Anemia

Anemia is an inadequate supply of red blood cells, resulting in a decrease in the oxygen-carrying capacity of the blood. A common reason that cancer patients experience anemia is as a side effect of chemotherapy. Anemia is important because it may cause unwanted symptoms, such as fatigue, tiredness or shortness of breath, and may exacerbate or cause other medical problems, such as a heart condition. Fortunately, anemia can be effectively managed.

Anemia can be treated by increasing the hemoglobin level with blood transfusions or with erythropoietin (epoetin alfa or darbepoetin alfa), a blood cell growth factor that increases red blood cell production. The two objectives for treating anemia are to first correct the underlying cause of the anemia and second treat the symptoms of the anemia. Successful management of anemia may require erythropoietin, transfusions or both.

Erythropoietin: Erythropoietin is a blood cell growth factor that selectively increases production of red blood cells. The body produces erythropoietin to increase red blood cell production.

Erythropoietin is FDA-approved for the treatment of anemia in patients with nonmyeloid cancers whose anemia is a result of chemotherapy. Treatment with erythropoietin causes a gradual increase in red blood cell production. The body uses iron in red blood cell production. Thus, supplemental iron may be required to adequately support erythropoietin-stimulated erythropoiesis. Virtually all patients receiving erythropoietin therapy will eventually require supplemental iron therapy.

The two commercially available forms of erythropoietin are darbepoetin alfa (Aranesp®) and epoetin alfa (Procrit®, Epogen®). Aranesp® is a longer-acting form of erythropoietin that allows patients to receive fewer injections.

Although erythropoietin has been shown to reduce the need for blood transfusions in patients with chemotherapy-induced anemia, some studies have reported serious adverse effects of erythropoietin in certain groups of patients. In response to these reports, and based on the advice of two advisory committees, the FDA released an updated Advisory on the use of erythropoietin in November 2007. Patients should discuss the risks and benefits of anemia treatment with their doctor.

Blood Transfusion: Blood transfusions rapidly replace the oxygen-carrying capacity of the blood. The goal of a blood transfusion is to increase oxygen and carbon dioxide exchange between the tissues and reduce the symptoms of anemia. However, transfusions are associated with complications. Patients should carefully consider whether to undergo a transfusion and the benefits should outweigh the risk or complications of the procedure.

Although improvements have lowered the risk of transfusion-transmitted complications, the only way to effectively eliminate the risk is to avoid exposure to allogeneic or “banked” blood. Despite the risks, red blood cell transfusions are common treatments for the severe anemia associated with cancer and chemotherapy.

Fatigue

Fatigue is one of the most common side effects of cancer and cancer treatment. There are many factors that contribute to fatigue, such as anemia, poor nutrition, inadequate rest, infection, stress, and others. Likewise, successful treatment of fatigue may require several approaches. For these reasons, it is important to tell your doctor if you have fatigue or if your fatigue is worsening so that you have the best chance of getting a treatment plan that will work for you.

The best ways to combat fatigue are:

Treat anemia: Anemia is the most common cause of fatigue in cancer patients. It is also very treatable. Learn more about the diagnosis and treatment of anemia.

Maintain good nutrition: Maintaining good nutritional intake during treatment is especially important because cancer treatments increase the nutritional demands of the body. However, treatments may also cause you to lose your appetite, or feel full early (Early satiety). Work with a dietician or nutritional specialist to ensure that you are getting proper nutrition.

Conserve energy: Try to be realistic about how much energy you have and what you can and can’t do. Only do the things that are most important and ask friends or family for help. It is important to recognize which activities create the most fatigue and also note the frequency, degree, and duration of fatigue so that you can report these to your doctor. If you’re having difficulty managing fatigue, you may wish to ask your nurse or doctor to help family members understand how they can help.

Maintaining normal rest and sleep patterns is important for ensuring quality rest. Plan your daily activities carefully, and schedule rest times between activities throughout your day. Try to rest when you feel the worst and do your activities when you feel better.

Evaluate medications: Review your medications with your doctor, pharmacist, or nurse to ensure that the medications are not causing or contributing to your symptoms.

Exercise: While conserving energy is important, it is equally important to understand that too much rest or inactivity can actually decrease the body’s ability to produce energy and can worsen fatigue.  Moderate daily exercise, such as walking, may help to increase your energy level.

Manage stress: Counseling, support services, and medications can all play a role in reducing stress and thereby alleviating fatigue

 Hair Loss

Chemotherapy damages rapidly dividing cells, such as cancer cells. Some healthy cells also divide rapidly, such as hair follicles. Chemotherapy damages these cells, leading to hair loss, also called alopecia.

Hair loss will typically begin two or three weeks after your first treatment. In addition to hair on your head, you may lose eyebrows, eyelashes, facial hair, pubic hair, underarm hair and leg hair. The amount of hair that you lose will depend on the type of chemotherapy drug you are taking. Hair typically begins to grow back approximately 2-3 weeks after treatment is finished. The hair may grow back differently than it was before treatment. For example color or texture (curly or straight) may be different.

Importantly, you should remember that hair loss associated with chemotherapy is temporary and the hair WILL grow back. In the meantime, here are a few tips to help you cope with the loss:

• You may wish to cut your hair before it starts falling out. The experience of losing the hair is sometimes worse than dealing with it once it’s gone. If you expect to lose all or a lot of your hair, cutting it first may be easier to cope with.
• Plan ahead; shop for a wig before your hair is gone, especially if you wish to match your natural color.  Or, take this opportunity to try something different.
• Try hats or head scarves; these are good alternatives or a compliment to a wig.
• Remember to cover your head or use sunscreen on your scalp. Skin that has been covered with hair may be particularly sensitive to UV rays of the sun.
• Ask your insurance company if they cover the cost of the wig.
• Treat your new hair gently once it grows back. Avoid chemicals, bleach, peroxide or colors.
• Get involved in a “Look Good… Feel Better” program, a community-based, free, national service that teaches female cancer patients beauty techniques to help restore their appearance and self-image during chemotherapy and radiation treatments

Infection/Fever

Fever is an abnormally high body temperature.  Fever is the body’s natural response to infection.  An infection-related fever may be particularly dangerous when your white blood cell count is low or is expected to be low, because this is when the body’s normal defenses against infection are low. Under these conditions, a fever needs to be carefully monitored and evaluated for a cause.

Medical treatment for a fever depends on the cause. If the fever is determined to be related to an infection, treatment will be prescribed for the infection. For a bacterial infection, such as pneumonia or tonsillitis, antibiotics are usually prescribed. For viral infections, including stomach flu (gastroenteritis), the best treatment is often rest and plenty of fluids, although anti-viral drugs may be used to treat some viruses. If an infection-related fever is tolerable, then doctors may not treat the infection but monitor it closely because the fever contributes to eliminating the bacteria or virus. If a cancer patient develops a low white blood count and fever, it is assumed that an infection is present and antibiotics are given until the fever is resolved and white blood cell count recovered.

If an infection-related fever is very high, over-the-counter medications may be prescribed to reduce the fever and associated discomfort. Non-steroidal anti-inflammatory drugs (NSAIDs), such as acetaminophen (Tylenol®) or ibuprofen (Advil®, Motrin®, etc.), are often used for this purpose.  Adults may also use aspirin to reduce a fever.  However, aspirin should not be administered to children as it may cause a rare, but potentially fatal disorder known as Reye’s syndrome.

If you have a bleeding disorder, you should avoid NSAIDs, as well as aspirin. These drugs may prolong bleeding by interfering with the activity of blood platelets. Use of such drugs to treat fever should be discussed first with your healthcare professional.

NSAIDs or aspirin are also used if the source of the fever is related to flu-like syndrome associated with biologic therapy or certain types of chemotherapy and not infection.

Low Blood Counts

A reduced number of blood cells in circulation is a common side effect of chemotherapy. Blood is composed of three basic blood cell types: red blood cells, white blood cells, and platelets. Blood cells are produced in the bone marrow and regularly released into circulation. Chemotherapy destroys rapidly dividing cells, a characteristic of cancer cells. However, bone marrow cells also divide rapidly and are frequently damaged by chemotherapy. The best way to treat low blood counts is to prevent them before they occur. This can be accomplished with the administration of blood cell growth factors. In some circumstances, blood transfusions may also be necessary.

Nausea and Vomiting

A specific location in the brain controls emesis (vomiting), called the vomiting center. Emesis occurs when the vomiting center receives a signal from the brain, the gastrointestinal tract, the heart and/or the inner ear, which detects motion. Chemotherapy causes the release of a substance called serotonin (5-HT), and of other chemicals in the small intestine, which through a series of signals stimulate the vomiting center in your brain to induce emesis.

There are several things you can do to prevent nausea and vomiting. First and foremost, make sure you receive and take your antiemetics (anti nausea medicines)  as your doctor has ordered. Let your doctor or nurse know if your drugstore does not have them, you cannot afford to pay for them, or you are not sure how to take them. Also, call your doctor if you experience any of the following:

• You have vomiting and cannot take your medication
• Your antiemetics help reduce your nausea and vomiting, but not as much as you would like. The dose may have to be changed or the doctor may change you to a different antiemetic.

In addition to taking your medication, the following general suggestions may help you prevent or control nausea and vomiting:

• Try eating foods and drinking beverages that have been easier for you to take or have made you feel better when you had the flu, morning sickness or were nauseated from stress. These might be bland foods, sour candy, pickles, dry crackers, ginger ale, flat soda or others. Eat small, frequent meals (5-6), instead of 3 large meals each day.
• Do not eat fatty or fried foods, very spicy foods or very sweet foods.
• If possible, have somebody else make the meals when you are nauseated.
• Do not eat your favorite foods when you are nauseated.
• If you have nausea and vomiting only for a few days after chemotherapy, cook and freeze several meals that you can reheat during times when you are nauseated.
• Eat foods that are at room temperature or cold. The smells from hot foods may make your nausea worse.
• Keep your mouth clean; brush at least twice a day.
• Consider shakes or liquid nutritional supplements to help maintain your nutrition.
• Ask your doctor or nurse about using acupressure (BioBands) on your wrists, which may help to decrease your nausea.
• Anticipatory nausea associated with chemotherapy is best controlled with relaxation techniques.
• Ask your doctor or nurse if they can help you learn a relaxation exercise. This might make you feel less anxious and more in control, and decrease your nausea.

What if I have anticipatory nausea and vomiting?

Anticipatory nausea and vomiting is poorly controlled with standard antiemetic treatment. In some clinical studies, drugs that treat anxiety (benzodiazepines) have provided some relief. A number of non-drug approaches, also called cognitive and behavioral intervention, may help. These include:

• Systematic desensitization
• Distraction from the negative experience with guided imagery or relaxation
• Elimination of consistently repeating patterns
• Manipulation of the setting and personnel associated with chemotherapy administration
• Biofeedback
• Blocking taste sensation with another strong taste (e.g., lemon)

Neutropenia (Low White Blood Cell Count)

Why is chemotherapy-induced neutropenia important?

Chemotherapy-induced neutropenia is important because it may:

• Increase your risk of life-threatening infection.
• Disrupt delivery of your cancer treatment, resulting in a change to the planned dose and time.

The fewer the neutrophils in the blood and the longer you remain without enough neutrophils, the more susceptible you are to developing a bacterial or fungal infection. Neutrophils are a major component of antibacterial defense mechanisms. As the neutrophil count falls below 1.0, 0.5, and 0.1 x 10⁹/L, the frequency of life-threatening infection rises steeply from 10% to 19% and 28%, respectively.  If you develop a fever during neutropenia you may require treatment with intravenous antibiotics and admission to the hospital until the number of neutrophils in the blood returns to sufficient levels to fight the infection.

Another reason neutropenia is important is that, in some cases, it can be severe enough that your chemotherapy treatment may need to be delayed or dose reduced, which reduces some patients’ chance for cure. When you are treated with chemotherapy, it is for the purpose of destroying cancer cells in order to reduce symptoms from your cancer, prolong your survival or increase your chance of cure. The dose and time schedule of chemotherapy drugs administered have been scientifically determined to produce the best chance of survival or cure.  If you develop neutropenia, your doctors may have to delay your treatment or reduce the doses of your chemotherapy until your neutrophil counts have recovered. Clinical studies have shown that, for certain cancers, reducing the dose of chemotherapy or lengthening the time between treatments lowers cure rates compared to full-dose, on-time treatment. Fortunately, there are strategies for the prevention of chemotherapy-induced neutropenia that have been proven to reduce the incidence of fever, infection, admission to the hospital and allow you to receive your treatment on schedule.

• Patients receiving chemotherapy that decreases the number of white blood cells
• Patients who already have a low white blood cell count, or who have previously received chemotherapy or radiation treatment
• Patients age 70 and older who may be at risk of more severe infection and longer hospitalizations
• Patients with other conditions affecting their immune system

Pain

What is pain?

Pain may be a side effect of cancer treatment or may be caused by the cancer itself. If not adequately managed, pain may have a tremendous effect on quality of life. Fortunately, there are many effective treatments for pain and most of your pain should be controlled with these treatments. You should always notify your doctor if you have pain or if your existing pain increases so that steps can be taken to find the medication or combination of medications and dose that will control it. Also, take your medication as prescribed.

How is pain treated?

The type of pain medication you are prescribed depends on how severe your pain is. Pain is rated on a scale of 1-10, with 0 being no pain and 10 the worst pain imaginable.

The World Health Organization recommends the following approach for relief of cancer pain:

Mild to Moderate Pain (1-3) For pain at the low end of the 1-10 scale, you will be prescribed over-the-counter medications, such as acetaminophen (Tylenol®) or a non-steroidal anti inflammatory drug (NSAID), such as ibuprofen (Advil®, Motrin®, etc.).

Moderate to Severe Pain (4-6) If over-the-counter medication did not relieve your pain, or you have moderate to severe pain, you will be prescribed one of the many types of opioids. Also known as narcotics, these drugs are similar to natural substances produced by the body to control pain, called endorphins, and are the strongest pain relievers available . Opioids prescribed for moderate to severe pain may include dihydrocodeine, propoxyphene and tramadol. Tylenol® or an NSAID may be added to the opioid, as in the drugs labeled codeine, oxycodone and hydrocodone.

Severe Pain (7-10) For severe pain or pain that was not relieved from one of the above opioids and/or over-the-counter medication, you will likely receive a stronger opioid. Opioids for severe pain may include morphine, oxycodone, hydromorphone, methadone, levophanol or fentanyl. A non-opioid analgesic and/or adjuvant drug may be added as circumstances require.

How is pain medication given?

Pain medication may be given in many different ways, including:

• Orally as a pill or liquid
• Topically as an ointment or patch
• Rectally as a suppository
• Intravenous (IV injection into your vein)

If your doctor gives you pain medication with instructions to “take as needed”, remember to take it before the pain becomes severe. If you wait, it may take a long time before the medication begins to work, causing unnecessary discomfort.

If your pain relief is not lasting long enough, ask your doctor about extended-release medicines, which can control your pain for a longer period of time. Morphine and oxycodone are made in extended-release forms. Also, a skin patch that releases the opioid fentanyl can be used.

If your pain is controlled most of the time, but occasionally gets bad enough that your medication does not appear to work, your physician may prescribe a rapid-acting medicine, such as immediate-release morphine, to give you more pain relief when it is needed.

Your dose may need to be adjusted as you get used to the medication. You may build a tolerance to the pain medication, which means that you are not getting the same relief from your medication. If this happens, your dose may be increased or you may be prescribed a new medication.

Will I become addicted to pain medication?

Pain medication was developed for controlling the type of pain that cancer patients frequently encounter. You should not worry about becoming addicted to pain medication when taking it for the purpose it was designed. Usually, pain medication is only necessary for a short period of time, such as while you are healing from treatment. In some circumstances, you may be taking pain medication daily for a longer period of time. Even in these circumstances, you will not become addicted; you are taking pain medication for a very different purpose than someone who is addicted and trying to get “high”. Talk to your doctor, nurse or pharmacist about how to use pain medicines safely and about any concerns you have regarding addiction.

Does pain medication have side effects?

Pain medication may make you feel sleepy, cause you to become constipated, or cause nausea and vomiting. Below are a few tips on dealing with these common side effects of pain medication.

Sleepiness: Try planning a rest time just after you take your pain medication to deal with the sleepiness that it may cause. Sleepiness may be relieved by taking a caffeine drink with your pain medication.

Constipation: Increase fluid and fiber intake to prevent constipation.  Go to the section on Constipation for more information.

Nausea and vomiting: Drugs that can relieve your nausea and vomiting are available. Go to the section on Nausea and Vomiting for more information.

Not everyone experiences these side effects and not every pain medication causes them to the same degree. Talk to your doctor if you experience these or other side effects with your pain medication.

Are there non-drug treatments for pain?

There are many additional techniques for controlling pain that you may wish to try to see if they work for you. Some are described below.

Acupuncture: In acupuncture, thin needles are inserted into the body at certain points and at various depths and angles. Each point controls the pain sensation of a different part of the body. When the needle is inserted, a slight ache, dull pain, tingling or electrical sensation is felt for a few seconds. Once the needles are in place, no further discomfort should be experienced. The needles are usually left in place between 15 and 30 minutes, depending on the condition treated. No discomfort is felt when the needles are removed. Acupuncture is now a widely accepted and proven method of pain relief. Acupuncture should be performed by a licensed acupuncturist. Ask your doctor, nurse or social worker where to get acupuncture.

Biofeedback: Learning this technique requires the help of a licensed biofeedback technician. With the help of special machines, people can learn to control certain body functions, such as heart rate, blood pressure and muscle tension. Biofeedback is sometimes used to help people learn to relax. You can use biofeedback techniques to help you relax and to help you cope with pain. This technique is usually used with other pain relief methods.

Emotional support and counseling: Anxiety or depression may make your pain seem worse. Also, pain can cause you to feel worried, depressed or easily discouraged. These are normal feelings that can be relieved. Try to talk about your feelings with someone you feel comfortable with — doctors, nurses, social workers, family or friends, a member of the clergy, or other people with cancer. You may also wish to talk to a counselor or a mental health professional. Your doctor, nurse or the social services department at your local hospital can help you find a counselor who is specially trained to help people with chronic illnesses. Go to the sections on Anxiety and Depression for more information.

Imagery: Imagery involves using your imagination to create mental pictures of situations. The way imagery relieves pain is not completely understood. Imagery can be thought of as a deliberate daydream that uses all of your senses — sight, touch, hearing, smell and taste. Some people believe that imagery is a form of self-hypnosis.

Massage: There are many forms of massage that may help reduce pain. Some massage therapists specialize in chronic pain. Or, you can ask friends or family members to help. You may also be able to do massage on yourself. Try using a slow, steady, circular motion. Massage over or near the area of pain with just your bare hand or with hand lotion or warm oil. Check with your doctor before getting a massage to make sure that it is acceptable for your condition.

Meditation: Meditation is the practice of quieting the mind and focusing it on the breath or a mantra. Meditation may help you learn to focus your mind on something other than the pain and give you the strength to better cope with pain.

Menthol: Many menthol preparations are available for pain relief. There are creams, lotions, liniments or gels that contain menthol. When they are rubbed into the skin, they increase blood circulation to the affected area and produce a warm (sometimes cool) soothing feeling that lasts for several hours.

What else can I do about pain?

It’s hard to be motivated to exercise when you are in pain. In fact, it’s probably the very last thing you want to do! However, regular exercise can help you combat your pain in a variety of ways. Exercise prompts your body to release special chemicals, called endorphins, that actually block pain signals from reaching your brain. These chemicals also help alleviate anxiety and depression, conditions that can make your pain more difficult to control. Regular exercise can also improve your sleep and gives you more energy to cope with your pain.

Reproduction/Sexuality

How is sexual dysfunction managed?

Coping with sexual dysfunction may be very difficult. Maintaining open communication with your doctor and your partner, as well as taking steps to improve your self-esteem may help.

Communication: Without a doubt, one of the most common problems regarding cancer and sexuality is people’s reluctance to talk about it with their sexual partner and their healthcare team. However, communication is the key to coping with this difficult topic. Cancer care specialists are accustomed to addressing these issues every day.

Perhaps more importantly, sharing your thoughts, feelings, and any fears you may have regarding sexual dysfunction with your partner is essential to maintaining an intimate relationship with that person. Through open communication, you and your partner can work toward finding other ways to express yourselves beyond intercourse, such as gentle touching, holding hands, kissing, hugging and sharing emotional closeness.

Self-esteem and body image: Concerns about the impact of cancer and treatment on sexuality are often closely linked to issues of self-esteem and body image. Cancer treatment often involves surgery; surgery can leave scars and cause physical or neurological damage. Radiation treatment and chemotherapy can produce side effects such as hair loss and extreme fatigue. These effects and others can strongly influence how a person with cancer feels about his or her body and sexuality.

To support a positive self-image, follow these suggestions that have helped many people with cancer:

• It sounds simple, but looking better may actually help you feel better. Try to maintain the same grooming habits—fashion, hairstyle, and so on—as you did before your diagnosis.
• Plan special activities for both the days when you’re feeling well and those when you aren’t. Acknowledge that cancer and treatment can cause shifts in mood.
• Enjoy the days when you’re feeling well. On those days that are difficult, keep a positive outlook—plan all you’d like to do as soon as you feel better.
• If you need help with clothes and hair and other aspects of your appearance, don’t hesitate to ask for it. The “Look Good…Feel Better” program of the American Cancer Society (ACS), for example, can help.
• The ACS publications, “Sexuality for Women and Their Partners” and “Sexuality for Men and Their Partners” may be helpful to you.

What treatments are available for reproductive or sexuality issues?

In recent years, several drugs have been developed for men with erectile dysfunction. These drugs help men maintain an erection by inhibiting an enzyme. Examples include sildafenil (Viagara®), tadalafil (Cialis®) and vardenafil (Levitra®).

There are also medications available to help women deal with the symptoms of menopause. Make sure to tell your doctor what symptoms you are experiencing so that proper steps can be taken to provide some relief.

What else can I do?

If you think you may want to have children after treatment and the cancer treatment is likely to cause sterility, you may wish to bank eggs or sperm. However, you must do this before you receive your treatment. Talk to your doctor about your wish to have children, so that steps can be taken to assure that you have this choice later.

Mouth Sores (Mucositis)

Chemotherapy- or radiation-induced damage to the cells lining the mouth, throat and gastrointestinal (GI) tract is called mucositis. This side effect of cancer treatment can significantly affect patient quality of life and may cause delays in treatment. Historically, treatment for mucositis has consisted of supportive therapies, such as mouthwashes, aimed at reducing discomfort until the cells regenerate themselves, which takes about 7 to 14 days. However, a new biological therapy called Kepivance™, which is the recombinant form of human keratinocyte growth factor, appears to reduce mouth and throat soreness and improve function by stimulating cells that protect the lining of the mouth and GI tract

What causes mouth sores?

Mouth sores are a common side effect of radiation and certain chemotherapy drugs. Chemotherapy and radiation kill rapidly dividing cells, a hallmark characteristic of some cancers. The GI tract, including the mouth and the throat, is made up of cells that divide rapidly. For this reason, the GI tract is particularly susceptible to damage by chemotherapy and radiation treatment. Chemotherapy- or radiation-induced damage to the cells lining the mouth, throat and gastrointestinal tract is called mucositis.

What are the signs and symptoms of mouth sores?

Symptoms of mouth sores commonly occur three to ten days following your treatment with chemotherapy.  You may experience a burning sensation followed by ulcers, and your mouth may appear red (inflammation) with sores (ulcerations).  There may be associated discomfort and pain.

Mouth sores can make chewing and swallowing difficult, thereby interfering with your nutrition and food intake, resulting in weight loss. Your speech may also be compromised because of the soreness.  Furthermore, the lining of your mouth serves to protect you against infection, so mouth sores may make you more susceptible to bacterial, fungal, or viral infections in the mouth. Ultimately, mouth sores can become severe enough that it is necessary to reduce your dosage or delay your treatment in order to allow your mouth to heal.

Furthermore, while mouth sores can occur with any treatment for cancer, mucositis is more severe if you are treated with the following:

• Stem cell transplants
• Radiation for head and neck cancer
• Combined chemotherapy and radiation therapy
• High-dose treatment
• Frequent dosing schedules, such as weekly chemotherapy

The technique used to administer radiation may also impact the severity and duration of mouth sores. The following radiation techniques tend to produce less severe side effects:

• Hyperfractionated radiation involves lower doses administered more frequently, resulting in less severe side effects.
• Intensity-modulated radiation therapy (IMRT) spares normal tissues, reducing mouth sores, while still delivering the full radiation dose or even an increased dose to the cancer.

What makes mouth sores worse?

A number of factors contribute to the severity of mouth sores, including:

• Poor oral and dental health prior to treatment
• Kidney disease
• Younger or older adults
• Smoking and the use of chewing tobacco during episodes of mucositis
• Harsh foods and alcohol
• Concomitant disease such as diabetes or AIDS

How are mouth sores treated?

Until recently, the only approaches to managing oral mucositis included good oral care; mouthwashes; cryotherapy (sucking on ice chips) to minimize the damage from chemotherapy drugs; Salagen®, a drug that stimulates salivary flow; and other investigational treatments. A promising new approach to the prevention and treatment of mouth sores is the use of growth factors. Growth factors are natural substances produced by the body to stimulate cell growth. The new drug Kepivance™ is a growth factor that is produced in a laboratory and designed to protect the cells in the mouth and GI tract from mucositis.

Oral care: Good oral care, defined as frequently rinsing the mouth with saline and brushing teeth 2-3 times per day, may help prevent mouth sores.

Mouthwashes: Salt and soda mouthwash has been shown to relieve mouth sores as well as medicated mouth washes, and is less expensive. In fact, some researchers suggest that rinsing with chlorhexidine, an antimicrobial drug used to treat gum disease, did not provide benefit, and actually increased the risk of mouth sores in chemotherapy patients.

Rinsing with a mouthwash containing the ulcer drug sucralfate has produced varied results in the treatment of mouth sores. Sucralfate has been shown to reduce mouth sores, but other researchers have found salt and soda to be equally effective.

Cryotherapy (ice chips): Symptomatic relief from mouth pain can be achieved by sucking ice chips when the chemotherapy drug is most concentrated in the body. This technique, called cryotherapy, works by decreasing blood flow to the cells in the mouth, reducing exposure to the drug and decreasing the risk of developing mouth sores. Furthermore, according to a recent Cochran review, sucking ice is the only measure proven to prevent mouth sores.

Low Platelets

What is Thrombocytopenia?

Thrombocytopenia refers to the presence of abnormally low levels of platelets in the circulating blood. Platelets, or thrombocytes, are a specific kind of blood cell that prevent bleeding. The most common reason that cancer patients experience thrombocytopenia is as a side effect of chemotherapy. When chemotherapy affects bone marrow, the body’s ability to produce platelets, the body’s chief defense against bleeding, is diminished. Platelets normally rush to the site of an injury and work with other blood factors to from a blood clot. Normally, there are billions of platelets in the blood; however certain chemotherapy drugs can lower the platelet count. The fewer platelets an individual has in his/her blood and the longer he/she remains without enough of them, the more susceptible he/she is to bleeding.

Chemotherapy-induced thrombocytopenia typically occurs 6-10 days following administration of the chemotherapy drugs and continues for several days before platelets recover to an appropriate level. Infrequently, cancer patients may also experience thrombocytopenia from other medications or as a consequence of their underlying cancer. When discussing the consequences and management of thrombocytopenia, it is important to distinguish between chemotherapy-induced thrombocytopenia and thrombocytopenia resulting from other causes.

The type and dose of chemotherapy also has an effect on how low the platelet count drops and how long it will take to recover. While receiving chemotherapy, a patient’s blood may be tested frequently to make sure he/she has enough platelets. Thrombocytopenia, or “low platelets”, are terms used to describe a low platelet level in the blood. Fortunately, having a low level of platelets can be corrected for many patients.

Why is Chemotherapy-Induced Thrombocytopenia Important?

Chemotherapy involves the use of drugs to destroy cancer cells. Chemotherapy works by destroying cancer cells that grow rapidly. Unfortunately, chemotherapy also affects normal cells that grow rapidly, such as blood cells forming in the bone marrow, cells in the hair follicles or cells in the mouth and intestines.

When patients experience thrombocytopenia following administration of chemotherapy, they are at risk of certain side effects. Specifically, the fewer platelets in the blood and the longer a patient remains without enough platelets, the more susceptible he/she is to experiencing bleeding. Thrombocytopenia confers a risk of bleeding and the magnitude of risk is closely correlated with the severity and duration of thrombocytopenia. As the platelet count falls below 20,000-50,000; 10,000-20,000; and less than 10,000 cells/µl, the frequency of life-threatening bleeding rises steeply from approximately 5-6% to 10% and 20-40%, respectively. Patients developing thrombocytopenia require treatment with platelet transfusions and occasionally, admission to the hospital, until the platelets return to sufficient levels in the blood to prevent bleeding.

Thrombocytopenia is important for another reason. When patients are treated with chemotherapy, it is for the purpose of destroying cancer cells in order to reduce symptoms from their cancer, prolong their survival or increase their chance of cure. Chemotherapy may be administered as a single drug or in combination with several drugs. The combination of chemotherapy drugs administered to a patient is referred to as a treatment regimen. In a chemotherapy treatment regimen, drugs are administered to patients at a defined dose and according to a specific time schedule. The dose and time schedule of drugs administered in the chemotherapy regimen has been scientifically derived to produce the best chance of survival or cure. When patients develop thrombocytopenia following administration of chemotherapy, doctors may have to delay treatment or reduce the doses of the chemotherapy. Clinical studies have shown for certain diseases that when the dose of therapy is reduced or the treatment cycles prolonged, patients have lower cure rates than if they had been able to receive therapy at the full dose on schedule. Fortunately, there are strategies for the treatment of chemotherapy-induced thrombocytopenia that have been proven to reduce the need for platelet transfusions and help patients receive their treatment on schedule.