also help to fight off infections once they're in the body, it's harder to get over an infection when your white counts are low. Therefore, you must do everything that you can to decrease the chance that you will become infected while you are receiving chemotherapy.

Normal white blood cells counts are usually in the range of 4,000 - 11,000 per mm3 of blood. After receiving chemotherapy, your white count may drop as low as 200 to 500 per mm3. While you are receiving chemotherapy your white blood cell count will be checked frequently.

Any time that your white blood cell count drops below 1,000 per mm3, you are considered to be neutropenic. A nurse will call you at home to review with you special steps that you must take in order to decrease the chance that you will get an infection. These are called Neutropenic Precautions and are discussed in greater detail below.

What Can I Do To Prevent Infections?

It is important to realize that there is nothing that you yourself can do to prevent neutropenia/low white blood cell count that is caused by chemotherapy. However, your physician may order injections that promote growth of your body's white blood cells (refer to section titled "How is Neutropenia Treated?"). Keep in mind that there are several things that you can do to prevent infections when your white blood cells are low and you are at high risk:
  • Know what to look for. The signs and symptoms of infection include:
    • fever, chills or sweats
    • cough, mucous production, shortness of breath or painful breathing
    • soreness or swelling in your mouth, ulcers or white patches in your mouth, or a change in the color of your gums
    • pain or burning with urination or an odor to your urine
    • redness, pain or swelling of any area of your skin
    • redness, pain, swelling or drainage from any tube you may have (e.g., Hickman catheter, J-tube, urinary catheter)
    • pus or drainage from any open cut or sore
  • Perform excellent personal hygiene
    • wash your hands frequently, especially before eating and after using the bathroom
    • use antiseptic mouthwashes (that contain no alcohol) daily
    • do not cut or pick at cuticles. Use a cuticle cream instead
    • use a deodorant rather than an antiperspirant. Antiperspirants block sweat glands and, therefore, may promote infection
    • when menstruating, use sanitary napkins rather than tampons which may promote infection in a neutropenic patient
  • Avoid situations that will increase your chance of getting an infection
    • stay away from people with colds or other infections
    • avoid contact with anyone who has recently been vaccinated, including infants and children
    • avoid crowds as much as possible. When going to places where there are often a lot of people (i.e., church, shopping), try going at off times when it's not as crowded
    • if possible, do not use public transportation. If you must, travel during off-peak times
  • Use extra precautions to decrease the chance of injury and infection
    • always wear shoes to prevent cuts on your feet
    • protect your hands from cuts and burns. When doing dishes, wear rubber gloves; always use potholders or some other protective covering when cooking or baking; wear gloves when gardening
    • wear sunscreen with a sun protection factor (SPF) of at least 15 and avoid getting sunburned
    • when shaving under your arms or your legs, only use an electric razor to avoid breaks in the skin
    • do not take vaccinations unless they have been approved by your oncologist
    • avoid activities that may lead to falling and/or injury, including but not necessarily limited to bicycling, roller-blading, skating, and skiing
  • If you cut or scrape the skin, immediately clean the area with soap and water and bandage as necessary

What Are Neutropenic Precautions?

If your white blood cell count drops to 1,000 per mm3 or below, you are neutropenic and a nurse will contact you by phone. Until your count rises, it will be necessary for you to take measures in addition to those discussed above to further decrease your risk for infection. These additional steps are referred to as Neutropenic Precautions and include:
  • Take your temperature by mouth four times each day. Call your doctor immediately if your oral temperature is above 100.5 degrees Fahrenheit
  • Eliminate uncooked foods, which may contain germs, from your diet, including:
    • cold soups made from fresh fruits or vegetables
    • salads of raw vegetables or fruits
    • raw meats or fish salads
    • natural cheeses
    • uncooked eggs
    • fresh, frozen and dried fruits
    • uncooked herbs, spices and black pepper
    • instant iced tea, coffee or punch
    • sushi and sashimi
  • Avoid fresh flowers and plants which may have germs in the soil
  • Avoid enemas, rectal suppositories and rectal temperatures
  • Unless an emergency, do not have any dental work performed. If you have an emergency that requires dental work, inform your dentist at the time you schedule your appointment that you are receiving chemotherapy and what your most recent white blood cell count is. You may want to suggest that your dentist contact your oncologist prior to your scheduled dental work.


Neutropenia: When Should I Call My Doctor?

Even after you have taken special precautions to prevent infection, it is still possible to get an infection. If any of the following signs or symptoms of infection occur, call your doctor or nurse immediately. Do not take any medications, even aspirin or other products to lower your temperature, before talking to your doctor.

Call your doctor if you have any one or more of the following:
  • oral temperature above 100.5 degrees which indicates a fever
  • cough, mucous production, shortness of breath or painful breathing
  • soreness or swelling in your mouth or throat, ulcers or white patches in your mouth, or a change in the color of your gums
  • pain or burning with urination or an odor to your urine
  • change in the odor, character or frequency of your stool, especially diarrhea
  • redness, pain or swelling of any area of your skin
  • redness, pain, swelling in the area surrounding any tube you may have (e.g., Hickman catheter, J-tube, urinary catheter)
  • pus or drainage from any open cut or sore or from any tube you may have (e.g., Hickman catheter, J-tube, urinary catheter)
  • an overall feeling of being sick, even if you don't have a temperature

How is Neutropenia Treated?

One of the greatest advances in the treatment of patients with cancer that has occurred in the past decade is the development of substances called growth factors. These substances work by stimulating the body's production of specific materials. An important growth factor used widely with cancer patients, especially those receiving chemotherapy, stimulates the growth of white blood cells, and is thus very effective in preventing or treating neutropenia. If the chemotherapy that you are receiving is known to have a severe impact on the white blood cell count, or if you experienced a severe decrease in your white blood cell count after a prior course of chemotherapy, your doctor may prescribe a growth factor before, during or following future courses of chemotherapy. By increasing your body's production of white blood cells, the growth factor is very effective in decreasing the likelihood that you will develop an infection.

The growth factor is administered by injection. You may receive the injection from the nurse in your doctor's office or you and/or a family member may be taught how to give the injections at home. Once your white blood cell count has returned to a normal level, the injections will be stopped until the next course of chemotherapy.

What is Thrombocytopenia?

Thrombocytopenia refers to a low level of platelets. Since chemotherapy kills both cancerous cells and other normal cells that grow at a fast rate, platelets are often destroyed.

Since platelets play an important role in clotting blood, any time your platelet count drops you are at higher risk of bleeding. Therefore, you must do everything that you can to decrease the risk of injury that could result in bleeding while you are receiving chemotherapy. Even the most minor of injuries such as a small cut or bump can result in excessive bleeding when your platelets are low and, therefore, must be avoided.

Normal platelet counts are usually in the range of 150,000 - 400,000 per mm3 of blood. After receiving chemotherapy, your platelet count may drop significantly lower than these normal ranges. While you are receiving chemotherapy your platelet count will be checked frequently.

Any time that your platelet count drops below 50,000 per mm3 you are considered to be at increased risk for bleeding. A nurse will call you at home to review with you special steps that you must take in order to decrease your chance for injury that could result in a bleeding episode. These are called Platelet Precautions and are discussed in greater detail below. If your platelet count drops below 10,000 per mm3 you will require immediate medical attention by your oncologist.

What Can I Do To Prevent Bleeding?

It is important to realize that there is nothing that you can do to prevent thrombocytopenia/low platelet count that is caused by chemotherapy. However, there are several things that you can do to decrease your risk for injury and bleeding when your platelet count is low and you are at high risk:
  • Know what to look for. The signs and symptoms of a low platelet count include:
    • excessive bruising of your skin
    • tiny, pinpoint red spots on your skin (called petechiae)
    • bleeding gums
    • nosebleeds that will not stop
    • excessive bleeding from a small cut, or bleeding that won't stop even after pressure has been applied
    • dark colored urine or blood in your urine
    • blood from your rectum, blood in your stool or black colored stool
    • menstrual bleeding that is heavier than usual, lasts longer than usual or occurs between periods
  • Take special precautions with personal hygiene to minimize the risk of bleeding
    • keep your mouth clean and moist
      • brush your teeth gently with a soft bristle toothbrush
      • if you cannot use a toothbrush, use a sponge toothette to clean your teeth and gums
      • do not use dental floss
      • avoid any commercial mouthwashes that contain alcohol. Alcohol can dry out your mouth and may lead to bleeding
      • use petroleum jelly or other lip balms to keep your lips moist and to prevent cracking
      • take sips of water or juice frequently if your tongue or mouth feel dry
      • rinse your mouth after each meal with a baking soda solution (2 tsp. baking soda to 8 oz. water)
    • follow these guidelines with feminine hygiene
      • use sanitary napkins rather than tampons during menstruation
      • avoid vaginal douching
    • take these other precautions
      • do not blow your nose too hard
      • do not cough forcefully or harshly. If you have a persistent cough, notify your doctor or nurse who may recommend a cough syrup
      • avoid straining too much with bowel movements. If you have a problem with constipation, ask your doctor for a stool softener or laxative
      • do not use rectal thermometers, suppositories or enemas
      • only use an electric razor for shaving
  • Avoid certain medications which affect blood clotting
    • do not take aspirin or anything that contains aspirin Check the labels of all drugs you are taking for salicylic acid. If you are not sure about a drug or cannot tell by reading the label, check with your physician, nurse or a pharmacist.
    • do not take any non-steroidal, anti-inflammatory medications such as Motrinr, Alever, Advilr, etc.
    • for headaches or other pain, use acetaminophen (Tylenol)
    • do not take blood-thinners
  • Adjust your lifestyle to minimize the risk of bleeding
    • avoid strenuous activity, lifting heavy objects, and bending over from the waist
    • adjust your diet
      • drink 8-10 8 ounce glasses of fluid a day to keep your mouth moist, the intestinal lining in good condition and to avoid constipation
      • avoid raw and course vegetables that are hard to digest and may cause damage to the intestinal lining
      • eat protein-rich foods and beverages such as chicken, turkey, cheese, cooked eggs, milk
    • wear shoes or slippers at all times to protect your feet
    • do not wear tight fitting clothing
    • use a water-based lubricant and avoid vigorous thrusting during sexual intercourse
    • avoid drinking alcoholic beverages, including beer and wine
    • avoid activities that could result in falling and/or injury including but not necessarily limited to bicycling, roller-blading, skating and skiing

What if I Start to Bleed?

Even after you have taken special precautions to decrease the chance of injury and bleeding, it is still possible that bleeding will occur. If bleeding occurs, apply firm pressure for 5 minutes to the area. If bleeding does not stop after 5 minutes, continue to apply pressure until it has stopped completely. Then call your doctor.

If you have a nosebleed, apply pressure with your fingers below the bridge of your nose until the bleeding stops. Keep your head raised.

Thrombocytopenia: When Should I Call My Doctor?

Call your doctor immediately if you have any one or more of the following:
  • bleeding that does not stop after you have applied pressure for 10 to 15 minutes
  • blood in your urine or your urine appears dark in color
  • blood from your rectum, blood in your stool or your stool is black
  • a change in your vision
  • a persistent headache, blurred vision or a change in your level of consciousness such as a decreased attention span, excessive sleeping, confusion, and/or difficulty being awakened
If you have a major injury or start spontaneously bleeding, go immediately to the nearest hospital emergency room. Make sure you inform the doctor that you are receiving chemotherapy and that your platelet count may be low indicating thrombocytopenia.

How is Thrombocytopenia Treated?

If your platelet count drops to a point that your doctor is concerned about significant risk of bleeding, they may order transfusions of platelets. These transfusions are most often done in the doctor's office or in an outpatient treatment center. Unless other problems exist, patients rarely are admitted to the hospital just to receive platelet transfusions.

What is Anemia?

Anemia refers to a decrease in the number of red blood cells (RBCs). Since chemotherapy kills both cancer cells and other normal cells that grow at a fast rate, red blood cells are often destroyed.

An important part of the RBC is hemoglobin, the part that carries oxygen throughout your body. Therefore, when your hemaglobin is low, oxygen levels are decreased, and your body has to work harder in order to compensate. The end result is that your body will show signs of being very tired.

Normal hemaglobin levels for women are usually in the range of 11.8 to 15.5 gm/dL. After receiving chemotherapy, your hemaglobin level may drop significantly lower than these normal levels. While you are receiving chemotherapy your hemaglobin level will be checked frequently. Any time that your hemaglobin level drops below 10.0 gm/dL you are considered to be anemic.

What Can I Do to Prevent Anemia?

Like neutropenia and thrombocytopenia, there is nothing that you can do to prevent anemia that is caused by chemotherapy. Anemia usually causes you to feel weak and tired; therefore, it is very important that when you are anemic you take actions that will prevent your body from becoming extremely tired. Failure to do so may result in your becoming ill. The actions to take include:
  • Know what to look for. The signs and symptoms of anemia include:
    • weakness or fatigue
    • dizziness
    • headache
    • shortness of breath or difficulty breathing
    • chest pain or palpitations
    • irritability
    • a heavy feeling in your upper legs
    • ringing in the ears
    • feeling chilled
  • Rest as much as necessary to save your energy
    • get plenty of sleep
    • avoid prolonged or strenuous activity
    • take rest periods during activities that make you feel tired. If necessary, take short naps throughout the day
    • prioritize your activities so you will have enough energy for important activities or the activities that you enjoy the most
    • ask friends and family to help you prepare meals or do chores when you're tired
  • Exercise caution to avoid injury if you're experiencing dizziness
    • change positions slowly especially when going from lying to standing
    • when getting out of bed, sit on the side of the bed for a few minutes before standing
  • Have a well-balanced diet
    • Eat green leafy vegetables, liver and cooked red meats
    • drink plenty of fluids
    • avoid caffeine and big meals late in the day if you're having trouble sleeping at night
  • Be sure to take your iron pills if you have been instructed to by your physician or nurse

Anemia: When Should I Call My Doctor?

Call your doctor immediately if you have any one or more of the following:
  • dizziness
  • shortness of breath or difficulty breathing
  • excessive weakness or fatigue
  • palpitations or chest pain