Patient Power- Includes a video from 2012, that has lots of useful information about our immune system and the blood tests that are used to assess its condition. Dr. Susan LeClair explains in clear easy to understand terms.
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For people newly diagnosed, they are daunted by the alphabet soup of laboratory tests and results. How would you tell someone to begin to understand it so that they can begin to break down what’s significant for them?
Dr. Leclair:
I think the first thing I would look at might be the CBC, the Complete Blood Count, because that’s where the disease is diagnosed. That is where it will be followed predominantly. So if they get a good handle on that one, the rest of them they can pick up one at a time. The problem with the CBC is that it’s 20 different tests altogether, so out of that, the very first things I would want to know is: what is the white cell count? The higher it is, the less good it is, so if I had my choice between a 50,000 and a 100,000 white count I would want the 50. If I had my choice between a 25,000 and a 50,000 white count I would want the 25. The numbers themselves don’t mean as much as the type of cells, but that one is an easy one to grasp, you know, seeing how many cells there are.
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And then I would want to know the next question. Leukemia is a disease of white blood cells. What are the white blood cells and what’s going on? So I would want to know the absolute lymphocyte count, and the thing that I would be concerned about on that is how fast it is doubling. Now, there is a complicated formula that physicians will use, but you can get a rule of thumb if you just look at it and compare that number with the last one and see if it’s doubling. It shouldn’t. You don’t want it to double. You want it to double very slowly over years, rather than months. So that would be the next one I would want to know.
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I would want to know the hemoglobin. Somewhere around 10 grams of hemoglobin or if you’re Canadian 100 grams of hemoglobin, they use a slightly different measure, is where you start getting fatigue, pallor, shortness of breath, the general signs and symptoms of anemia. Lower than eight, you start getting actual damage to tissues. So I would want to know what that is in the sense of how am I feeling, am I going down? Up is good in that instance, down is not.
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I would want to know the platelet count. Platelets control how your blood clots, so I would want to know I have enough of them. The problem with “enough” platelets is that it doesn’t actually go by number because most people take aspirin and aspirin interferes with platelet quality. So you could have a very good number of not-so-good platelets, and that doesn’t work as well as a lower number of active platelets. So for that one I would just follow it again. The trend that you don’t want to see is downward, but if it’s bouncing around and you’re not bruising or bleeding, then you’re probably fine.
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Andrew Schorr:
I want to ask you about one for people in treatment. I know I started to pay a lot of attention to neutrophils.
Maybe you could explain what that is and why somebody who is getting these powerful medicines, why that number matters.
Dr. Leclair:
Okay. The neutrophil is the most common white blood cell in the peripheral blood. It should be somewhere around 60 percent of the cells. In absolute numbers, somewhere between 2- and 7,000 cells should be neutrophils. They are responsible for two big things: general defense against bacteria, viruses, and healing. We tend to ignore the one on healing a lot because we’re more interested in, oh, you have an elevated white blood cell count and they’re neutrophils so we think of infections. The problem when you don’t have enough of them is not only are you at risk for infections, you’re also much slower on healing.
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So how does that connect to the drugs? The drugs that you’re taking are to a certain extent cellular poisons. Sadly, the origin of chemical treatment of all malignancies is the mustard gas that was used in World War I. So it’s diluted, but still that’s the stuff we are using are cellular poisons. That’s the fludarabine. That’s the cytosine, or arabinoside. That’s all of those kinds of drugs. That means that these drugs are stupid. They don’t know sick cells from healthy cells. They tend to kill off cells that are short-lived, that are rapidly or metabolically active.
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Well, your neutrophils, your granulocytes only live seven days. They are extremely active because they are fighting off the bacteria that you gave yourself this morning when you missed your teeth and jabbed your toothbrush into the hard pallet and you scraped it a bit. Well, bacteria got into your bloodstream. The polys are supposed to get rid of it. If you don’t have enough of them or they don’t function well, then that bacteria stays around longer and you can have an infection from it. So what happens is physicians get nervous when the Absolute Neutrophil Count, the ANC, gets below two because that’s kind of like the minimum to keep you pretty much healthy.
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Between one and two they are going to tell you, oh, don’t go to rock concerts. Don’t go to weddings where everyone has to kiss people. Stay away from your grandchildren because as we all know--I have three--they are sewers of infection for you. So you just want to stay away from that. Wash your hands a lot. Make sure that you are a little bit comfortable in that sense.
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Below one you are a walking infection waiting to happen, so that’s again all of the things we just went through, and then you add on no raw foods. No foods that you can’t peel or cook to 165 degrees because you’re sitting there saying, oh, I’m going to have this wonderful strawberry except that strawberry is covered with bacteria. You eat it, you don’t have any white cells to fight them off, you could have a problem.
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And then there’s the healing issue. You were going down the stairs and you just tripped, you got a couple of bruises. Well, those bruises will be around for maybe three weeks, four weeks. And when you have dead or damaged tissue it’s very easy to set up other foci of other things. So granulocytes, neutrophils--we have not yet figured out what to call them--are critically important in that sense, and so we want to husband them. We want to care for them.
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New ones that are just coming out of the bone marrow are shy. They are like boys in the seventh-grade dance, they like to line up against the walls of the blood vessels and marginate. That’s what it’s called. You want to shake them off every now and then with a little bit of exercise. Not running a marathon, not doing a dash, but walking, climbing stairs if you can. Whatever it is that will get you moving gets them moving and will help you a little provide a little extra defense for yourself.
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Andrew Schorr:
I want to ask you a question that came in from someone who I suspect has had treatment. This is Marsha Glow wanted to know about IgG, IgA and IgM. And I know some people get infusions. What is all this stuff and where does it come into play?
Dr. Leclair:
In your plasma, in the liquid part of your blood, there are proteins. Within those proteins there are two basic kinds: albumin, which we’re not going to talk about, and globulins. Within the globulins there are four different kinds, one of which is the gamma globulins. Those are antibodies. Within the antibodies or gamma globulins there are five immunoglobulins that are identified as Ig A, M, G and so on.
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IgM--we’re going to do this in chronological order. IgM is the very first one that you make. When you were a baby you came out of your mother essentially with no immunoglobulins other than hers. You started to eat, you started to interact with the world around you, you developed antibodies. These are the first antibodies that you make. Those are IgM antibodies. Now that you’re an adult you went somewhere and you ate something that wasn’t so wonderful and you needed to develop antibodies against it. The very first ones that you’re going to develop still are the IgM because that’s the first one you make.
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But they just tend to disappear because they did what they were supposed to do in the early stage of damage and then they fall away. They are replaced by a memory antibody, and that’s the one we have to talk about because that’s IgG. IgG is what you have in your body right now from the Sabin vaccine you got when you were 16 and going off to school. It’s the antibody that you make every single year when you get the flu shot. It’s the antibody that stays around to remember what happened the last time so that you are able to respond faster or more efficiently the next time you see that antigen. The other three, A, D and E, we’ll just skip for the moment.
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IgG then is the one that you really want to have around because most of us have survived a lot of different experiences. The next door neighbor with the measles, your own German measles, whatever it happened to be, you’ve got that, and that provides you protection. Where do antibodies get made? They get made by lymphocytes. Mmm, which kind of lymphocytes? B lymphocytes. So now you get a person who has a malignancy of B lymphocytes. What do those B lymphocytes, those malignant ones, going to do? I don’t know. Some of them make antibodies just fine, for which we’re pretty grateful because it means that your immune system is probably going to function at least acceptably for the flu and for the usual things of life.
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Others make immunoglobulins that don’t work so well, and they cannot work so well in two categories. They can cross react to something. You make an immunoglobulin that is supposed to be against a bacteria that you sometimes get pneumonia, but that antibody is just different enough so that it eats your red cells, and you get an immune hemolytic anemia. So this is like a not-so-good reaction. The flip side to that is that these cells cannot make antibodies at all. Or they might make M or they might make some of the others, but they’re not going to make G, and at that point you lose the memory protection for measles, mumps, diphtheria, whooping cough, the flu, all of those kinds of things that got you to the age of 45, 55, 65, what have you.
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So what does that mean? That means any time somebody sneezes in your direction you’re probably going to come down with something because you have none of that memory defense. And if you put that lack of memory defense along with somebody who doesn’t have very functional granulocytes, well, now you’ve got a serious problem. So what do you do? You go get donated from somebody else, so it’s not exactly yours, you get infusions of IgG because that’s going to give you at least somebody else’s memory. Now, maybe it’s not as wise a person as you or as old a person as you, but it’s memory, and so you get immunoglobulins.
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Len
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