Find out how cancer drugs can affect your bone marrow, blood and blood cells and what treatments are used to help.
What bone marrow is
Bone marrow is a spongy material that fills the bones.
It contains early blood cells, called stem cells. These develop into the 3 different types of blood cells.
Normally stem cells in your bone marrow keep dividing to make new blood cells. This keeps the numbers of cells circulating in your blood within a normal range.
When doctors measure the number of blood cells you have, they call this your blood count.
White blood cells are part of your immune system. The white cells that fight infections are called neutrophils.
When the number of white cells in your blood is low, you are more likely to get infections because there are fewer neutrophils to fight off bacteria and viruses.
When your level of white blood cells is very low you have a high risk of infection. This is known as neutropenia (pronounced new-troh-pee-nee-ah).
Treatments can lower your white blood cell levels
Some drugs lower your white blood cell levels. So your white cell count will begin to fall after each treatment.
With some treatments your blood count can stay low until the treatment ends.
You might have treatment every few weeks. That means your white blood cell count will be at its lowest mid way between treatments. For example, if you have treatment every 3 weeks, then your lowest counts will be at about 7 to 14 days after your treatment.
This is called the nadir (pronounced nah-deer).
You will probably feel very tired. You might also feel depressed at this time.
After the nadir, the level of white blood cells gradually goes up until it is almost back to normal. Then, it is time for your next treatment and they will go down again. It is not surprising that many people feel as if they are on a roller coaster, emotionally as well as physically, when having some types of cancer drugs.
Antibiotics to fight infection
You might have antibiotics to fight infection during your chemotherapy or biological (targeted) therapy treatment.
Your doctor checks your number of white cells with regular blood tests. If you need antibiotics you might be able to have them as tablets or capsules to take at home. But sometimes you may need to have antibiotics given directly into your bloodstream (intravenously) in hospital.
Doctors sometimes prescribe antibiotics before you get an infection, to try to prevent it from happening. These are called prophylactic antibiotics. Prophylactic (pronounced prof-il-ak-tik) just means preventative.
If you think you have an infection
If you get an infection when your white blood count is likely to be low, you must contact your doctor urgently. You might need antibiotics straight away.
Your specialist will tell you if you are at risk of infection and should give you contact telephone numbers for emergencies. Ring immediately, day or night, if you have any symptoms that suggest you might be developing an infection, such as:
- a sore throat
- a high temperature (fever)
- pain passing urine
- a cough or breathlessness
- any redness or swelling, for example around a drip site or central line
Growth factors for white blood cells
Your doctor might decide to give you injections of man made (synthetic) blood cell growth factors if your level of white blood cells goes very low.
These growth factors boost the number of white blood cells your body makes. The growth factor used in cancer treatment to boost white blood cells is granulocyte colony stimulating factor (G-CSF).
There are different types of G-CSF:
- Lenograstim (Granocyte)
- Filgrastim (Neupogen, Zarzio, Nivestim, Ratiograstim)
- Long acting (pegylated) filgrastim (pegfilgrastim, Neulasta)
These growth factors all work in a similar way. The treatment usually starts a few days after you have your cancer drug. You have G-CSF as a small injection into the fatty tissue of your stomach, arm or leg.
With filgrastim or lenograstim you have a daily injection for up to 7 days. These are the most commonly used forms of G-CSF.
The pegylated filgrastim releases the G-CSF much more slowly in the body so that it works over a longer period. It is given as a single injection after each treatment cycle instead of a number of daily injections. Pegylated filgrastim is not used very often.
Side effects of G-CSF
All treatments cause side effects but the side effects of G-CSF are usually quite mild. They can include:
- a skin rash and reddening around the injection site
- bone pain in the legs, arms, back or hips
- feeling sick
- a high temperature (fever) and chills
If you have any of these side effects tell your doctor or specialist nurse. They may be able to give you medicines to help.
Red blood cells contain haemoglobin which carries oxygen around the body. When the level of haemoglobin in your blood is low, it is called anaemia.
You can feel very tired. You might also become breathless because the amount of oxygen carried around your body is lower.
Some chemotherapy drugs and biological therapies can make you anaemic. During treatment you have regular blood tests to check the number of red cells in your blood.
You can have a blood transfusion if they are very low. The new red cells in the blood transfusion pick up the oxygen from your lungs and carry it around your body to other tissues and organs. After a transfusion you will feel more energetic, less tired and less breathless.
You might worry about getting an infection from a blood transfusion. All blood is now very carefully screened before it is used. The chances of getting an infection from a transfusion are extremely small.
Red blood cell growth factor (EPO)
Erythropoietin (or EPO) is a natural growth factor made by the kidneys.
It encourages the bone marrow to make more red blood cells. In certain circumstances, EPO can help you to feel less tired and breathless. EPO can be made in the laboratory in larger amounts than we make naturally in our bodies.
Its names include epoetin alfa, beta, theta and zeta (Eprex, NeoRecormon) and darbepoetin alfa (Aranesp).
The National Institute for Health and Care Excellence (NICE) says that women with ovarian cancer who have had chemotherapy with platinum drugs such as carboplatin or cisplatin can have EPO.
NICE also says EPO can be used in people with other cancers who have severe anaemia due to cancer treatment but can't be given blood transfusions. Research suggests that it is only these groups who are likely to benefit from this type of treatment.
Some studies seem to show that EPO might not be safe for people with breast cancer, head and neck cancers, or cervical cancer. You can ask your doctor whether it could be helpful for you.
Taking EPO and its possible side effects
You have EPO as an injection just under the skin (subcutaneous injection). How often you have the injection depends on your situation and level of anaemia. You could have it 3 times a week, once a week or every 3 weeks.
EPO can cause side effects, like any drug. Possible side effects include:
- flu-like symptoms
- high blood pressure
- blood clots
Platelets help to clot the blood to prevent bleeding.
If the number of platelets in your blood is low you might:
- bruise easily
- bleed more than usual, even from small cuts or grazes
- have nosebleeds
- have a rash of small purple or red dots
The rash is called purpura and is caused by bleeding within the skin.
If your platelet count is very low you will need a platelet transfusion in hospital.
You have a drip of a clear fluid containing platelets. It takes about 15 to 30 minutes for each bag of platelets to go through into your vein. The new platelets start to work right away. You can have a platelet transfusion in hospital as often as you need one.
Growth factors are being developed that may boost the number of platelets in your blood. These are not yet used routinely.
Which drugs affect blood cells
Some cancer drugs can slow the production of blood cells by killing them off as they grow and divide.
Chemotherapy drugs and some biological therapies can reduce your red cell, white cell and platelet counts.
The white blood cell count usually goes down first, because these cells have the shortest life span in the blood. So if your bone marrow isn't making new ones, the numbers start to drop after a few days.
Other drugs such as hormone therapies and bisphosphonates are very unlikely to affect your blood cells.
Drugs affect people in different ways
Even if a drug can cause a drop in blood cells, it may not affect you.
Drugs affect people in different ways and it is not possible to tell in advance who will have side effects. It depends on:
- the drug or combination of drugs you are having
- the dose
- how you react to the drug
- how you have reacted to drug treatment in the past
If you have low blood counts
There are precautions you need to take if you have a low blood count due to cancer drug treatment.
- Tell your doctor or specialist nurse immediately if you get a temperature over 38° Centigrade (100° Fahrenheit)
- Tell your doctor or nurse straight away if you notice any bleeding or bruising
- Put pressure on cuts for longer than usual to stop bleeding
- Try to avoid cuts and grazes - wear thick gloves if you are gardening
- Keep as clean as you can and wash your hands before preparing food or eating
- Wash all fruit and salads well in clean water
- Try to eat a healthy diet
- Make sure cooked food is properly heated through to kill off bacteria
- Keep away from animals to avoid infection, especially cat litter trays and bird cages
- Let your doctor know if you have pets, so they know about any possible infection risks
- Rest when you feel tired and avoid doing too much in the middle of each treatment cycle - your blood counts will be low and you might feel very tired
- Avoid contact with anyone who has, or may have been, exposed to chicken pox - let your doctor know if you think you may have been close to anyone with chicken pox
Breakdown of tumour cells (tumour lysis syndrome)
Tumour lysis syndrome can be a complication of having some cancer drugs. It can happen when large numbers of cancer cells are killed. It is most common during treatment for high grade lymphoma or acute leukaemia.
When cancer drugs kill the cancer cells, the body breaks down the dead cells. In tumour lysis syndrome, large amounts of substances produced by the breakdown of these cells are released suddenly into the bloodstream. One of these is uric acid. High levels of uric acid can cause kidney damage.
You also have changes to the levels of chemicals such as potassium, phosphate and calcium in your blood. These changes can affect your heart or kidneys. Your doctor will closely monitor your blood levels during treatment.
Preventing tumour Iysis syndrome
If you are at risk of tumour lysis syndrome, you usually have:
- extra fluids before your treatment - a drip of fluids before you start your treatment helps to flush any extra chemicals out of your body
- drugs such as allopurinol or rasburicase to help keep the levels of uric acid in your blood stable