Written by Dr. Keith I. Block, MD
As I’ve discussed in recent blog entries, most patients don’t die from cancer, they die from the complications associated with the disease and its treatment. And the most deadly of these cancer-related complications is infections, particularly pneumonia. This problem is closely linked with the depleted number of white blood cells (WBCs), our immune system’s microscopic warriors against infection. It is these very white cells that are essential to protect us against infection, and it is our neutrophils (the most common type of white blood cells) that make up 60 percent of all of our immune cells. When the WBC count is low – as often happens in the wake of chemotherapy – we have what is medically known as neutropenia. Of course, when neutropenia does occur, one becomes more vulnerable to frequent infections and fevers.
Conventionally-administered cancer treatments are often an assault on the immune system. Chemotherapy-induced neutropenia is a major risk factor for potentially deadly infections, and so prevalent, approximately half of all chemotherapy patients will have their treatments postponed or altered at least once because their WBCs are precariously low.
The Most Deadly Infection
I often tell my patients to stay alert toward fever, chills, aching muscles, headache, nausea or other early signs of infection. Developing an infection while experiencing a moderate to marked neutropenia should be considered a medical emergency. If you suspect an infection, call your doctor and get yourself to the hospital as soon as possible. You will likely be started right away on a broad-spectrum antibiotic or antimicrobial therapy.
The most serious infectious disorder related to cancer treatment is sepsis. This involves the presence of toxic bacteria, fungi or (in some cases) viruses in the bloodstream and tissues. These pathogens can spread throughout the body, causing high fever and shivering. When the infection becomes overwhelming, it results in a major drop in one’s blood pressure and lack of blood flow (septic shock). The lack of blood flow and accumulation of toxins in the blood leads to malfunctioning of the brain, heart, kidneys, and liver. At some point, if the condition goes untreated, these organs eventually shut down altogether.
Among cancer patients, those most at risk for sepsis are older patients undergoing chemotherapy, and patients with hematologic cancers, namely lymphomas or leukemias, or any cancers that call for intensive chemotherapy. Other illnesses or conditions can further heighten your susceptibility to sepsis, including candida yeast overgrowth, diabetes, and any diseases of the genitourinary system, biliary system, or intestinal system. Prolonged antibiotic therapy and recent surgery are also considered additional risk factors.
About Neutropenia
Neutrophils are measured in terms of an “absolute neutrophil count,” or ANC. In healthy people, the normal range for neutrophils is 2,500 to 6,000 per cubic millimeter of blood. Once the ANC dips below 2,000, you are considered mildly neutropenic, and the risk of infection increases. At this point, you should take certain precautions to prevent infections: wash your hands frequently, steer clear of people with colds and flu; and try to avoid even minor cuts or tears in your skin.
Your oncologist will likely proceed with chemotherapy so long as the ANC stays in the 500-to-1000 range, or higher, which is considered moderate neutropenia. An ANC below 500 is classified as severe neutropenia, and is dangerous for two reasons: first, it places you at risk of life-threatening infections, and second, it means having to delay chemotherapy or reduce the amount of chemotherapy administered. Unfortunately, we know that delays in chemotherapy administration or reduction in dosing can lead to a less effective treatment, which can adversely impact outcome.
Among the major symptoms of neutropenia are the following: fever (temperatures greater than 100.4°F); chills and sweating; diarrhea or burning sensation during urination; sore throat or cough; mouth ulcers; and pain, redness, or swelling around a sore or wound. If you’ve recently had chemotherapy, don’t be overly alarmed by having fevers or chills, if they are single symptoms. But do be sure to contact your physician to check you out for an infection and neutropenia. Medical advice is certainly warranted in such situations.
Reversing Immune Suppression
To quickly restore chemotherapy-reduced white cell counts, there are two basic options. The usual strategy in recent years has been an injection with filgrastim (Neupogen), a synthetic version of a natural immune-stimulating substance our body produces called a colony-stimulating factor. Neupogen steps up the production of neutrophils, and it’s usually given shortly after your last treatment in a cycle and is continued for up to two weeks. Another drug, called pegfilgrastim (Neulasta), also may be helpful in preventing neutropenia accompanied by fever. This drug works just like Neupogen but has the practical advantage of requiring only one administration per chemotherapy cycle.
Both drugs just mentioned are capable of reducing the incidence and severity of neutropenia and the complications that accompany it. I also recommend taking additional steps to help you fortify your immune system and lower your risk of infections.
Immune fortification is best accomplished through an individually tailored nutrition and nutraceutical program that can include whey protein, specific micronutrients, melatonin, and other natural agents (which supplements and their appropriate doses are all determined by detailed testing). Supplementing with glutamine – 10 to 30 grams per day, depending on the type of cancer, and the extent of treatments you’ve received – may be especially helpful at this time. Echinacea, bromelain, astragalus, reishi and maitake mushrooms, and various other botanicals may be useful immune-restoring agents in this context. Glycine supplementation appears to be helpful against sepsis. Colostrum has also been used successfully to help reverse neutropenia, at least on an anecdotal basis.
Tending to your immune system is a whole-lifestyle endeavor, requiring attention to diet, exercise, rest, sleep and emotional well-being. The use of agents like those mentioned above can be used to improve general health, change the biochemical environment these cells reside in, help boost treatment effectiveness, and reduce treatment toxicity. I firmly believe – and my 30+ years as a clinician suggests – that if you are living in ways that enhance immunity, optimally supporting your immune system, and utilizing Neupogen and other pharmaceuticals as needed, you will greatly reduce your risk of a life-threatening infection following a diagnosis of cancer.
What are your thoughts on supplements for people on 10 mg Revlimid maintenance? Is it tricky to decide on which supplements to take because you don’t want to overstimulate the immune system? Do you have recommendations on supplements to mitigate the side effects of the drug?
Most important, based on the recent results of ASH, do you think that maintenance therapy is a good idea or is it better to give the body a break?
It’s very frightening to have this disease. Cancer is the cause of death of many people. Treating it might be hard for the person infected, but preventing it may be a bit easier by living a healthy life.
We should be more cautious when it comes to our health to avoid or at least prevent this kind of disease.
What do you recommend for stimuluting or not stimulating the immune system of a patient with Waldenstrom’s B cell lymphoma, who is just recovering from Klebsiella sepsis and febrile neutropenia while on Rituxin, cyclophosphamide and steroid chemotherapy with one cycle left to go? Which parts of your chapter 16 program are safe and which should be avoided, and when can whatever is safe be started? Thanks in advance.
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