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Course: Oncology Nursing

Topic: Nursing Management of Cancer

Treatment Related Neutropenia and Mouth/throat Problems

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Module Goals

Learners will be able to:

Describe neutropenia and mouth/throat problems as side-effects related to cancer and cancer treatment.
Describe management of these side effects.
Describe nurse’s role in management of these side-effects.

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Neutropenia

Neutrophils: a type of white blood cell, fight infection by destroying pathogenic micro-organisms¹.
Neutropenia: decrease in absolute number of neutrophils (ANC) in the blood^1,2, i.e ANC < 1500 cells/mm³.
ANC 500-1000 cells/mm³: still able to confer normal protection against infections².
ANC 200-500 cells/mm³: significant increase in incidence of serious infections².
ANC <200 cells/mm³: severe neutropenia requiring admission to hospital and antibiotics.

Canadian Cancer Society, n.d., Low white blood cells
Hassan et al. (2015)

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Neutropenia: Adverse Effects

Sepsis and septic shock- major cause of mortality in chemotherapy induced neutropenia¹
Other adverse effects²:

Fatigue
Delay in chemotherapy treatment resulting in increased cancer cell growth and tumor size
Dose reduction of chemotherapy
50% of cancer patients received less than 85% of prescribed dose due to neutropenia
Delay in or dose-reduction in chemotherapy can lead to serious effects or death

Kochanek et al (2019)
Hassan et al. (2015)

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Neutropenia: Causes

Neutropenia is caused by:

Chemotherapy^1,2
Radiation therapy^1,2
Certain biological therapies such as interleukin-2 or rituximab¹
Bone marrow cancers such as leukemia, lymphoma, myeloma^1,2
Older age ²
Prolonged use of drugs like diuretics, chlorpromazine, allopurinol²

Risk of neutropenia is greater if¹

Chemotherapy and radiation therapy are given in same time
Large areas of bone marrow are in the radiation treatment area

Canadian Cancer Society, n.d., Low white blood cells
Hassan et al. (2015)

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Neutropenia: Sign/symptoms

Neutropenia itself does not cause any symptoms
Usually identified in cancer patient from blood tests or when they get an infection
Sign/symptoms of infections are:

fever/chills
Swelling/redness
sores, red/white patches in mouth
sore throat
severe cough/shortness of breath/abnormal breath sounds
pain/burning/foul smelling urine
diarrhea
drainage, pus, redness, swelling from a cut, sore incision, venous access device or drainage tube
unusual vagainal discharge or itching

Canadian Cancer Society, n.d., Low white blood cells

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Neutropenia: Diagnosis

Neutropenia is diagnosed by¹:

Complete blood count (CBC), test repeated if low ANC result
Bone marrow aspirate usually from large pelvis, ilium or sternum from two sites

one from middle of bone
one from solid, bonier part of bone

Febrile neutropenia^1,2:

ANC <1000/mm³ and a single temperature >38.3^oC (101 ^o F)
OR, sustained temperature ≥ 38 ^oC (100.4 ^oF) for > 1 hour

Hassan et al. (2015)
US Department of Health

and Human Services (2010)

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Case Study/Critical Thinking Question/What would the nurse do?

A client with leukemia has neutropenia. Which of the following functions must be frequently assessed?

Heart sounds
Bowel sounds
Breath sounds
Blood pressure

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Neutropenia: Management

Colony -stimulating factors^1,2

Stimulate bone marrow to make different types of blood cells
Granulocyte colony-stimulating factors help make granulocytes
Granulocyte-macrophage colony-stimulating factors help make granulocyte and macrophages

Antimicrobial therapy

May be given if white blood cell count is low, risk of infection is high, or suspicion of infection ¹
May be given as chemoprophylaxis²
Broad spectrum antibiotic may be started before lab identification of causative organism¹

Canadian Cancer Society, Low white blood cells
Hassan et al. (2015)

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Neutropenia: Management

Fungal treatment is of most significance in neutropenic patient¹

Treated with fluconazole or amphotericin B¹
Delay or provide low dose treatment²

To lessen impact on white blood cells

Special precautions²

Severe neutropenia cases might have to put in protective isolation
Visitors may not be allowed, if allowed

need to wash hands and wear protective mask/gown, shoes
Flowers and outside foods not allowed

Hassan et al. (2015)
Canadian Cancer Society, Low white blood cel

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Patient Education on Prevention of Infection

Patient counselling on following infection prevention practices:

Report signs/symptoms of infection immediately to the healthcare profession

Do not take fever medication before checking with healthcare professional

Wash hands often especially before eating and after bathroom

Carry small bottle of hand sanitizer if possible
Clean anal area gently but thoroughly after bowel movement

Take warm instead of hot shower every day

Gently pat skin dry rather than rubbing briskly

Canadian Cancer Society, Low white blood cells

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Patient Education on Prevention of Infection

Soft toothbrush or clean cloth to clean teeth, gums.
Use pads rather than tampons
Protect skin:

Use dermatologist/pharmacist suggested moisturizer to prevent dryness/cracks.
Use rubber gloves doing dishes, cleaning gardening.
Do not squeeze or scratch pimples.
Use electric shaver instead of razor.
Avoid burns when ironing or cooking.

Stay away from anyone who has infectious diseases like cold, flu, measles.

Canadian Cancer Society, Low white blood cells

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Patient Education on Prevention of Infection

Canadian Cancer Society, Low white blood cells

Cook vegetables/meat to get rid of pathogens.

Wash thoroughly with clean water and peel fruits.
Avoid uncooked vegetables, raw or undercooked meats/poultry/fish/seafood.

Maintain good general health

Get enough rest and sleep.
Eat well-balanced diet and drink plenty of fluids.
Get regular exercise if possible.

Avoid cleaning cat litter boxes or birdcages.
Consult healthcare team if precautions necessary during sexual activity.

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Nurse’s Role in Care of Neutropenic Cancer Patient

Assess and identify patients at risk of neutropenia or neutropenic sepsis.
Provide patient teaching/counseling on infection prevention practices mentioned in previous slides.
Inform patients to report signs of infection as soon as possible to the healthcare professional.
Practice infection prevention protocol for severely neutropenic patients.
Provide appropriate therapies.

National Cancer Institute, n.d., Side Effects of Cancer Treatment

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What would the nurse do?

A patient is undergoing treatment for severe neutropenia. The nurse teaches family members about infection precautions. Which of the following statements by family members indicates that the family needs more education?

We will bring in books and magazines for entertainment.
We will bring in personal care items for comfort.
We will bring in fresh flowers to brighten the room.
We will bring in family pictures and get well cards.

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Mouth and Throat Problem

Radiation therapy to the head and neck may harm the salivary glands and tissues in mouth.
Chemotherapy and immunotherapy can harm cells in mouth, throat, and lips.
Drugs used to treat cancer and certain bone problems may cause oral problems.
Mouth and throat problems are more serious if they interfere with eating and drinking.

can lead to dehydration and/or malnutrition.

National Cancer Institute, 2020, Mouth and Throat Problems during Cancer Treatment

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Mouth and Throat Problem

Problems include^1,2:

Changes in taste (dysgeusia) or smell
Dry mouth (xerostomia), cracked lips
Infections , mouth sores
Pain or swelling in mouth (mucositis)
Sensitivity to hot or cold foods
Swallowing problems (dysphagia)
Raw feeling in throat
White spots in mouth
Tooth decay (cavities)

Above signs and symptoms usually occur from 5-14 days after initiation of cancer treatments².

National Cancer Institute, 2020, Mouth and Throat Problems during Cancer Treatment.
Canadian Cancer Society, n.d.,

Sore mouth and throat

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Mouth and Throat Problem: Management

Pain Medication
Treat Bleeding
Prevent/Treat Infections
Patient Education/Counseling

Good oral/dental hygiene practices
Consuming adequate nutrition/hydration

National Cancer Institute, 2020, Mouth and Throat Problems during Cancer Treatment.
Canadian Cancer Society, n.d.,

Sore mouth and throat

Contact info: info@nursesinternational.org

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Mouth and Throat Problem: Management

Pain Medication:

Pain medications like acetylsalicylic acid (Aspirin), that weaken platelets or make bleeding worse, are avoided.
Acetaminophen or opioids may be recommended.

be aware of side-effects like drowsiness and constipation.

Gels or ointments that can be applied to sores in mouth.
Mouthwash/rinse like lidocaine rinse.
Numbing lozenges numb tongue/throat to make swallowing easier.

Canadian Cancer Society, n.d., Sore mouth and throat.

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Mouth and Throat Problem: Management

Prevent/Treat Bleeding¹

Medicines to decrease bleeding and help clots form
Topical agents including absorbable gelatin or collagen on accessible mucosal sites
Avoiding dental flossing if with low platelet count
Rinsing mouth carefully to prevent dislodging of clots

Prevent/Treat Infections¹

Antimicrobial drugs/mouthwashes for prevention/treatment of infection
Low-level laser therapy may be used for prevention/treatment of mucositis²

Canadian Cancer Society, n.d., Sore mouth and throat
Lima et al. (2020)

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Patient Education on Mouth/Dental Care

Importance of mouth care and dental care during cancer treatment.
Getting dental check-up before starting treatment.
Checking and cleaning mouth daily

Check daily and report any changes like sores, white spots and pain to health care professional.
Rinse mouth daily with health care professional recommended solution.
Brush with gentle soft toothbrush or cotton swabs after each meal.

National Cancer Institute, 2020, Mouth and Throat Problems during Cancer Treatment

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Patient Education on Mouth/Dental Care

For sore mouth and throat:

Soft, wet, easy to swallow foods
Prescribed pain drugs that numb mouth to make eating less painful
Avoid smoking or use of tobacco products
Avoid crunchy, spicy, salty, sugary foods and alcoholic drinks

For dry mouth:

Plenty of liquids to keep mouth hydrated
suck on ice chips or sugar free candy/gum
use lip balm
Ask saliva substitutes that coat/protect/moisten mouth and throat

National Cancer Institute, 2020, Mouth and Throat Problems during Cancer Treatment

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Patient Education on Mouth/Dental Care

For changes to sense of taste¹:

Try different foods that taste best
Cold foods may help
If food taste metallic, switch to plastic utensils and non-metal cooking dishes
For bad taste in mouth, try sugar-free lemon drops, gum, or mints

Maintain good nutrition^1,2:

choose oods gentle to mouth but provide nutrition like eggs, yogurt, mashed potatoes, applesauce, etc.²
Limit tart, salty, acidic and spicy food that irritate mouth²

National Cancer Institute, 2020, Mouth and Throat Problems during Cancer Treatment.
Canadian Cancer Society, n.d.,

Sore mouth and throat

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Nursing Management of Patient’s Mouth/Dental Care

Provide patient education/counseling:

Good mouth hygiene and dental care practices
Adequate nutrition and hydration
Dentist consultation before cancer treatment
Methods to treat mouth/throat problems, and when to seek health care professional advice

Assessment of mouth/dental problems in patient
Provision of appropriate care

Prescribe antimicrobial to manage infection
Hydration of patient, especially those on fluid restriction
Managing bleeding, dressing sores

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What would the nurse do?

A client who has undergone surgery and radiation therapy to treat oral cancer and reports persistent dry mouth. What will the nurse teach this patient about managing this symptom?

Use saliva substitutes, especially when eating dry foods.
This condition is common but is temporary.
Use lozenges and hard candies to prevent dry mouth.
This indicates a complication of therapy.

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Reference:

Canadian Cancer Society (n.d.). Low white blood cell count. Accessed from: https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/low-white-blood-cell-count/?region=on

Canadian Cancer Societyj(n.d.). Sore mouth and throat. Accessed from: https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/sore-mouth-and-throat/?region=on

Hassan, B.A.R, Yusoff, A.B.M., & Othman, S.B. (2015). A Close Look at Neutropenia among Cancer Patients — Risk Factor and Management. Licensee IntechOpen under terms of the C reative Commons Attribution 3.0 License. . Accessed from: https://www.intechopen.com/books/updates-on-cancer-treatment/a-close-look-at-neutropenia-among-cancer-patients-risk-factor-and-management

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Reference:

Kochanek, M., Schalk, E., von Bergwelt-Baildon, M., Beutel, G., Buchheidt, D., Hentrich, M., Henze, L., Kiehl, M., Liebregts, T., von Lilienfeld-Toal, M., et al. (2019). Management of sepsis in neutropenic cancer patients: 2018 guidelines from the Infectious Diseases Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO). Annals of Hematology, 98(5): 1051–1069. Accessed from: https://link.springer.com/article/10.1007/s00277-019-03622-0

Lima, V.H.S., Oliveira-Neto, O.B., Hora Sales, P.H., Torres, T.D.S., & Lima, J.C. (2020). Effectiveness of low-level laser therapy for oral mucositis prevention in patients undergoing chemoradiotherapy for the treatment of head and neck cancer: A systematic review and meta-analysis. Oral Oncology, 102. Accessed from: https://www.sciencedirect.com/science/article/abs/pii/S1368837519304348?via%3Dihub

Contact info: info@nursesinternational.org

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Reference:

National Cancer Institute (January 2020). Mouth and Throat Problems during Cancer Treatment. Accessed from: https://www.cancer.gov/about-cancer/treatment/side-effects/mouth-throat

US Department of Health and Human Services (2010). Common Terminology Criteria for Adverse Events (CTCAE), Version 4.03. National Institute of Health, National Cancer Institute. Accessed from: https://nciterms.nci.nih.gov/ncitbrowser/pages/multiple_search.jsf?nav_type=terminologies

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