Bug off!

It is important to consider the risk of infection associated with chemotherapy early on.

Words: Michael Jameson and Jenni Scarlet
Medical treatment options for breast cancer depend on its stage at diagnosis and the specific characteristics of the cancer, such as potential sensitivity to hormones and other treatments. The treatments used, and the order in which they are given, will vary depending on whether the cancer is confined to the breast and glands in the armpit (early breast cancer) or has spread to other parts of the body (secondary or advanced breast cancer). Chemotherapy can be effective for early or advanced breast cancer, but other treatments may include surgery, targeted treatments such as trastuzumab (Herceptin), radiotherapy and hormone therapy (e.g. tamoxifen, letrozole, anastrozole or exemestane).
Chemotherapy treatment is usually only recommended for women with early breast cancer if there is a risk of cancer cells having spread outside of the breast and armpit area. Treatment with chemotherapy can lower the risk of breast cancer coming back or spreading to other parts of the body, and increase the chance of surviving breast cancer. It may also be recommended for other breast cancers that cannot be removed surgically, such as inflammatory and locally-advanced breast cancers.
The aim of chemotherapy for secondary breast cancer is to shrink the cancer, relieve symptoms, improve quality of life and keep it under control. The benefits of treatment with chemotherapy can last for some time - maybe for years.

Attacking cancer cells with Chemotherapy
Chemotherapy is the name given to a variety of medicines that destroy fast-growing cancer cells. There are different kinds of chemotherapy and the specific drugs, or combination of drugs, may depend on the type, stage and other characteristics of the cancer, what other treatments a person is receiving and their age and general health status. Chemotherapy is given in a series of cycles (for example, one cycle might consist of one treatment every three weeks). The doctors who prescribe chemotherapy include Medical Oncologists and Haematologists.

Risk of infection
Unfortunately chemotherapy can't tell the difference between fast-growing cancer cells and areas of the body where there are fast-growing normal healthy cells, such as those making hair, blood cells and the lining of the gut. As a result people may experience side effects such as losing their hair or getting mouth ulcers.
One of the more serious side effects that can occur with some types of chemotherapy is a fall in the number of white blood cells. One type of white blood cell that is particularly important for fighting off infections is called a neutrophil; when the number of these cells in the blood falls to particularly low levels, this is called “neutropenia”. Neutropenia affects many people with cancer undergoing chemotherapy, though it is more common with some types of chemotherapy than others. This leaves the person vulnerable to infections, even those that would not normally trouble healthy people, and any infection in a person with neutropenia can be very severe.

Signs of Infection
Signs of a more severe, life-threatening infection may include; 1) a fever (a temperature higher than 38 degrees Celsius; 2) chills; and 3) severe sweats. If these symptoms develop immediate medical advice should be sought as urgent treatment with antibiotics through a drip may be required. Waiting a few hours could be fatal. There may be other symptoms including: a cough; mouth ulcers or a sore throat; loose bowel motions; a burning sensation when urinating; unusual vaginal discharge or itching.

Reducing infection risk
Most people who have neutropenia with their chemotherapy do not get infections or other problems related to it. However, the risk of infection increases with the length of time a person has neutropenia on each cycle of treatment and how low the neutrophil count goes. Blood counts (including neutrophils) will be checked before each cycle of chemotherapy and sometimes part-way through too. If the white blood cell count drops, it will usually happen 1-2 weeks after a treatment, and can mean people are prone to catching infections.
Some steps to take to lower the chance of getting an infection include:
• Always wash hands well with soap and water and dry them thoroughly before you cook or eat, after you use the bathroom and after being in a public place
• Ask other people around you wash their hands well too
• Use a hand sanitizer if soap and water isn’t available
• Brush teeth after meals and before going to bed. Use a very soft toothbrush.
• Keep away from people who are sick, even if it is only a cold
• Try to keep away from big crowds and public places if possible
• Wash raw fruits and vegetables before eating
• Wash hands carefully after handling raw meat
• Cook meat well before eating it
• Have someone else clean up after the family pet
• Try not to get cuts; for example, use an electric shaver not a razor

Treatment of infection in a person with neutropenia
For most people who develop signs of an infection when they have neutropenia, treatment with antibiotics through a drip is needed in hospital, and this usually lasts until the neutrophil level has improved enough to be reasonably safe. Occasionally a person might be able to have antibiotics at home, but only after they have been assessed by a doctor experienced in looking after people having chemotherapy. Some people might need additional treatment that helps the body to produce more white blood cells to fight the infection. These are called granulocyte colony-stimulating factor (G-CSF) medicines. They have their own side effects, but using them is worthwhile in people with neutropenia who have a very severe infection.

Prevention of neutropenia
There are some situations where doctors prescribing chemotherapy in New Zealand agree that it is worthwhile using G-CSF to minimise neutropenia and reduce the risk of infections. This includes for people with curable cancers whose chemotherapy is more aggressive and is very likely to cause severe neutropenia for a long time, where the infection risk is particularly high, or where they have already had an infection with neutropenia. While the infection risk could be lowered by reducing the chemotherapy doses, or giving it less often, this could also mean that the treatment might not give such good results.

In conclusion
Ask the doctor or nurse involved in prescribing or giving your chemotherapy if it is going to put you at risk of infection. If it is then ask what steps you can take to reduce your risk of infection, what signs and symptoms of infection to look out for, and what to do if it develops.
References and useful websites:
www.cancer.gov
www.nbocc.org.au