November 1st, 2011

Today I was supposed to have my final chemotherapy (in this case Glemcitabine, see below for details) in a range of twelve.

The drill at the hospital is as follows:

1. Blood sample
2. Hour waiting for the blood sample test results
3. Chemotherapy subject to the blood sample test being OK

Awaiting the test results of my blood samples in the waiting lounge of the hospital the nurse came to me and told me I cannot have my last chemotherapy because of my bad general condition and the extremely low white blood cell count (0.5 instead 1.6, see below for more details on white blood cells) that I apparently had as a result of the blood sample just taken. I was shocked by this news since I saw it as a sign of my weakness and I was scared that “missing” this last chemo treatment could have an effect on controlling the oxidation process of the cancer cells. Since everybody else was listing with us present in the waiting lounge  in our discussion about the effects of this decision I asked the nurse for a somewhat more private discussion location. I was taken to a treatment room, the room where I would have had the final chemotherapy had my white blood cell count in order, and we continued our discussion. I asked the nurse if this may have been a result of not having had a Neulasta injection after the previous double chemotherapy that I had a week earlier. Neulasta (see below for more details on Neulasta) is a kind of “fertilizer” that quickly makes new white blood cells after a chemotherapy that causes the drop in the white blood cells count. I also asked her to for me to see my internist and or to ask him what the effects are to my overall treatment program. She left to ask the internist for me to meet him, meanwhile another patient arrived in my room to have his first chemotherapy (cancer of the bladder) and I found myself explaining to the couple about the ins and outs of the full treatment. The nurse came back and we continued to have our private discussion in the presence of the newly arrived chemotherapy candidates. The nurse told me that the internist had no time to meet me and that missing this last chemotherapy would not mean a lot since I was going to have my CT scan and cystoscopy in a few weeks anyway. If this last chemotherapeutic session does not make much difference, “why am I here than?” I asked here. I was getting upset just like the time the MD told me that following their new treatment program could improve my chances with 6%…. 6% of what, I asked him. They assume that everyone is plain and stupid. The nurse told me that they would try to give me the final chemotherapy the day before the CT scan assuming my white blood cell count would then be OK. She hoped there was space for me in the day care center that day to do the final chemotherapy, but I would be contacted.

White blood cells, or leukocytes (also spelled “leucocytes”, leuco- Ancient Greek “white”), are cells of the immune system involved in defending the body against both infectious disease and foreign materials. Five different and diverse types of leukocytes exist, but they are all produced and derived from a multipotent cell in the bone marrow known as a hematopoietic stem cell. They live for about 3 to 4 days in the average human body. Leukocytes are found throughout the body, including the blood and lymphatic system.

The number of leukocytes in the blood is often an indicator of disease. There are normally between 4×10⁹ and 1.1×10¹⁰ white blood cells in a litre of blood, and ranging from 7 and 21 micrometres in diameter, they make up approximately 1% of blood in a healthy adult.^[3] An increase in the number of leukocytes over the upper limits is called leukocytosis, and a decrease below the lower limit is called leukopenia. The physical properties of leukocytes, such as volume, conductivity, and granularity, may change due to activation, the presence of immature cells, or the presence of malignant leukocytes in leukemia.

What is Neulasta?

Neulasta (pegfilgrastim) is a colony stimulating factor. It is a man-made form of a protein (amino acid) that stimulates the bone marrow and promotes the growth of white blood cells called neutrophils in your body. White blood cells help your body fight against infection.

Neulasta is used to prevent neutropenia, a lack of certain white blood cells caused by receiving chemotherapy.

Neulasta may also be used for purposes not listed in this medication guide.

Important information about Neulasta

You should not use Neulasta if you are allergic to pegfilgrastim or filgrastim (Neupogen).

Before using Neulasta, tell your doctor if you have sickle cell disorder, chronic myeloid leukemia, myelodysplasia (also called “preleukemia”), or if you are allergic to latex.

Do not self-inject this medicine if you do not fully understand how to give the injection and properly dispose of used needles and syringes.

Neulasta is usually given once per chemotherapy cycle. Neulasta should not be given within 14 days before or 24 hours after you receive chemotherapy.

Before using Neulasta

You should not use Neulasta if you are allergic to pegfilgrastim or filgrastim (Neupogen).

To make sure you can safely use Neulasta, tell your doctor if you have any of these other conditions:

• sickle cell disorder;
• chronic myeloid leukemia;
• myelodysplasia (also called “preleukemia”); or
• if you are allergic to latex.

FDA pregnancy category C. It is not known whether Neulasta will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using Neulasta.

The Final Chemotherapy: Glemcitabine

Gemcitabine

Trade Name: Gemzar ^®

Drug Type:

Gemcitabine is an anti-cancer (“antineoplastic” or “cytotoxic”) chemotherapy drug.  Gemcitabine is classified as an antimetabolite.  (For more detail, see “How Gemcitabine Works” below).

What Gemcitabine Is Used For:

• Pancreas cancer
• Non-small cell lung cancer
• Bladder cancer
• Soft-tissue sarcoma
• Metastatic breast cancer

Note:  If a drug has been approved for one use, physicians sometimes elect to use this same drug for other problems if they believe it might be helpful.

How Gemcitabine Is Given:

• Gemcitabine is given by infusion through a vein (intravenously, by IV).
• There is no pill form of Gemcitabine.
• The amount of Gemcitabine you will receive depends on many factors, including your height and weight, your general health or other health problems, and the type of cancer you have.  Your doctor will determine your exact dosage and schedule.

Side Effects of Gemcitabine:

Important things to remember about the side effects of Gemcitabine:

• Most people do not experience all of the side effects listed.
• Side effects are often predictable in terms of their onset, duration and severity.
• Side effects are almost always reversible and will go away after treatment is complete.
• There are many options to help minimize or prevent side effects.
• There is no relationship between the presence or severity of side effects and the effectiveness of the medication.

The following side effects are common (occurring in more than 30%) for patients taking Gemcitabine:

• Flu-like symptoms(muscle pain, fever, headache, chills, fatigue)
• Fever  (within 6-12 hours of first dose)
• Fatigue
• Nausea (mild)
• Vomiting
• Poor appetite
• Skin rash
• Low blood counts.  Your white and red blood cells and platelets may temporarily decrease.  This can put you at increased risk for infection, anemia and/or bleeding.

Nadir: Meaning low point, nadir is the point in time between chemotherapy cycles in which you experience low blood counts.

Onset: none noted
Nadir: 10-14 days
Recovery: day 21

• Temporary increases in liver enzymes
• Blood or protein in the urine

These are less common side effects (occurring in 10-29%) for patients receiving Gemcitabine:

• Diarrhea
• Weakness
• Hair loss
• Mouth sores
• Difficulty sleeping
• Shortness of breath (see lung problems)

Not all side effects are listed above, some that are rare (occurring in less than 10% of patients) are not listed here.  However, you should always inform your health care provider if you experience any unusual symptoms.

When To Contact Your Doctor or Health Care Provider:

Contact your health care provider immediately, day or night, if you should experience any of the following symptoms:

• Fever of 100.5ºF (38ºC) or higher, chills (possible signs of infection)

The following symptoms require medical attention, but are not emergency situations.  Contact your health care provider within 24 hours of noticing any of the following:

• Nausea that interferes with eating and is not relieved by medications prescribed by your doctor.
• Vomiting (more than 4-5 episodes within a 24-hour period)
• Extreme fatigue (inability to perform self-care activities)
• Diarrhea (more than 4-6 episodes in a 24-hour period)
• Unusual bleeding or bruising
• Black or tarry stools, or blood in your stools or urine

Always inform your health care provider if you experience any unusual symptoms.

Gemcitabine Precautions:

• Before starting Gemcitabine treatment, make sure you tell your doctor about any other medications you are taking (including prescription, over-the-counter, vitamins, herbal remedies, etc.).  Do not take aspirin or products containing aspirin unless your doctor specifically permits this.
• Do not receive any kind of vaccination without your doctor’s approval while taking Gemcitabine.
• Inform your health care professional if you are pregnant or may be pregnant prior to starting this treatment. Pregnancy category D (Gemcitabine may be hazardous to the fetus.  Women who are pregnant or become pregnant must be advised of the potential hazard to the fetus).
• For both men and women: Do not conceive a child (get pregnant) while taking Gemcitabine. Barrier methods of contraception, such as condoms, are recommended. Discuss with your doctor when you may safely become pregnant or conceive a child after therapy.
• Do not breast feed while taking Gemcitabine.

Gemcitabine Self Care Tips:

• For flu-like symptoms, keep warm with blankets and drink plenty of liquids.
• Drink at least two to three quarts of fluid every 24 hours, unless you are instructed otherwise.
• You may be at risk of infection so try to avoid crowds or people with colds, and report fever or any other signs of infection immediately to your health care provider.
• Wash your hands often.
• To help treat/prevent mouth sores, use a soft toothbrush, and rinse three times a day with 1/2 to 1 teaspoon of baking soda and/or salt mixed with 8 ounces of water.
• Use an electric razor and a soft toothbrush to minimize bleeding.
• Avoid contact sports or activities that could cause injury.
• To reduce nausea, take anti-nausea medications as prescribed by your doctor, and eat small, frequent meals.
• Avoid sun exposure.  Wear SPF 15 (or higher) sunblock and protective clothing.
• In general, drinking alcoholic beverages should be kept to a minimum or avoided completely.  You should discuss this with your doctor.
• You may experience drowsiness or dizziness; avoid driving or engaging in tasks that require alertness until your response to Gemcitabine is known.
• Get plenty of rest.
• Maintain good nutrition.
• If you experience symptoms or side effects, be sure to discuss them with your health care team.  They can prescribe medications and/or offer other suggestions that are effective in managing such problems.

Monitoring and Testing While Taking Gemcitabine:

You will be checked regularly by your doctor while you are taking Gemcitabine, to monitor side effects and check your response to therapy.  Periodic blood work will be obtained to monitor your complete blood count (CBC) as well as the function of other organs (such as your kidneys and liver) will also be ordered by your doctor.

How Gemcitabine Works:

Cancerous tumors are characterized by cell division, which is no longer controlled as it is in normal tissue.   “Normal” cells stop dividing when they come into contact with like cells, a mechanism known as contact inhibition.  Cancerous cells lose this ability.  Cancer cells no longer have the normal checks and balances in place that control and limit cell division.  The process of cell division, whether normal or cancerous cells, is through the cell cycle.  The cell cycle goes from the resting phase, through active growing phases, and then to mitosis (division).

The ability of chemotherapy to kill cancer cells depends on its ability to halt cell division.  Usually, the drugs work by damaging the RNA or DNA that tells the cell how to copy itself in division.  If the cells are unable to divide, they die.  The faster the cells are dividing, the more likely it is that chemotherapy will kill the cells, causing the tumor to shrink.  They also induce cell suicide (self-death or apoptosis).

Chemotherapy drugs that affect cells only when they are dividing are called cell-cycle specific.  Chemotherapy drugs that affect cells when they are at rest are called cell-cycle non-specific.  The scheduling of chemotherapy is set based on the type of cells, rate at which they divide, and the time at which a given drug is likely to be effective.  This is why chemotherapy is typically given in cycles.

Unfortunately, chemotherapy does not know the difference between the cancerous cells and the normal cells.  Chemotherapy will kill all cells that are rapidly dividing.  The “normal” cells will grow back and be healthy but in the meantime, side effects occur.  The “normal” cells most commonly affected by chemotherapy are the blood cells, the cells in the mouth, stomach and bowel, and the hair follicles; resulting in low blood counts, mouth sores, nausea, diarrhea, and/or hair loss.  Different drugs may affect different parts of the body.

Gemcitabine belongs to the family of drugs called antimetabolites.  Antimetabolites are very similar to normal substances within the cell.  When the cells incorporate these substances into the cellular metabolism, they are unable to divide.  Antimetabolites are cell-cycle specific.  They attack cells at very specific phases in the cycle.  Antimetabolites are classified according to the substances with which they interfere:

• Folic acid antagonist:  Methotrexate
• Pyrimidine antagonist:  5-Fluorouracil, Foxuridine, Cytarabine, Capecitabine, and Gemcitabine
• Purine antagonist:  6-Mercaptopurine and 6-Thioguanine
• Adenosine deaminase inhibitor:  Cladribine, Fludarabine and Pentostatin

Note: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice.