Low White Blood Cell Count

Neutropenia is a low level of white blood cells. Because radiation therapy and chemotherapy destroy cells that grow at a fast rate, white blood cells are often affected. Patients receiving a combination of radiation therapy and chemotherapy are at greater risk for neutropenia.

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 an infection. Since these cells also help to fight off infections once in the body, it may be harder to get over an infection when your white blood cell counts are low. Therefore, you need to take precautions to decrease the risk of infection while receiving treatment.

Your white blood cell count will be checked periodically throughout the course of your treatments. Any time that your white blood cell count drops below 1,000 per mm3, you will be considered neutropenic. Should this happen, a nurse will review with you special steps that you must take in order to decrease the chance that you will get an infection. These neutropenic precautions are discussed below.

What Can I Do To Prevent Neutropenia?

Since white blood cells are destroyed as a side effect of chemotherapy, there is nothing specifically that you can do to prevent neutropenia from occurring. Nonetheless, there are several things that you can do to reduce your risk of getting an infection when your white blood cells are low:

• Wash your hands frequently, especially before eating and after using the bathroom.
• Use alcohol-free, antiseptic mouthwashes daily.
• Do not cut or pick at cuticles. Use a cuticle cream instead. Even if you have a manicure, only cuticle cream should be used.
• 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.

• Stay away from people who are ill.
• 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-peak times, when they are not as crowded.

• 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.
• Do not receive any vaccination, including the flu vaccine, unless your oncologist has approved it.
• Avoid activities that are prone to falling and/or injury, including but not necessarily limited to bicycling, roller-blading, skating, and skiing.

If you cut or scrape the skin, clean the area immediately 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 considered to be neutropenic. Until your count rises, it will be necessary for you to take additional measures to further decrease your risk for infection.

• Take your temperature by mouth four times each day. Call your oncologist if your oral temperature is above 100.5o F.
• Eliminate uncooked foods, which may contain germs, including:
  • raw meats or fish salads
  • natural cheeses
  • uncooked eggs
  • sushi and sashimi
• You may eat fresh fruits and vegetables if they are thoroughly washed and peeled.
• 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 when you schedule your appointment that you are receiving chemotherapy. You may want to suggest that your dentist contact your oncologist prior to your scheduled dental work.

When Should I Call My Doctor?

Even if you have taken great care to prevent an infection, you may still become infected. 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.

• oral temperature above 100.5o degrees, chills or sweats
• cough, excess mucous, 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, mediport, feeding tube, urinary catheter)
• pus or drainage from any open cut or sore
• an overall feeling of being sick, even if you don't have a temperature or any other sign of an infection

How is Neutropenia Treated?

Growth Factors

One of the most significant advances in the past decades has been the development of "growth factors," which stimulate the body's production of specific substances. One growth factor stimulates the growth of white blood cells and is used frequently with cancer patients, especially those receiving chemotherapy and radiation therapy. By increasing your body's production of white blood cells, this growth factor can decrease your risk of developing an infection.

Growth factors are administered by injection, usually 24 hours after your chemotherapy has completed.

Neulasta® Onpro® On-body Injector

An on-body injector is sometimes used so that you don't have to return to the office the next day for an injection. Your cancer care team will explain how it works and what you need to do. If you have any issues with your on-body injector, watch this video for recommended next steps.

What to Do If You Develop an Infection?

If you develop an infection, your doctor will order medications to treat the infection. Depending on the cause and severity of the infection, the medications may be given either by mouth or through a vein using an intravenous (IV) catheter. If you require IV medications, accommodations can be made for you to receive them in our office or possibly at home. Some patients require admission to the hospital in order to effectively treat their infection.

If necessary, your oncologist may decide to delay further treatments until your white blood cell count has returned to normal levels and/or you are free of infection.

Low Platelets-Thrombocytopenia

Platelets are the blood cells that help the body to form clots. This is important to prevent bleeding from cuts or other injuries. Normal platelet counts usually range between 150,000 – 400,000 per mm3 of blood. Anytime platelets drop below 50,000 per mm3, there is an increased risk for bleeding. If platelets drop below 20,000 per mm3 and there are signs of bleeding, then you may require a platelet transfusions.

There are a number of causes for low platelets. Some patients have low platelets as a result of receiving chemotherapy; others may have autoimmune diseases or blood disorders. Whatever the cause of the low platelets, there are several precautions to follow to prevent injuries that may result in bleeding.

• Excessive bruising
• Tiny, pinpoint red spots on your skin (called petechiae)
• Bleeding gums
• Nosebleeds that do not stop
• Excessive bleeding from an injury that will not stop even after pressure has been applied
• Dark colored urine or blood in your urine
• Blood from the rectum, blood in the bowel movement (BM), or black colored BM
• Menstrual bleeding that is heavier than usual, lasts longer than usual, or occurs between periods

What to do to avoid bleeding

• Avoid strenuous activity, contact sports, lifting heavy objects, bending from the waist, straining to cough, blow your nose, or constipation.
• Avoid medications (see below) that affect blood clotting (unless approved by your doctor).
• Do not take aspirin or any product that contains aspirin. Check the labels of all drugs you are taking for salicylic acid, the chemical name for aspirin. If you are not sure about a drug or cannot tell by reading the label, check with your oncologist, nurse or a pharmacist. Do not take any non-steroidal, anti-inflammatory medications such as Motrin®, Aleve®, Advil®, etc. For headaches or other pain, use acetaminophen (Tylenol®).
• Avoid procedures that may cause a break in the skin. Avoid rectal exams, vaginal exams, vigorous thrusting during sexual intercourse, enemas, suppositories, douches, tampons, vaginal or rectal applicators, rectal thermometers, dental exams, surgeries, etc.
• Take special precautions with personal hygiene.
• Avoid falls in the shower or tub by using slip guard mats.
• Keep your teeth clean with a soft toothbrush. Do not use alcohol-based mouthwashes. Do not use dental floss. Keep your lips moist with lip balm to prevent cracking.
• Use an electric razor for shaving.
• Wear shoes to protect your feet.
• Avoid tight constrictive clothing or jewelry.
• Use stool softeners to avoid hard bowel movements that may cause injury to the rectum.

• Bleeding that does not stop after applying pressure for 15 minutes.
• Bleeding from the rectum, blood in the stool, or black stools.
• Blood in the urine or dark colored urine.
• A change in your vision.
• Persistent headache, blurred vision, or a change in your level of consciousness such as decreased attention span, excessive sleepiness, confusion, or difficulty being awakened.

*If you have a major injury or start spontaneous bleeding, go immediately to the nearest emergency room.