radiotherapy

[dm2009]

Hi, I have been out of touch for some time. My sister finished her chemotherapy and has started radiation therapy. I have been busy with my sister's radiotherapy. She is experiencing low white cell count but no fever, she has received one GCSF, which has not raised the white cell count? Any suggestions.

[kontak TeamBCI]

Doctor Rohit and Sumeet will guide. Lets wait

[dm2009 in reply to kontak]

ok....dr rohit and Sumeet .... pls let me know

[sumeet_shah Administrator]

Well, it's difficult to point out the reason as such. Chemotherapy can occasionally have lingering effects. However, there could be many other causes. Sometimes, viral infections also cause low WBC count.

Assessment of the cause needs a proper assessment of the patient as also to review all reports. I suggest, you must visit your Oncologist and sit with him / her and discuss it out.

[roxboxfox RadiationOncologist]

1. When was her Last cycle of Chemotherapy, what were her prechemo bloods (WBC and neutrophil count)

2. What was the chemo regimen used ?

3. When was G-CSF given .... what brand .... what dose

was it given by hospital or by yourself

was it appropriately stored in the cold chain

4. Was G-CSF given as prophylaxis (means it was predecided by your oncologist to give this on D5 or D6 etc from the date of your chemo OR was this given on learning that the counts are low... oh so i must give it.

5. When was radiotherapy initiated ?

(We can calculate the gap between chemo and RT)

6. Did she have problems with her blood counts in the previous cycle 5, 4, 3, 2....... etc

if so what was the level of severity of neutropenia

Gr 1 just under the Lower limit of normal

Gr 2 < 1.5 ,

Gr 3 < 1.0 ,

Gr IV < 0.5

At the end all i can say it will come up with time, as the body heals and rejuvenates so will the Blood cells heal and mature and come out of the constant stress / bombardment done by the chemo.

All the best to your Sis ...

With best Wishes

Dr Rohit Malde

[Hidden in reply to roxboxfox]

Dr Rohit , thank you very much the way you are helping us.

I wish to know is this GCsf is the same Grafeel from Dr Reedy, s.

Do you favour gcsf and if so in which cases?These are costly injections as far I know.

Also, during infusion with every chemo, I suffered with severe headaches, is this related to any condition of blood supply to brain?

[dm2009 in reply to roxboxfox]

Hi dr rohit her last cycle was on jan 6 2015 she was given 4 AC 4 Taxol she recd grafeel twice 2nd 3 rd AC it was given in the hospital each time the grade of neutropenia was 2 she started radiation on 20 th jan 2015 14 th day post taxol TLC was 3640 p51 e12; 2nd week TLC 4100 P80 E8; 3rd week TLC 3700 P75. end of this week she recd prophylactic fastograf 300 mcg SC; 4th week TLC 3100 P62% so today she was given neupogen Roche. fastograf alkem was bought by us in the hospital apparently in b/ w cold pack was given sc in the hospital neupogen I had bought yesterday recd in cold pack imdkept in the fridge and carried with me in cold pack and given 300 mcg sc in the hospital now the counts will be done on coming mon ...........she will get her rad on fir and sat sun being rest

[dm2009 in reply to dm2009]

Thanks a lot

[PK53]

Hi dm2009

I had my chemo between Aug 2014 and Oct 2014. I was given G-CSF Neupogen (filgrastim) to maintain the White Blood Cells. During chemo my WBC counts were well above the lower normal. I had seven injections after the first day of chemo for each chemo sessions (painful days..)...Once the chemo was over I had a break for a month and then radiation. During radiation, my WBC came back to lower than normal (1.6) and continue to remain the same until today. Its going to almost two months since my radiation is over. My oncologist told me as I recover, my cells will nourish and it should get back to normal. She indicated that she will continue to monitor my situation.

I don't have fever or any other infection.

I will keep you posted if any other action has been taken in my case

Regards

PK

[dm2009 in reply to PK53]

Thank you and take good care of yourself

[roxboxfox RadiationOncologist]

Growth factors are of two type:

1) Short acting (G-CSF) FILGRASTIM available as Fastograf, Filgen, Fillif, Frastim, Grafeel, Neupogen, Grasfil

Std dose = 300 micrograms

These need to be given for at least 5-8 days on a daily basis as their half life = 3-4 hrs

2_ Long acting (GM-CSF) PEGFILGRASTIM available as Pegasta, Pegex, Neulasta, Neulastim, Peg-grafeel, Neupeg

Std dose = 6 mg

This is a single shot Injection with human half life upto 80 hrs.

It uses a Pegylated technology specially designed for slow release of drug over a period of time, so its expensive.

In Oncology, we use these growth Factors in 2 settings:

1) PROPHYLAXIS: To prevent an episode of Febrile Neutropenia, so as to prevent hospitalisation and its cost and more so to avoid any delay in the chemotherapy so as to maintain dose intensity.

2) Therapeutic Setting: Once episode of Febrile neutropenia has occured, then to prevent further episode.

The first indication is usually determined by clinical trial evidence and whenever the incidence of Febrile Neutropenia is >15-20%, one may use PROPHYLAXIS GROWTH FACTORS right from cycle 1

For eg when i use TAC , FEC-100, Docetaxel, dose dense chemotherapy like using AC every 2 weeks instead of 3 weekly..

Rest of the regimes, like AC, Paclitaxel, FEC 80 or 75, CMF, etc there is no reason to use it upfront.

However a few pts we encounter the counts are dropping, and GCSF may be introduced at the physicians discretion and patients anxiety level, affordability and concern.

In UK, in the latter category we used to give GCSF only if Absolute Neutrophil Count < 1.0 (Gr III Neutropenia), in US it may be 1.5 as the cut off.

After the 6th cycle of chemotherapy, i never test the Blood counts .... for the fun of it to see whether counts have come up or not ! ! !

I do them only if patient is symptomatic (eg FEVER or too unwell).

I usually tell my patients take a break and Radiotherapy is recommended 4-6 weeks later.As mentioned earlier in my post, there is no detriment in outcome as far as radiation is initiated within 12 weeks from clinical trials data. Still many patients are in a hurry as they dont want to miss the 1:40 am ki local train or the last bus, and hurry the clinician to initiate treatment early, or at times the clinicians may be in a hurry to grab the patients before someone else snatches their meal...

I must admit, that if Chemo has finished on 6th Jan 2015, and if Radiation is initiated on 20th Jan 2015, this is certainly a bit too early to have started treatment. My patient would have rested for the whole month of January 2015 , and we would have initiated Radiation comfortably in the first / 2nd week Feb 2015, thereby having given rest to human body which has just been recovering and recouperating from a battle.

Following completion of chemotherapy, there is little sense in requesting Blood tests to see if WBCs and neutrophils have recovered or not. It makes sense to spend money on a nice holiday and concentrate on rich and nutritious food items to aid the internal healing. Medical opinion and blood tests are needed, if you have fever, infection, cough, explosive diarrhoea or u feeling too unwell.

Everybody is different, someone may recover in 2 weeks, some may take 4 weeks, some may recover in 2-3 months. But if you are a HUMAN being, you will certainly heal and recover at some point thats a gurantee.

Just imagine, your self as a child, have you never been hurt or got a bruise, you have always Healed with or without a scar..thats the beauty of the HUMAN body.

A very happy Valentines Day to all of you a day ahead !!

Dr Rohit Malde MD, DNB, FRCR (UK)

Consultant Clinical & Radiation Oncologist

[Hidden in reply to roxboxfox]

Thanks doctor!Very informative.

[greenbear in reply to roxboxfox]

Thanks Dr. Rohit for all the details. Do we not need to check WBC counts after the last chemo to check if we have the necessary ammunition to face the infectious outside world especially in a place like Mumbai where you need to use public transport like the local trains? Also PK has written that her counts dropped after she started radiation. Can radiation cause a drop in WBC counts? I have not checked my blood counts after radiation.

[roxboxfox RadiationOncologist in reply to greenbear]

Well the counts are likely going to be low following 6th cycle of chemo. The counts may be low at 1st week or 2nd week or 3rd week or 4 the week or 5th week or 6th week or at times even low at 7th or 8th week.

So will u go out in public transportation every time after checking u r blood counts.

You are at risk we know that.

All what a blood test does is cause unnecessary anxiety.

Ignorance at times is bliss.

The indication of an antibiotic is only when u have an infection.

The decision to use growth factor has already been taken before u have the 6th cycle of chemo.

Either based on your previous counts u r at risk and u LLC be having growth factors...or u be been fine so far..there is no need for Growth factors.

If there was no plan for using growth factor, and someone gets a blood test after the 6 the cycle of chemo and he gives growth factor, one may argue that even if GCSF was not given the blood count would have come up spontaneously anyways.

In medical community there is always overtreatment and overinvestigations done in paying patients.

What I m telling is just evidence based and what is considered as basic minimum.

If someone has daily or weekly blood's I personally have no objection but all what I m saying it does not change my medical management.... nor will I downgrade the risk level... I would still say u r at risk of infection and stay away from anybody u think may be infected.

The worst case scenario is if u can't avoid travellingtravelling and u still have to go out there is infectious city of Mumbai...u may get an infection...and have a course of antibiotic which will cost Rs 114 as opposed to cost of growth factors.

Of course I m saying this only after 6th cycle as the Radiotherapy comes only at 4-6 weeks and even if its delayed upto 12 weeks there is no detrimental outcome at all.

We be been following this policy for the last 8 years and documenting outcomes of the hospitals where I ve worked with no concerns.

Even in India for the last 1.5 years the same policy.

Out of may be 16-18 pts just given oral antibiotics to just one patient.

Look at Please she us absolutely fine no fever no infection but just the fear or anxiety or concern that one goes thru at monitoring counts.

Of course every scenario is different as no 2 patients are alike, but here we are talking about broad guidelines about giving a message out there to our members that its OK if blood counts are not done after the 6th cycle. Unless u have fever, infection or u r unwell.

Believe me All is going to be well.

The outcomes are not going to be brilliantly better nor are they going to be worse.

So once u finish u r chemo my advice is take a break and spend time with u r family and loved onesones and ring u r doc only if u have fever or infection.

Regards

[dm2009 in reply to roxboxfox]

But guidelines say that radiation should be initiated within six months

[manish_vkg TeamBCI in reply to roxboxfox]

Well explained...thanks dr

[greenbear]

I am a bit confused by what you have written Dr. Rohit. It is mentioned on the net and also my oncologist and Dr. Sumeet confirmed that nadir for FEC chemo is usually 8-14 days after infusion. During chemo we were asked to not have raw fruits and vegetables, avoid crowded places, eat home cooked food etc to avoid infections as our immunity was low due to low blood counts. And it was not about infections that could be easily cured but serious infections like pneumonia, septicemia, hepatitis which could sometimes become fatal . I have never taken any growth factors but my blood counts came back to normal before the next cycle. I also took leave and stayed at home throughout the entire FEC cycle for these reasons. After my last cycle of FEC my blood counts dropped after 7 days but came back to normal after 3 weeks, I had radiation therafter and am now back to work. My work requires me to travel by Mumbai's train and also to eat out. So what I wished to know was that since my blood counts came back to normal can they drop once again for some reason like radiation. I do know that there could be a drop due to infection. In other words am I still at risk as I was during chemo.

[roxboxfox RadiationOncologist]

Radiation does not cause a drop in Blood counts. It is the chemotherapy which may have a delayed onset and result in a drop usually seen within 3-4 weeks. After the 3-4th week, unlikely it drops. Quite a few infections can result in a drop in WBC like for eg Typhoid.

Those pts who have had significant drop in their blood counts during chemo, have a knackered bone marrow, and it may take upto a month or two for it to normalise.

During your chemotherapy... you had bloods prechemo -1 Day ... subsequently did u have blood counts every week ? ??

you directly had them at D20 ( prior to cycle 2), then prior to cycle 3..... etc

After 6th cycle..... there is no cycle 7.... so no point in doing bloods that time. It seems silly to do bloods to see whether you can eat raw vegetable or fruits or go to crowded places or travel in train in Mumbai if blood counts are back to normal or not....

The serious infections you talk about ... Pneumonia, Septicaemia etc if when you have FEVER and you ignore them due to Ignorance of its severity, when we come across life threatening infections. The moment you have FEVER whilst you are on Chemotherapy = Emergency = Possibility of Neutropenic SEPSIS.

But low counts during chemo is not equal to emergency is not equal to Infection in not equal to need for Hospitalisation. It is just anxiety and tension for pts, and = more investigations = sleepless nights = more costs.

I would simply continue to follow precautions upto 4 or 6 weeks .... which you ve been doing anyways over the last 2.5-3 months.

And if u ve been travelling in the trains of Mumbai during chemo and taking risk .... then its your choice.

not everybody can afford taxis or have a car. As my advice is to avoid crowded places and avoid outside food etc for upto 4 weeks or so post chemo anyways, i do not need a blood test to give approval for travelling ..

I have a pt travelling from Virar... they cant afford to take taxi during their chemo or for their Radiation... Its the Virar Local train which is the most cost effective for this middle class family. My advice is to avoid crowded places etc etc but thats is ..... IF POSSIBLE,

This lady has eight members in her family in a 1BHK flat. These are circumstances beyond our control. Yet she has bravely fought her cancer, finished her chemo and in her last week of Radiation.

At the end, all what i can say, One may treat a patient comfortably without causing concern or anxiety to a patient, OR one may treat by being overcautious and overprotective and scaring the wits of it... telling a pt.. that this may happen and that may happen etc...

Giving right information to the patient is important, but overemphasising things and making a mountain out of a molehill is also not Appropriate.

[greenbear]

Thanks doctor Rohit. I have not travelled to work during chemo. I was on leave. I joined work 2.5 months after my last chemo. So from what you say I think it is OK. No one has scared me but I know of people who have passed away due to infections during chemo and not the cancer and hence wanted to be cautious.

[dm2009]

thanks dr rohit for the detailed information so now that we have finished the IV week from mon its the V week then 5 days of booster how do you suggest it should pan out .......