The Incidence Of Thrombocytopenia And The Use Of Platelet Transfusions Vary With The Type Of Chemotherapy
Although many factors may lead to reduction of chemotherapy RDI, it is difficult to identify how much is attributed to thrombocytopenia. In a review of different chemotherapy regimens in 614 patients with solid tumors, CIT was seen in 21.8% of all subjects thrombocytopenia was unaccompanied by other cytopenias in 6.2%.54 Grade 3 thrombocytopenia was seen in 3.6% and grade 4 thrombocytopenia in 3.3%. CIT occurred in 82% of those receiving only carboplatin, and in 58%, 64% and 59% of those receiving combination therapies with carboplatin, gemcitabine or paclitaxel, respectively.
In a retrospective analysis of 43,995 patients who received 62,071 chemotherapy regimens in the USA between 2000 and 2007,55 CIT occurred in 13,304 regimens. Grade 3 and grade 4 thrombocytopenia occurred in 2,660 and 2,087 regimens, respectively: 7.8% and 3.4% of gemcitabine-based regimens 6.5% and 4.1% of platinum-based regimens 3.0% and 2.2% of anthracycline-based regimens and 1.4% and 0.5% of taxane-based regimens.
The incidence of thrombocytopenia-related bleeding and platelet transfusions has been very poorly studied in CIT. Bleeding events were not measured for the 62,071 chemotherapy regimens described above, but platelet transfusion data were available for 10,582 transfusions occurred in 2.5% of patients . Table 3 provides an overview of the reported frequencies of thrombocytopenia and platelet transfusions with various chemotherapy regimens.
How Do I Know If I Have Thrombocytopenia
A complete blood count measures the levels of the three basic blood cells: white cells, red cells and platelets. In the United States, the CBC is typically reported in the following format:
Result column: The result column shows counts that fall within the normal range.
Flag column: The flag column shows counts that are lower or higher than the normal range.
Reference Interval column: The reference interval shows the normal range for each measurement for the lab performing the test. Different labs may use different reference intervals.
White blood cells: White blood cells help protect individuals from infections. The above CBC report shows that the patients total white cell count is 1.5, which is lower than the normal range of 4.0-10.5. The low white cell count increases the risk of infection.
Differential: This portion of the CBC shows the counts for the 5 main kinds of white cells, either as percentages , or as the absolute number of cells .
Absolute neutrophil count: Neutrophils are the main white blood cell for fighting or preventing bacterial or fungal infections. In the CBC report, neutrophils may be referred to as polymorphonuclear cells or neutrophils. The absolute neutrophil count is a measure of the total number of neutrophils present in the blood. When the ANC is less than 1,000, the risk of infection increases. The ANC can be calculated by multiplying the total WBC by the percent of polymorphonuclear cells. For example, this patients ANC is .34 = 1.5 x 23%.
Why Blood Counts Are Important
The number and type of cells in your child’s blood can tell the doctor a lot about your child’s condition. A blood count helps to show the doctor how well the treatment is working. If your child is getting chemotherapy or radiation therapy, the doctor needs to check the blood counts regularly to see what effects the treatments have on normal cells.
The next section lists the different kinds of cells in the blood, the signs and symptoms to look for when blood counts are low, and suggestions for caring for your child at home.
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Clinical Consequences Of Low Platelets And Thrombocytopenia
Compromised Chemotherapy Outcome
The standard practice of reducing the dose of chemotherapeutic drugs and/or delaying treatment to avoid the risk of clinically significant bleeding secondary to thrombocytopenia could result in suboptimal outcome, including reduced antitumor efficacy and/or reduced survival rates or shorter duration of remission.
The study of Bonadonna et al has provided the longest follow-up data for analysis of the relationship between delivered dose and survival outcome. In this study, patients received either 12 cycles of adjuvant CMF chemotherapy or no chemotherapy after radical mastectomy for primary breast cancer with positive axillary lymph nodes. Chemotherapy doses were reduced in older patients and if myelosuppression was present. A total of 386 women, including 179 who received no chemotherapy after mastectomy and 207 who received adjuvant combination chemotherapy, were followed for approximately 20 years.
Results consistent with Bonadonnas findings were provided by a large randomized prospective study that evaluated outcome effects following treatment with three different dose levels of cyclophosphamide, doxorubicin, and fluorouracil. This study observed significantly longer disease-free survival and overall survival rates after a median of 3.4 years among women treated with high or moderate dose intensity regimens, compared with women treated with less intense doses.
Lifestyle Changes To Lessen The Risk Of Bleeding:
- Avoid strenuous activity and lifting heavy objects.
- Avoid sports and activities that could result in falling and/or injury, like bike riding, roller-blading, skating, and skiing.
- Drink 8 to 10, 8-ounce glasses of non-alcoholic fluid a day to keep your mouth moist, to avoid constipation, and to keep the intestinal lining working well.
- Wear shoes or slippers at all times to protect your feet.
- Do not wear tight-fitting clothing.
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Not All Cases Of Thrombocytopenia In Chemotherapy Recipients Are Due To Chemotherapy: The Clinical Approach To Thrombocytopenia In The Cancer Patient
Although chemotherapy and radiation are by far the major causes of thrombocytopenia in the cancer patient, other etiologies should be considered in all patients. In general, the following checklist should be considered in cancer patients with platelet counts less than 100×109/L.
Is the underlying disease the cause of the thrombocytopenia?
Tumor that metastasizes to bone marrow is common in patients with breast and lung cancer as well as in those with primary hematologic malignancies such as lymphoma. Most such patients also demonstrate pancytopenia and these cytopenias generally occur when over 80% of the bone marrow is infiltrated. As discussed below, patients with infiltrated bone marrow respond poorly to TPO-RA.27
Is there an associated immune thrombocytopenia?
Up to 1% of patients with Hodgkin disease,28,29 2 to 10% of patients with chronic lymphocytic leukemia,30-32 and 0.76% of patients with other non-Hodgkin lymphomas29 develop a secondary ITP. These patients respond to steroids, rituximab, splenectomy, and TPO-RA just like patients with primary ITP,33 although treatment of the underlying lymphoma may be effective.29
Has there been a recent infection?
Has the patient received a new medication? Heparin-induced thrombocytopenia should be considered.37 Antibiotics and antiviral agents commonly induce thrombocytopenia either by direct bone marrow toxicity or by immune drug-dependent antibody clearance.38,42
Does the patient have a coagulopathy?
What Can Cause A Low Platelet Count
There are several common causes, including:
Chemotherapy. Some types of cancer medications, such as chemotherapy, damage bone marrow. This is the tissue inside your bones where your body makes platelets. A low platelet count from chemotherapy is usually temporary. It is rare that chemotherapy permanently damages bone marrow cells.
Radiation therapy. Radiation therapy does not usually cause a low platelet count. But your platelet levels may go down if you receive a large amount of radiation therapy to your pelvis or if you have radiation therapy and chemotherapy at the same time.
Antibodies. Your body makes proteins called antibodies. They destroy substances that may harm you, such as bacteria and viruses. But sometimes the body makes antibodies that destroy healthy platelets.
Specific types of cancer. Certain cancers such as leukemia or lymphoma can lower your platelet count. The abnormal cells in these cancers can crowd out healthy cells in the bone marrow, where platelets are made.Less common causes of a low platelet count include:
Cancer that spreads to the bone. Some cancers that spreads to the bone may cause a low platelet count. The cancer cells in the bones can make it difficult for the bone marrow inside of bones to make platelets.
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Treatment Delays During Folfox Chemotherapy In Patients With Colorectal Cancer: A Multicenter Retrospective Analysis
Lawrence G. Kogan1, S. Lindsey Davis2, Gabriel A. Brooks1,3
1Department of Medicine, University of Colorado Cancer Center , 3Norris Cotton Cancer Center, Lebanon, NH, USA
Contributions: Conception and design: GA Brooks Administrative support: None Provision of study materials or patients: None Collection and assembly of data: All authors Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors.
Background: FOLFOX is the most commonly used chemotherapy regimen for the treatment of colorectal cancer. FOLFOX is administered in 14-day cycles, though toxicities frequently lead to unplanned delays. We report the incidence of unplanned delays among patients receiving FOLFOX and describe the reasons for delays.
Methods: We conducted a retrospective analysis of patients receiving FOLFOX chemotherapy for colorectal cancer. Patients were treated at one of two tertiary cancer centers between January 2012 and April 2016. Cycles 26 were assessed for delays, and treatments were considered delayed when the interval from prior treatment was > 18 days. Reasons for unplanned delays were categorized based on review of clinical records.
Keywords: Treatment delay chemotherapy neutropenia oxaliplatin fluorouracil
Submitted Apr 12, 2019. Accepted for publication Jun 06, 2019.
Increased Bleeding And Bruising
Chemotherapy can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot.
Tell your doctor or nurse if you have any unexplained bruising or bleeding. You may have:
- blood in your urine or stools
- tiny red or purple spots on your skin that may look like a rash.
Some people may need a platelet transfusion. This is given by drip . The platelets will start working immediately to prevent bruising and bleeding.
Here are some tips for avoiding injury:
- Wear protective gloves when doing work around the house or in the garden.
- Be careful to avoid bumping into things or tripping.
- Use a soft toothbrush to protect your gums from bleeding and do not floss.
Your doctor or specialist nurse will tell you if the chemotherapy is likely to cause hair loss. Knowing what to expect gives you time to prepare and find ways of coping.
The digestive system is made up of the stomach and bowels. Chemotherapy can affect the digestive system in different ways.
You may need to go to hospital to have fluids through a drip.
You may get a bitter or metal taste in your mouth. Sucking sugar-free sweets may help with this. Some foods may taste different or have no taste. Try different foods to find out what tastes best to you. Taste changes usually get better after treatment finishes. Your nurse can give you more advice.
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Signs And Symptoms Of Low White Count
A decrease in the number of white blood cells is called neutropenia . If your child’s ANC is low, there is an increased risk of an infection. Signs of infection include:
- Any areas of redness, warmth, or pain
- Drainage from central venous catheter site
If your child is exposed to any contagious diseases call the hematologist/oncologist.
Your Bone Marrow And Blood
Chemotherapy can reduce the number of blood cells made by the bone marrow. Bone marrow is a spongy material that is found in the middle of your bones. It makes special cells called stem cells. These develop into the different types of blood cells:
- red blood cells, which carry oxygen to all parts of the body
- white blood cells, which fight and prevent infection
- platelets, which help the blood to clot and prevent bleeding and bruising.
You will have regular blood samples taken to check the number of these cells in your blood. This is called a full blood count.
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The Pathophysiology Of Thrombopoietin In Chemotherapy
Thrombopoietin is the major regulator of platelet production. In animals or humans deficient in TPO or its receptor, the platelet count is 1015% of normal.84,85 Megakaryocyte, erythroid, and myeloid precursor cells are all reduced in such knock-out animals but their white blood cell and red blood cell counts are normal.86 TPO is produced by the liver usually at a constant rate and its production is decreased by liver disease87 and increased by interleukin-6 in rare conditions such as that associated with ovarian cancer.88,89 TPO has no storage form and is secreted into the circulation and cleared by TPO receptors on platelets. In disorders such as in CIT, TPO levels are inversely related to the rate of platelet production and rise in a log-linear fashion .90-93
How Is A Low Platelet Count Treated
During chemotherapy. If you have a low platelet count during chemotherapy, your doctor may decide to adjust your treatment. You might get a lower dose of chemotherapy or wait longer between treatment cycles. Your doctor may prescribe a drug called oprelvekin . It helps prevent an extremely low platelet count.
Before surgery. If you are preparing for surgery and have a low platelet count, you may need to wait until your platelet counts are normal again to have the operation. This lowers the risk of heavy bleeding.
When platelet counts are very low, you may receive a transfusion. A transfusion of platelet cells into your blood can help prevent heavy or unexpected bleeding. However, this is a temporary treatment. The platelets from a transfusion only last about 3 days. If you have many transfusions, the platelets do not usually last as long each time.
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Possible Late Effects Of Chemotherapy
Sometimes side effects do not go away, or they can develop months or years after treatment. These are called late effects.
Late effects may be minor and not affect your daily life much. Or, they may be more difficult to live with. There are usually things that can help you cope with them. Some late effects improve over time and may eventually go away on their own.
Your cancer doctor or specialist nurse can explain any possible late effects of your chemotherapy treatment. Different drugs cause different late effects. Some drugs may cause an early menopause and infertility. We have more information about how cancer treatment can affect fertility in men and fertility in women.
How Is Chemotherapy Induced Thrombocytopenia Treated
The most common way to treat thrombocytopenia is with platelet transfusions. Transfusions only temporarily correct thrombocytopenia and are associated with complications.
Platelet Transfusion: The goal of a platelet transfusion is to prevent or stop bleeding. Traditionally, the assessment of a patient for a platelet transfusion was based on a clinical trigger value, which is a laboratory value below which a transfusion was automatically prescribed. However, transfusions are associated with complications. It is important to carefully evaluate all options when considering a platelet transfusion, as the benefits should outweigh the risk or complications of transfusion.
Although improvements have lowered the risk of transfusion-transmitted complications, the only way to effectively eliminate the risk is to avoid exposure to allogeneic blood. Despite the risks, platelet transfusions are common treatments for thrombocytopenia associated with cancer and chemotherapy.
Complications of Platelet Transfusion: Patients receiving platelet transfusions are at risk for several reactions that range from mild allergic reactions to life-threatening anaphylaxis. Febrile reactions are the most common, occurring in 1 in every 100 transfusions, but most are not a significant clinical problem. Clinically, the most significant complications are the immunomodulatory effects of alloimmunization, immunosuppression and graft-versus-host disease , all of which are rare.
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Numb Or Tingling Hands Or Feet
Sometimes the feeling in your hands or feet can be affected by chemotherapy. This usually gradually gets better after treatment ends. This may take several months or more.
Sometimes nerves do not fully recover and you may continue to have difficulty with fiddly tasks. This could be things like picking up very small objects or doing up buttons.
People generally find these kinds of changes become less noticeable over time as they adapt and find ways of coping with them. We have more information about peripheral neuropathy.
When Should I Call My Care Team
- Bleeding does not stop after you have applied pressure for 10 to 15 minutes.
- You have blood in your urine or your urine looks dark in color.
- You see blood coming from your rectum, have blood in your stool, or if your stool is black.
- You have a change in vision.
- You have a headache that wont go away, blurred vision, or a change in your level of consciousness such as trouble paying attention, sleeping more than usual, confusion, and/or trouble being woken up.
If you have an injury or start bleeding for no reason, go to the nearest hospital emergency room right away. Tell the provider that you are being treated for cancer and that your platelet count may be low.
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How Long Do Low Counts Last
Thrombocytopenia related to chemotherapy is often a short term problem. Platelet levels begin to drop around one week after a chemotherapy session and reach the lowest level at around 14 days following an infusion.
Platelets in the bloodstream live approximately eight to 10 days and are rapidly replenished. When levels are low, they most often return to normal in around 28 to 35 days , but may take up to 60 days to reach pre-treatment levels.
Delayed Hematologic Recovery In Aml Patients After Induction Chemotherapy Is Associated With Inferior Relapse
Tracy Murphy, Jinfeng Zou, Georgina S Daher-Reyes, Vikas Gupta, Caroline J McNamara, Mark D. Minden, Aaron D Schimmer, Hassan Sibai, Karen W.L. Yee, Tracy L. Stockley, Suzanne Kamel-Reid, Dawn Maze, Scott Bratman, Andre Schuh, Steven M Chan Delayed Hematologic Recovery in AML Patients after Induction Chemotherapy Is Associated with Inferior Relapse-Free Survival and Persistence of Preleukemic Mutations. Blood 2018 132 : 992. doi:
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