Chemotherapy Induced Neutropenia
Editor: Dr. Heidi Kussmann, ND, FABNO
Some cancer specific treatments can cause neutropenia. People who have cancer are unique in that the cancer they have is inherently immunosuppressive [1], and the cancer treatments are immunosuppressive.[2] Chemotherapy-Induced Neutropenia (CIN) is a type of acquired neutropenia due to a direct stem cell toxic effect upon the bone marrow. It causes a decline in neutrophil production that is transient but which has serious complications. When the neutrophil number becomes too low to support the immune response to everyday pathogenic bacteria and viruses, a person with neutropenia cannot engage their immune system and easily become infected throughout the body’s blood circulation system, leading to sepsis and death.
Contents
Causal Factors
Chemotherapy-induced neutropenia is caused by various types of radiation and chemotherapies.[3] Below are examples of the more common chemotherapy agents with known adverse effects of Grade 4 Neutropenia (ANC <500/mm3):
- Taxol + Carboplatin
- Irinotecan +5Flourouracil
- Gemzar + Carboplatin
- Navelbine
- Cytoxa, Oncovin, Adriamycin and Prednisone
- Taxanes
- Cyclophosphamide + Epirubicin + Flourouracil
Characteristics
Blood levels of neutrophils are tested before each chemotherapy infusion. Generally accepted neutropenia occurs when a neutrophil count is reduced to less than 1000 cells/mm3. When the Absolute Neutophil Count (ANC) is measured at less than 500cells/mm3, serious life-threatening infections tend to occur.[4] Normal values for ANC are between 3000-7000/mm3. [5]
Related Signs, Symptoms and Conditions
Some of the initial non-emergency symptoms that can indicated compromised humoral and cell-mediated immune function include:
- mouth sores/stomatitis
- irritation of the mucosal surfaces in the mouth with eating salty, sour, spicy or sweet foods
- fatigue or a change in energy requiring more naps and resting often.
Symptoms that indicated a worsened state and that may require emergency intervention include:
- fever indicated by a single oral temperature over 101F (38.3C) or a temperature greater than 100.4F (38.0C) for more than 60 minutes.[6]
Naturopathic Assessment
Registered and licensed naturopathic doctors do not differ from medical doctors in their approach to monitoring their patients who have cancer for signs of neutropenia. The assessment process is as follows:
- Monitor blood neutrophil and ANC counts either weekly or biweekly (via CBC with Differential).
- Perform physical examination when symptoms or fatigue levels are reported to change, or at regular intervals if patients are not monitoring their symptoms.
- Educate patients about taking their oral temperature, and, if it fits the definition of a fever than advise patients to report to the emergency department of their local hospital/urgent care center or MD office for treatment.
Naturopathic Treatment
Lifestyle strategies and other factors aid in prevention, early detection and treatment of chemotherapy-induced neutropenia.
Early Detection
To ensure that signs of a comprised immune system are identified early, patients with cancer are adviced to follow these steps.
- Take an oral temperature at the same time each day and report any elevation as well as the time duration of the temperature elevation. Some people have temperatures that elevate in the evening and return to normal by morning. This is a medical emergency if the ANC is below normal limits and needs to be reported immediately.
- Monitor for taste changes, oral tenderness or mouth sores and tongue soreness. Check the inner surface of their mouth for white spots or a white coating on their tongue, which could indicate thrush or a Candidal infection, as this often occurs in treatment and can cause further complications. Thrush is a sign of decreased immune function and when combined with ANC below normal it can be serious.
- Caregivers should record temperature changes and other symptoms about oral health and general wellness from the beginning of diagnosis and the start of treatment. To have a record of changes and become educated in detecting symptoms which indicate a downward trend in immune function is important in tracking and preventing neutropenia related complications.
- Naturopathic Doctors should ask about the above and note changes in functional immunity from baseline assessment, lab values, physical examination and with each office consultation.
Prevention
Prevention is one of the naturopathic principles. The following steps will assist in preventing chemotherapy-induced neutropenia.
- Following general hygiene including hand washing regularly before coming into contact with someone who is receiving chemotherapy, as the germs on the hands of well-meaning family and friends are the same germs that can cause sepsis in an immune-compromised individual.
- Promote hugging with family, friends and children instead of kissing, or try the European cheek to cheek greeting.
- Kitchen hygiene includes cooking food well and avoiding raw foods where possible to prevent parasitic, E. coli, infections (i.e. avoid rare-cooked steak, steak tartar & sushi; wash fruits and vegetables with a good fruit/vegetable detergent).
- People with cancer are advised to:
- avoid shaving with razors and use electric razors if necessary.
- avoid contact with poison ivy/oak and others who have chickenpox, HSV, the common cold, or other communal diseases. Alternatively, family members who are sick can also wear an N-95 mask to prevent spread of droplet and airborne bacteria and viruses when sick and in the company of someone with cancer.
- avoid public swimming pools and saunas of any type if their ANC is below normal limits.
Evidence-Based Prevention Strategies
Do not attempt to self-prescribe any Natural Health Product or Drug to prevent neutropenia without the guidance of a Licensed and Registered Naturopathic Doctor with additional expertise and certification in Oncology. When treating any complication of cancer or chemotherapy diligence regarding dosage guidelines and drug interactions are required.
Research has indicated the following are beneficial to prevent Chemotherapy-Induced Neutropenia.
- Echinacea angustifolia, pallida, purpures root alcohol extract [10]
- Honey from bees pollinating Echinacea and Echinacea pallidum, Uncaria tomentosa, Eleutherocossus senticosus, Urtica dioica, Calendula officinalis, Ribes nigrum, Chicorium intubus, Vaccinium myrtillis, Inula helenium, Avena sativa, Melilotus officinalis, Ficus carica, Beta vulgaris [16]
- Helianthus tuberosus [17]
- Viscum album, low dose. [18]
References
- ↑ Stevenson H, Tsang KY. Tumor immunology. In. Virella G, ed. Introduction to Medical Immunology. 3rd ed. New York:Marcel Dekker; 1993:497-515
- ↑ Kopreski, MS. Interactions between chemotherapeutic drugs and biologic agents. In:Chabner BA, Long DL, eds. Cancer Chemotherapy and Biotherapy. 2nd ed. Philadelphia:Lippincott-Raven; 1996:765-785.
- ↑ Zidan J et al. Prevention of chemotherapy induced neutropenia by special honey intake. Medical Oncology. 2006; 23(4):549-552.
- ↑ Casciato, DA, Manual of Clinical Oncology, 5th ed. Lippincott Williams & Wilkins, 2004 pp. 657 – 682.
- ↑ Fischback, F. A Manual of Laboratory and Diagnostic Tests, 6th ed. Lippincott. 2000 pp. 50-52
- ↑ Casciato, DA, Manual of Clinical Oncology, 5th ed. Lippincott Williams & Wilkins, 2004 pp. 657 – 682.
- ↑ Imataki O, et al. Pancytopenia complicated with peripheral neuropathy due to copper deficiency: clinical diagnostic review. Intern Med 2008;47(23):2063-5.
- ↑ Imataki O, et al. Pancytopenia complicated with peripheral neuropathy due to copper deficiency: clinical diagnostic review. Intern Med 2008;47(23):2063-5.
- ↑ Khanna-Gupta, 2009
- ↑ Braunig B, Dorn M, Knick E. Echinacea purpurea radix: zur Starkung der korpereigenen Abwehr bei grippalen Ifekten. Z Phytother 1992;13:7-13. In: Melchart D, et al. Results of five randomized studies on the immunomodulatory activity of preparations of echinacea. J Alt Comp Med. 1995;1(2);145-159.
- ↑ Melchart D, et al. Results of five randomized studies on the immunomodulatory activity of preparations of echinacea. J Alt Comp Med. 1995;1(2);145-159.
- ↑ Goel V, et al. A proprietary extract from the echinacea plant (Echinacea purpurea) enhances systemic immune response during a common cold. Phytother Res. 2005;9, 689-694.
- ↑ O'Neill W, McKee S, and Clarke AF. Immunological and haematinic consequences of feeding a standardized Echinacea (Echinacea angustifolia) extract to healthy horses. Equine vet J. 2002;34(3)222-227.
- ↑ Scaglione F, Cattaneo G, Alessandria M, Cogo R. Efficacy and safety of the standardized Ginseng extract G115 of potentiating vaccination against the influenza syndrome and protection against the common cold. Drugs Exper Clin Res. 1996;22(2):65-72.
- ↑ Keith I, Block and Mark N. Mead Immune System Effects of Echinacea, Ginseng, and Astragalus: A Review Integr Cancer Ther 2003 2: 247
- ↑ Zidan J et al. Prevention of chemotherapy induced neutropenia by special honey intake. Medical Oncology. 2006; 23(4):549-552.
- ↑ Veruska BM, et al. Helianthus tuberosus agglutinin directly induces neutrophil migration, which can be modulated/inhibited by resident mast cells. Biochem Cell Biol. 2005;83:659-666.
- ↑ Savoie A, et al. Activation of human neutrophils by the plant lectin Viscum album agglutinin-I: modulation of de novo protein synthesis and evidence that caspases are involved in induction of apoptosis. J Leuk Bio. 2000; 68:845-863.
