Core Counseling Points for Chemotherapy Patients
Core counseling points for patients undergoing chemotherapy include anemia, thrombocytopenia, diarrhea, constipation, chemotherapy-induced nausea and vomiting (CINV) and infection risk.
Although these are not the only topics that should be covered during patient education, they include some of the most frequent chemotherapy side effects. Providing patients with key counseling points associated with their treatment helps keep them safe, empowering them to identify and report any side effects to their provider. This article does not aim to serve as a substitute for medical advice, but as a conversation starter between patient and provider.
Neutropenia & Infection Risk
White blood cells (WBC), also known as leukocytes, are made up of neutrophils, eosinophils, basophils, monocytes and lymphocytes. These cells are essential when mounting an attack against foreign invaders, such as bacteria, in the body. Out of all of the different WBC in the body, neutrophils are the most common. These first responders are essential to the immune system as they are the first to arrive and recruit other cells in response to an attack. To eliminate unwanted invaders, neutrophils engulf their target and break them down with enzymes.
Unfortunately, chemotherapy kills neutrophils along with other healthy cells, while trying to eliminate cancer. Generally, this reduction in healthy immune cells weakens the immune response. This exposes patients taking chemotherapy to infections that they would not normally obtain. In severe cases, a condition called neutropenia may arise. This is when the total number of neutrophils in the body drops extremely low. During this time patients are advised to take extreme caution and continue to follow infection prevention strategies. This includes washing hands regularly, practicing good oral hygiene, staying away from family/friends who are sick, avoiding uncooked foods and wearing a protective mask when in highly populated areas (ex. supermarket).
Washing hands and using alcohol-based hand sanitizers tend to dry out the hands; moisturizers or lotions may be used to combat this. Practicing good oral hygiene keeps the mouth moist and reduces the risk of getting mouth sores; soft toothbrushes also help reduce gum bleeds. Uncooked food is more likely to carry unwanted bacteria versus cooked food and that is why it should be avoided. Wearing a protective mask is encouraged, but not required as social distancing and avoiding highly populated areas can be effective.
Thrombocytopenia & Anemia
This monster of a word, “thrombocytopenia” refers to the reduction of an essential player in wound healing, platelets. These cell fragments are found in the blood and move throughout the circulatory system until activated. Once activated, platelets move to a site that is damaged and adhere to its surface. As more and more platelets arrive they form a colt. This can be thought of like the body’s version of a plug. In this condition there is a severe drop in how many platelets are circulating within the body. As a consequence, it is harder for your body to plug up damaged blood vessels, resulting in excessive bleeding.
Thrombocytopenia is closely monitored by treatment centers through blood work. Platelet counts are assessed through a complete blood count (CBC) laboratory test which includes platelet concentrations in the blood.
At home, this condition can be monitored through observation. Patients should report increased bruising, darkened stool, darkened urine or cuts that won’t stop bleeding to their provider, as these may be signs of thrombocytopenia.
Red blood cells (RBC), also known as erythrocytes, are responsible for the transportation of oxygen throughout the body. Oxygen is loaded onto RBC in the lungs and shot out to the rest of the body by the heart. RBC return to the heart with carbon dioxide after making their deliveries. Carbon dioxide is then exchanged for oxygen in the lungs and shot out of the body when we breath. When there is a decrease in healthy RBC, there is a decrease in oxygen delivery. In severe cases this leads to another condition monitored through blood tests called anemia. Signs and symptoms that can be monitored for at home include fatigue, weakness, dizziness and shortness of breath.
There are several different types of anemia, however, one of the most common types seen in chemotherapy is “iron-deficiency anemia”. This type of anemia is due to low levels of iron within the body. Iron is required for the proper binding of oxygen to red blood cells. When iron levels drop, red blood cells are not able to effectively carry oxygen throughout the body. Patients may develop a sudden urge to eat things with no nutritional value such as clay, paper, ice or dirt; this is known as “pica” and is a sign of iron deficiency anemia. This condition usually is resolved with iron supplementation by the provider.
Constipation & Diarrhea
Constipation and diarrhea are both commonly associated with various chemotherapy regimens. Constipation is suspected when there are fewer than 3 bowel movements a week, while diarrhea is suspected when there are 3 or more watery stools in one day. A good non-pharmacological recommendation for both of these conditions is increasing the amount of total daily fiber consumed.
Constipation may arise from many sources such as supplemental iron, pain medication, chemotherapy medication or even the medications being used to prevent nausea and vomiting. In severe cases, constipation may lead to bowel perforation, which is when a hole is made in the intestinal lining. This hole then allows bacteria to leak into the body causing a cascade of problems. Constipation is typically managed first with stool softeners and lifestyle changes before moving to more aggressive therapies. Increased physical activity also helps push things along and has many other health benefits.
Diarrhea typically arises from chemotherapy medications. Irinotecan is an example of a chemotherapy medication that is closely linked to severe diarrhea. A silly, but effective way of remembering that irinotecan causes diarrhea is the term “I ran to the can” (irin-o-te-can).
Our biggest concern with diarrhea is the excessive loss of fluids and electrolytes, leading to dehydration and other complications. During my oncology rotation this past January, we would counsel patients taking irinotecan to keep a bottle of loperamide on hand at all times. This provides patients an immediate option to combat spontaneous diarrhea while at home or when out of the house. Avoiding triggers such as spicy foods can also help prevent the sudden onset of diarrhea.
Chemotherapy-Induced Nausea & Vomiting (CINV)
An antiemetic is a medication used to prevent vomiting.
Antiemetic therapy for chemotherapy-induced nausea and vomiting (CINV) relies heavily on what chemotherapy agents are being given to the patient. Some medications carry a high risk of developing nausea and vomiting, while others carry a low risk. This distinction guides how patients are treated with antiemetics.
According to the National Comprehensive Cancer Network (NCCN), agents can be divided into high, moderate, low and minimal emetic risk groups. Their treatment algorithm for CINV breaks down how each treatment group should be managed and what medications can be used. Many of these therapies utilize several drugs with different mechanisms of action. This helps attack nausea and vomiting from various different angles.
Some non-pharmacological therapies for CINV include avoiding foods that are known to trigger nausea such as excessive fatty foods, spices and sweets. Eating several small meals a day also helps improve symptoms and ensures that patients are well-nourished during chemotherapy; avoiding low energy levels, fatigue and malnutrition.
The goal of CINV therapy is to prevent nausea and vomiting from ever occurring. Most patients are issued prescriptions to take home for “breakthrough therapy”. These medications are used to help combat uncontrolled nausea and vomiting that presents 5 days following the administration of chemotherapy, despite being treated with appropriate antiemetics. In most cases, nausea does not resolve on its own and vomiting may occur. This is why it is encouraged to take these breakthrough medications at the first onset of nausea and not wait for it to pass. In addition to the unpleasant nature of vomiting, excessive fluid loss may lead to other complications such as dehydration, low blood pressure, fatigue and lethargy. Patients should notify their provider if they experience nausea or vomiting at home so that appropriate adjustments to therapy can be made.
Key Points
Anemia:
- Patients typically experience symptoms such as fatigue, weakness, dizziness and shortness of breath.
- Patients may develop a sudden urge to eat things with no nutritional value such as clay, paper, ice or dirt; this is known as “pica” and is a sign of iron deficiency anemia.
Thrombocytopenia:
- Patients should report increased bruising, darkened stool, darkened urine or cuts that won’t stop bleeding to their provider as these may be signs of thrombocytopenia.
Infection Risk:
- Patients should wash hands regularly, practice good oral hygiene, stay away from family/friends who are sick, avoid uncooked foods and if needed, wear a protective mask when in highly populated areas.
Constipation:
- Constipation is typically managed first with stool softeners and lifestyle changes before moving to more aggressive therapies.
- Increased physical activity also helps push things along and has various other health benefits.
Diarrhea:
- Our biggest concern with diarrhea is the excessive loss of fluids and electrolytes, leading to dehydration and other complications.
- Avoiding triggers such as spicy foods can also help prevent the sudden onset of diarrhea.
- Loperamide can be carried around in the event of spontaneous bouts of diarrhea.
CINV:
- Breakthrough medications should be taken at the first onset of nausea.
- Avoid foods that are known to trigger nausea such as fatty foods, spices and sweets.
- Eating several small meals a day helps improve symptoms and ensures that patients are well-nourished during chemotherapy; avoiding low energy levels, fatigue and malnutrition.
- Excessive fluid loss may lead to other complications such as dehydration, low blood pressure, fatigue and lethargy.
- Patients should notify their provider if they experience nausea or vomiting at home so that appropriate adjustments to therapy can be made.
Written by,
Peter Austin
Fairleigh Dickinson University School of Pharmacy & Health Sciences
