Every cancer patient in active treatment shares a common enemy — infection. Developing an infection can mean hospitalization, delays in treatment, serious complications and additional care.

People in cancer chemotherapy and radiation treatment are most vulnerable to infection at a certain time in the treatment cycle when the number of neutrophils (a kind of white blood cell) dips very low. This is called neutropenia, and usually occurs 10-14 days after receiving chemotherapy. Neutropenia leaves people vulnerable to infection, since the body no longer has a normal number of white blood cells to fight off infection. Each person has a unique pattern of neutropenia within these general guidelines, so if you become neutropenic, you and your health care team need to determine your pattern and monitor you accordingly.

Not every patient receiving cancer treatment experiences neutropenia — but many do. Many people develop neutropenia yet never contract an infection. Finally, people can contract infections without being neutropenic — which is why every cancer patient needs to understand how to reduce the chances of infection through personal effort, and how to respond to the signs and symptoms of infection, should any occur.

Once the white blood cell count drops, most people's blood counts remain depressed for a week or ten days (again, each person is different and unique). This is called your nadir — your low point in blood counts when your resistance to infection is weakest. During the nadir, cancer patients must do everything possible to

• Minimize the chances of infection
• Seek immediate treatment, if you even suspect infection.

Once your nadir is past, your white cell counts begin to rise again, and the immediate danger of infection eases a bit. However, infection is always possible for people in cancer treatment. If infection is suspected, you must act at once to seek diagnosis and treatment.

While you should always do everything possible to reduce the chances of getting an infection, it's important to understand that despite your best efforts, infection may occur. Many cancer patients contract infections during the course of their treatment, despite hard work to prevent it, simply because their bodies cannot fight off all onslaughts of bacteria from many sources (including their own bodies) while in a weakened condition from treatment. What's important, once a hint of infection is present, is how quickly you seek help and treatment. Infections can become deadly very quickly — and time is of the essence.

Symptoms

The warning signs of infection can be subtle — so it is very important for every cancer patient and his or her caregiver to know them well. The National Cancer Institute identifies these warning signs:

• Fever over 100º F or 38ºC
• Chills, especially shaking chills
• Sweating
• Loose bowel movements
• Frequent urge to urinate or a burning feeling when you urinate
• A severe cough or sore throat
• Unusual vaginal discharge or itching
• Redness, swelling, or tenderness, especially around a wound, sore, ostomy, pimple, rectal area or catheter site
• Sinus pain or pressure
• Earaches, headaches or stiff neck
• Blisters on the lips or skin
• Mouth sores

The most common indicator of infection, often the one most patients notice first, is a slight increase in temperature. This demands immediate action on your part! Call your health care team at once. An infection that is untreated, even for a short time, can very quickly become life-threatening while you are in treatment for cancer.

The purpose of seeing your health care provider quickly is to determine if your fever or other symptoms are triggered by an infection. Not all fevers in cancer patients are due to infection. Sometimes people develop fevers from the chemotherapy or immunotherapy medication itself, or even the cancer itself. Your health care team will be able to determine the cause in your case, and start necessary treatment.

A special warning: should your temperature rise high (104º F) very quickly, it is possible that you might develop convulsions or seizures. This is an emergency situation, and your caregivers should have you taken to the closest emergency room at once, explaining that you are receiving cancer treatment.

Prevention

Cleanliness is a key weapon each of us can use to fight infection. Another is making certain to get sufficient rest, and to eat well to maintain a well-nourished body. Here are some prevention tips recommended by cancer survivors and health care providers to follow at all times, with particular attention during your nadir:

• Wash your hands frequently, using soap and running water. Make sure you wash rings that you wear, too. And don't forget to moisturize your hands after washing.
  
  
• If you must garden, you must wear gardening gloves — sturdy ones, too. Avoid pruning tasks and other yard work where you can be scratched.
  
  
• Keep your whole body very clean and your skin soft. Shower every day and use good quality moisturizers everywhere on your body to avoid dry, cracked skin.
  
  
• Avoid injuring your gums with too-vigorous toothbrushing. Use a soft brush, a mild toothpaste, and gentle brushing technique. If you use an alcohol-based mouthwash, consider not using it during your nadir.
  
  
• Avoid the sick. Stay far away from people with other infections and diseases, a cold, the flu, etc. Politely explain that their presence can endanger you, so they don't think you've become unfriendly. Stay in touch by phone or e-mail.
  
  
• During your nadir, avoid large crowds of people if possible, especially in enclosed spaces like movie theatres. Large crowds can mean lots of sniffles, colds and so forth.
  
  
• Be careful of the sun. When you are outside, wear sun block. Blisters from a severe sunburn can invite infection.
  
  
• Exercise special cleaning techniques after a bowel movement. Remember, many infections develop not from other people's germs and bacteria, but your own. Wipe thoroughly but gently from front to back. If you suffer from hemorrhoids, ask your health care team for recommendations for cleaning your rectum.
  
  
• Be especially careful using razors for shaving. If possible, use an electric razor.
  
  
• If you cut or scratch yourself, immediately clean the wound with soap and water, apply an antibiotic or antiseptic cream, and cover the wound.
  
  
• Some health care professionals recommend that women who are menstruating use sanitary napkins instead of tampons. It is believed that tampon use is more likely to promote infection.
  
  
• If you must clean a pet's litter box, cage or other habitation, wear gloves and a mask while doing so.
  
  
• Managing food and food preparation is important as well:
  
  
  • Food preparation means washing your hands immediately before and after handling any food, especially during your nadir.
    
    
  • During your nadir, avoid fresh fruit and vegetables that cannot be peeled. If these can be peeled, wear gloves while you do the peeling.
    
    
  • Focus on fruits that can be peeled and eaten, such as bananas, melons, oranges, grapefruits. These should all be washed first.
    
    
  • If your tap water is a concern, use bottled water while in treatment, or consider purchasing a home faucet filtering component.
    
    
  • To reduce the chance of contamination from bacteria, wipe clean the tops of cans and jars before opening them.
    
    
  • Many health care providers strongly urge people in cancer treatment to avoid raw food — period. This means no raw shellfish, sushi, and no raw, uncooked fruit or vegetables that cannot be peeled, especially sprouts and raspberries.
    
    
  • While you are on treatment, give up that rare burger. In general, all meats, poultry and seafood should be cooked through before you eat it. This rule applies to eggs, too — avoid runny centers.
    
    
  • Whether or not alcohol is permitted in your diet will depend on your conversation with your health care team. In general, alcohol adds stress and work for your liver and kidneys — essential organs that are already under additional stresses from your cancer treatment.
  
  
• Don't have any routine medical or dental care unrelated to your cancer without consulting first with your oncology health care provider. Anyone treating you during this period will need to consult with your oncologist before proceeding.
  
  
• In general, think before you act, as often as possible. Annoyingly, fighting the odds of infection is just one more reminder that life with cancer isn't the same as life before it — but the time and thought you give to finding the safest possible ways to care for yourself will pay dividends. And it won't go on forever.

Treatment

If you develop an infection while you are neutropenic:

• You'll receive systemic antibiotics — meaning antibiotics delivered by IV, usually in a hospital setting, where your progress can be monitored.
  
  
  • When you are first seen, you'll immediately have blood drawn to help determine the cause and nature of your infection — but meanwhile, health care providers should immediately start you on a broad-spectrum antibiotic, especially if you are neutropenic or have a history of frequent infection, even before a complete diagnosis is made. Which medication is selected will depend on your kind of cancer and your condition. This is excellent medical practice, exercising caution and taking no chances, because infections can accelerate so fast. You may also have other examinations, such as chest x-rays and cultures taken to check for other possible causes of infection. If you have a catheter (a central line) implanted for delivery of medications, this may receive special attention, as it is a common site of infection.
    
    
  • The reason for hospitalization is to monitor your condition while waiting for the results of your tests. Once the organism causing your infection is identified (and this can take from 24 to 48 hours), your treatment might be altered.
    
    
• For most infections, antibiotic treatment will continue for 5-10 days, depending on the cause of infection, your response to treatment, and your overall condition. You may not be required to stay in the hospital throughout this time; many people go home once it is clear the antibiotic therapy is working.
  
  
• If your infection does not respond after a week or so, your health care provider may decide to add an antifungal and/or antiviral medication to your treatment.
  
  
  • In some cases, based on symptoms and past history, these medications may be started right away.
    
    
• Talk with your health care team about the following approaches to help with a fever:
  
  
  • Increasing your fluid and food consumption a bit; both help people with fevers feel better.
    
    
  • Using ice packs to reduce your fever. They will advise you how best to do this, if it's appropriate.
    
    
  • Taking your temperature. Find out what temperature indicates the need to call your health care team.

Managing Neutropenia

Untreated neutropenia can cause people with cancer to have to delay their treatments — never a good idea. If you experience significant neutropenia that is causing great fatigue and even delays in treatment, your health care team may want to treat you with granulocyte growth factor to raise your white blood cell counts. These medications, G-CSF (Neupogen) and GM-CSF (granulocyte-macrophage colony stimulating factor — Neulasta), stimulate your bone marrow to produce more white blood cells — which, in turn, reduces neutropenia and the likelihood of infection. This enables you to continue with your treatments as planned. Using these medications also helps manage fatigue, a particularly unpleasant side effect of treatment.

Understand that taking these medications does not eliminate the risk of infection — but it does reduce the chances of it. You'll need to remain vigilant to the warning signs of infection, even if you're receiving Neupogen or Neulasta.

These medications are usually given by injection under the skin (subcutaneously), over a number of days. Your health care provider will determine how many days of shots you'll need. Many patients are successfully taught to self-administer these medications, including those at the National Cancer Institute. It isn't hard, and self-administration means you will not have to go to a physician's office every day for shots. Ask your health care provider to teach you to self-administer these medications, which will need to be kept in your refrigerator for your use. If self-administration is a problem and traveling to your doctor's office is a problem, it may be possible to teach a family or friend to administer the medication. Failing this, home health care staff can come to your house and give the injection every day.

These medications have side effects, which vary from patient to patient. Some of the more common side effects are:

• Bone pain, especially during the first cycle of the medication
  
  
  • Over-the-counter pain relievers usually control this pain; if that doesn't work, consult your health care team for relief.
    
    
• Skin sensitivity around the injection site
  
  
• Fever and chills: let your health care provider know at once

Growth factors are expensive medication. If you need assistance in finding ways to cover the costs (and many insurers will pay for it if prescribed by a physician), speak with your oncologist. Often the pharmaceutical manufacturers will offer programs that cover the costs of the medication, but physician involvement is essential in making the application. Don't let the cost of this medication keep you from using it.

Questions for Your Doctor

In treating infection and neutropenia, your health care team may include an oncologist, nurse, infectious disease specialist, internist and social worker.

1. What are your recommendations on how I can best protect myself from infection?
   
   
2. What are the warning signs of infection?
   
   
3. Am I at especially high risk for infection? Why? And are there additional steps I should take to further protect myself?
   
   
4. Specifically, if I suspect an infection, who should I call first? And should I be prepared to come in for further examination?
   
   
5. If I have a fever, should I try to manage it first, or immediately seek your help?
   
   
6. How will you treat my infection? What will be your first steps?
   
   
7. Are the medications I am taking for my cancer likely to cause neutropenia?
   
   
8. Should I be given treatments like Neupogen before I am neutropenic, to head off this condition?
   
   
9. If you do not recommend treatment to avoid neutropenia, please tell me why not?
   
   
10. Are there any conditions under which you would be unwilling to treat me for neutropenia?
    
    
11. If I am given Neupogen or another medication like it, what side effects should I expect? How should I manage these?
    
    
12. Once I am given treatment for neutropenia, will the treatment continue throughout my course of cancer treatment?
    
    
13. Will you provide assistance in helping me receive medications like Neupogen at little or no cost, if I am uninsured and need financial assistance?

Resources