Leukemias & Nausea/Vomiting

Posted by Jenna at Thursday, July 28, 2011

Leukemias stem from 2 lines: the myeloid lineage (granulocytes including platelets, monocytes, basophils, eosinophils, neutrophils, & erythrocytes) or the lymphoid lineage (B & T lymphocytes). A leukemia diagnosis is made when >20% of the cells in the bone marrow are blasts, or immature blood cells.

Typical leukemia treatments consist of an induction phase aimed at achieving remission (>5% blasts in the bone marrow & recovery of blood counts), a consolidation phase to eradicate clinically undetectable disease, and a maintenance phase to prevent relapse & prolong remission. CNS prophylaxis is routine during all stages of ALL (acute lymphoblastic leukemia) treatment since the brain & spinal cord serve as a sanctuary for blasts. A cure is considered greater than 5 years out of treatment without return of disease.

ALL accounts for approximately 1 out of every 3 pediatric oncology diagnoses. Patients are usually stratified into 1 of 2 groups: low risk for relapse vs. high risk for relapse. A variety of factors including age, cytogenetics, WBC (white blood cell) count at diagnosis, & phenotype determine which category of treatment the patient will be placed in. Patients are either enrolled in a COG (children’s oncology group) protocol or are treated with the standard of care.

Other cancers that are 'common' in kids include neuroblastoma (cancer of the sympathetic nervous system), Wilm's tumor (mass in one or both kidneys), retinoblastoma (cancer of the retina), rhabdomyosarcoma (cancer of the muscle), osteosarcoma (cancer of the bone), AML (acute myelogenous leukemia), & various brain cancers (gliomas).

Unlike adult oncology, where pharmacists may have more say in the actual selection of chemo, peds oncology is more about supportive care treatment (since most chemo regimens are protocol). The most common supportive care issue in oncology is trying to prevent and also treat a patient's nausea/vomiting related to their chemo regimen. With highly emetogenic chemotherapy agents or regimens, giving scheduled (rather than prn) antiemetics help make sure your patient is as comfortable as possible during their course of treatment. There are a handful of other supportive care measures but I'm sure some of the other bloggers will cover in time.

The Ups and Downs of Chemo

Posted by Shannon Hough at Tuesday, February 02, 2010

In therapeutics, we learned that we can treat cancers with chemotherapeutic agents. However, they are accompanied by toxic side effects. This month, I had a chance to see first-hand how these drugs affect our patients. This was a lesson in side-effect profiles I will never forget.

Lesson 1: Myelosuppression (decreased blood counts)
Many of the patients that we saw this month were receiving some form of 3+7 (3 days of an anthracycline and 7 days of cytarabine) for a leukemia diagnosis. These patients often became neutropenic (low white blood cells), anemic (low red blood cells), and/or thrombocytopenic (low platelets). Patients who are neutropenic can be at risk for infection, and were monitored very closely for fevers or other symptoms. Patients who have low red blood cells often had very low energy levels that improved when we gave them a blood transfusion. And patients with low platelets often experienced more bruising or bleeding, including nosebleeds. Many times, these effects can be delayed, and the patient can feel great during chemo, and even a few days afterward. It was almost predictive, that when we saw the patient’s blood counts decreasing, their spunk would decline as well. One of my favorite times to see patients was when their counts were recovering and they were excited at the prospect that they had had a successful treatment and would soon be able to go home.

Lesson 2: Cold-Induced Neuropathy
In this case, a patient with colorectal cancer was receiving FOLFOX, a chemotherapy regimen containing oxaliplatin. Certain patients can experience sudden pain when exposed to cold temperatures when receiving oxaliplatin. This can even be triggered by drinking a cold beverage or holding something cold. This is an important side effect to discuss with our patients as this pain can certainly be avoided with adequate education.

Sometimes studying drug side effects can be difficult. There are so many drugs and so many side effects. But as we continue to work as students, we can collect experiences to help our memories along the way.