Lacey Marlow

When a person is cut or injured, the body relies on a steady supply of platelets in the bloodstream to control bleeding. Platelets, also called thrombocytes, are blood cells that rush to an injured site and help form clots to slow or stop bleeding. An abnormally low number of platelets—called thrombocytopenia&mdash;increases the risk of bleeding and is a common complication of cancer treatment.

Chemotherapy can suppress the bone marrow— where blood cells are made&mdash;making it unable to create enough platelets. Radiation therapy usually doesn’t cause thrombocytopenia unless it is given along with chemotherapy or high doses are directed at the pelvis, which is rich in bone marrow. Cancers such as leukemia and myeloma can overcrowd the bone marrow with malignant cells, leaving no room to make healthy blood cells. Other causes of reduced platelet production include viral infections that affect the bone marrow (hepatitis C, HIV, chicken pox) and aplastic anemia&mdash;a rare disorder in which the bone marrow doesn’t make enough new blood cells.

	The body may destroy platelets faster than they are made due to widespread bacterial infections in the blood, certain medications, or conditions that affect the immune system. For example, autoimmune disorders such as idiopathic thrombocytopenic purpura (ITP) can cause the immune system to destroy platelets. Abnormal reactions to certain medications (heparin, interferon, anticonvulsants) can confuse the immune system and cause it to destroy platelets. Other conditions can cause too many clots to form, using up platelets too quickly.

	Normally, most platelets circulate in the blood, while about a third are stored in the spleen. If the spleen is enlarged, it will hold on to too many platelets so that there aren’t enough in the bloodstream.

Common symptoms of thrombocytopenia include bruising or bleeding more easily or frequently than usual. Tiny red dots on the skin—called petechiae&mdash;and purple, brown and red bruises, called purpura, are symptomatic of external bleeding due to a low platelet count.

	Other symptoms may include bleeding from the nose or gums; bloody stools, urine or vomit; profuse or prolonged bleeding from a minor injury; increased weakness; and, in rare cases, severe headaches or dizziness from bleeding in the brain.

	When the platelet count is significantly below normal, excessive bleeding may occur during surgery or from a minor injury such as a small cut or bump. Severe thrombocytopenia can also cause excessive internal bleeding in the intestines or brain, which can be life-threatening and require immediate treatment.

Treatment for thrombocytopenia depends on the severity and underlying cause. A completely normal platelet count isn’t necessary to prevent abnormal bleeding. Thus, mild thrombocytopenia may not require any treatment.

	If chemotherapy causes thrombocytopenia, a lower dose may be given or the next cycle may be delayed until platelets increase to a safe level. Cancer surgery may also be delayed until platelet counts are normal.

	For severe thrombocytopenia, platelet transfusions are often given to prevent or manage spontaneous, heavy bleeding. Multiple transfusions may be required, because transfused platelets only last a few days. Some people may be given Neumega (oprelvekin) to prevent chemotherapy-induced thrombocytopenia and decrease the need for platelet infusions.

	Treatments for ITP aim to slow platelet destruction by altering or blocking the immune system. Corticosteroids such as prednisone or dexamethasone are often given as initial treatment. Other options include intravenous immunoglobulin or rituximab. If initial treatments are unsuccessful, newer medications such as the tablet Nplate (romiplostim) or Promacta (eltrombopag), via injection, may be given to stimulate the bone marrow to make more platelets. Severe ITP that has not responded to other courses of treatment may be treated with a splenectomy, which eliminates the main source of platelet destruction and can improve platelet count. Medications that keep platelets from aggregating, particularly aspirin, should be avoided if the platelet count is low.

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Certain types of cancer treatments can result in the body having too few platelets, a condition called thrombocytopenia, which can increase the risk of bleeding.

Managing Thrombocytopenia

	Many cancer treatments can cause severe joint pain—a condition called arthralgia&mdash;which can diminish quality of life and daily functioning. Persistent symptoms can lead some patients to discontinue treatment.

	Aromatase inhibitors (AIs), commonly used as adjuvant therapy for postmenopausal women with early stage, hormone receptor-positive breast cancer, can cause arthralgia, as can taxane chemotherapy drugs, such as paclitaxel and docetaxel, and drugs that stimulate white blood cell production, such as filgrastim.

	About half of women taking AIs experience arthralgia. The incidence of taxane-related arthralgia varies, with studies reporting that docetaxel causes more pain than paciltaxel.

	AI-related arthralgia often appears about two months after starting therapy, but can also begin up to two years later. Symptoms can diminish or resolve within several months or persist until AI therapy is stopped.

	Taxane-induced arthralgia usually begins 24 to 48 hours after infusion and can last for three to five days, occasionally lingering for a week or longer.

	The term arthralgia means “joint pain,” whereas arthritis is a disease that causes joint inflammation, which can in turn cause joint pain and stiffness. Arthralgia can be accompanied by symptoms such as joint stiffness, aches, muscle pain (myalgia) and inflammation, such as swelling, tenderness and redness around the joint.

	This pain can affect only one joint or area, or it may affect multiple joints. The pain can be mild or severe, and it can last for a few minutes, come and go, or be constant. Joint pain or stiffness is often worse upon waking or after long periods of inactivity and can improve with movement. Treatment-related arthralgia can cause new pain or exacerbate preexisting joint pain. The exact physiology of arthralgia is unclear and may involve several different mechanisms depending on the drug and the individual. Therefore, the symptoms and time course can be highly variable.

	Common areas of joint pain or discomfort include the hands (fingers and wrists), arms, knees, feet, pelvic and hip bones, shoulders and back. Arthralgia can make it difficult to perform normal activities, interfere with sleep, and diminish quality of life and day-to-day well-being. Importantly, studies show that joint pain is the main reason women stop AI therapy early.

	Mild pain relievers, such as acetaminophen, and nonsteroidal antiinflammatory drugs, such as ibuprofen, can provide partial or complete relief of moderate joint and muscle pain. More severe or persistent pain may require the addition of stronger pain relievers, such as acetaminophen combined with either codeine or oxycodone for short-term relief, corticosteroids, such as prednisone and dexamethasone, or antidepressants, such as Effexor (venlafaxine) or Cymbalta (duloxetine).

	For women with AI-associated arthralgia, switching to a different AI has been shown to be effective sometimes if symptom management is inadequate. Changing to tamoxifen may also be an option.

	In addition to medications, complementary therapies, such as exercise, acupuncture and dietary supplements, can also provide symptom relief. A 2013 study of women with AI-related arthralgia found that a yearlong exercise program reduced the severity of joint pain by at least 20 percent. In a small study of postmenopausal women with breast cancer with AI-related arthralgia, a six-week course of acupuncture resulted in improvements in pain severity, pain-related interference and physical wellbeing. Glucosamine, a supplement commonly used for arthritis, has also shown potential in managing joint pain.

Painful joint pain doesn't have to disrupt treatment.

Managing Arthralgia

It’s normal to feel anxious, scared or depressed when diagnosed with cancer. But prolonged and severe anxiety symptoms that interfere with daily activities, work and relationships might indicate a more serious problem known as posttraumatic stress disorder (PTSD), an anxiety disorder that can develop after an extremely frightening or life-threatening experience.

 The exact triggers for PTSD in cancer survivors are unclear, but a number of areas might be the cause: the diagnosis, aspects of treatment, test results, details about recurrence, pain, hospitalization or other experiences.

 Studies show that the full diagnostic criteria for PTSD are seen in 3 to 4 percent of newly diagnosed, early-stage cancer patients and in up to 35 percent who have completed treatment. The incidence of those who experience some but not all of the symptoms, however, is higher, ranging from 20 percent in people with early-stage cancer to 80 percent in those with recurrent cancer.

 PTSD, characterized by feelings of horror and intense fear, can be identified by symptoms from three clusters: re-experiencing, avoidance and hyperarousal. Symptoms of reexperiencing include reliving an event through nightmares or flashbacks and thinking about it constantly with recurrent memories. Avoidance symptoms involve avoiding places, events and people that are reminders of the traumatic event. Feeling distant, displaying less interest in usual activities or thinking future plans won’t happen are also signs of avoidance. Hyperarousal symptoms can be expressed as trouble concentrating, jumpiness or irritation as well as having outbursts of anger and difficulty sleeping.

PTSD can be addressed with a number of approaches to fit the severity and specific symptoms of each person.

PTSD can have a negative impact on survivors’ quality of life in a number of areas. Survivors might avoid hospitals or doctors, which can interfere with treatment or follow-up.

 Certain mental, physical or social factors might make some people more likely to develop PTSD than others.

Individual and social factors associated with a higher incidence of PTSD include younger age at diagnosis, less formal education, low income, female gender, previous trauma, higher general stress level, little or no social support, maladaptive coping, negative perceptions of treatment intensity and a family or personal history of psychiatric disorders, such as anxiety and depression.

Disease-related risk factors for PTSD include treatment time, hospital stay, advanced disease, pain and other physical symptoms, and intensive cancer care.

 PTSD can be addressed with a number of approaches to fit the severity and specific symptoms of each person. These might include psychotherapy (“talk therapy”), support groups, cognitive-behavioral therapy, medications or a combination of these.

Psychotherapy focuses on talking through problem-solving and coping skills in a safe and supportive environment with a mental health professional, either one-on-one or in a group setting. Cognitive-behavioral therapy helps patients change their behaviors by changing their thinking patterns, such as understanding PTSD symptoms, learning coping skills, stress management strategies and cognitive restructuring.

Two antidepressants are FDA-approved to treat PTSD: sertraline and Paxil (paroxetine), both of which might help with symptoms such as sadness, worry and anger. Other antidepressants that might be used include fluoxetine and citalopram. Antianxiety medications, such as alprazolam or clonazepam, might help control hyperarousal symptoms and anxiety, and, in certain circumstances, antipsychotic medications might also help.

Cancer’s traumatic impact can have lasting effects.

Post-Traumatic Stress Disorder after Cancer

Pain after major surgery is to be expected, but pain persisting beyond the normal healing period is considered chronic. Post-mastectomy pain syndrome (PMPS) is a type of chronic pain that occurs after breast cancer surgeries such as mastectomy, lumpectomy and axillary lymph node dissection, which involves removing lymph nodes in the underarm region. Pain from PMPS has been described as a burning sensation; a shooting, stabbing pain; or a throbbing, aching or oppressing pain. Study results vary, but show that anywhere from 20 to 68 percent of breast cancer survivors experience PMPS. This condition can develop up to several months after surgery and can persist for three to six or more years.

Direct injury to the intercostobrachial nerve and other sensory nerves in the underarm (axilla) and breast areas during surgery causes PMPS. Subsequent formation of scar tissue from surgery for breast cancer may also be a cause. And, contrary to its name, studies have shown that PMPS may occur more often after breast-conserving therapy (lumpectomy) than after modified radical mastectomy.

Studies have also shown that the risk of PMPS may increase with the extent of axillary intervention, as axillary dissection has been shown to be a critical component in chronic pain following breast cancer surgery. Other factors that increase the risk of PMPS include treatment with radiation or chemotherapy after surgery, younger age (under 40) at time of diagnosis and larger tumor size. A tumor located in the upper, outer quarter of the breast (near the underarm) also increases the risk of PMPS because surgery in this area carries a higher risk of nerve damage.

Pain from PMPS typically occurs in the upper arm, underarm region, shoulder and chest wall—areas served by the damaged intercostobrachial nerve. However, pain could also occur in the surgical scar. PMPS symptoms might also include abnormal sensations, such as an electric-shock type of pain that overlies a constant aching and burning feeling.

The pain can be mild and manageable, or severe enough to interfere with daily activities. It could also impair movement or use of the affected arm, which can lead to stiffness, pain and limited shoulder rotation, a condition called frozen shoulder. PMPS symptoms can be continuous or intermittent, with pain occurring every day or only a few days a week. The pain can also be aggravated or worsened by shoulder strain, household chores and even simple stretching.

Managing the symptoms of PMPS is important not only for pain relief but also to reduce the negative impact it can have on daily activities and quality of life. Initial treatment can involve routine use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Pain limited to the surgical scar can often be managed with injections of a local anesthetic or steroid. Capsaicin cream, a topical anesthetic, has also been shown to be effective for scar pain. Sometimes more extensive pain management is required. In these cases, antidepressants, such as amitriptyline, anticonvulsants, such as gabapentin, and opioids, such as oxycodone, can be used to relieve neuropathic pain. Another option is a nerve block, which involves injecting an anesthetic or steroid into the nerves of the affected area.

Non-drug interventions can also be helpful, and include massage therapy, acupuncture, reflexology and counseling. Physical therapy with arm and shoulder exercises is also helpful when it comes to increasing range of motion to prevent frozen shoulder.

Pain after breast cancer surgery can be persistent and debilitating.

Post-Mastectomy Pain Hits a Nerve

Insomnia is a serious sleep disorder experienced by 30 to 50 percent of people with cancer. It can involve difficulty falling or staying asleep, waking too early or not getting quality sleep. It can also cause distress or impaired functioning. But there are many ways to treat insomnia, and this is important because insomnia can negatively impact overall health and quality of life, especially for people who have cancer.

 Situational factors that contribute to insomnia include cancer- and treatment-related symptoms, such as pain, nausea, hot flashes, diarrhea and incontinence. Poor sleep habits, daytime napping and negative thoughts about sleep can also contribute to and perpetuate insomnia. In addition, drugs that treat cancer or its side effects, such as steroids and anti-nausea agents, may cause insomnia. Anxiety about procedures and their side effects, as well as the side effects themselves, are also contributing factors.

 Failure to get enough sleep or to obtain quality sleep can contribute to fatigue, daytime sleepiness, diminished concentration and memory, mood changes, depression, impaired immune function, pain and poorer quality of life. It can also affect performance at work, caring for dependents and social life. In severe cases, insomnia could even affect safety.

 The first step in treating insomnia is to identify and treat the underlying cause. This may involve drugs or other treatment strategies to control symptoms, such as pain or hot flashes, that might be disrupting sleep. It is also important to rule out other physical sleep disorders, such as obstructive sleep apnea, restless leg syndrome or periodic limb movement. 

The most common treatment for insomnia involves the use of hypnotic drugs, but they generally should not be used for more than a few weeks. Possible limitations of some drugs include dependence and tolerance, as well as withdrawal or perhaps rebound insomnia when discontinued. Moreover, many hypnotics cause significant side effects, such as daytime drowsiness, light-headedness, headaches and memory impairment. Non-pharmacologic strategies include avoiding or minimizing intake of caffeine and alcohol, as well as regular physical activity during the day to help normalize sleep patterns.

The National Cancer Institute recommends patients use cognitive-behavioral therapy (CBT) before resorting to drug therapy. CBT helps patients change negative thoughts and quell anxiety about sleep and learn to change sleep habits that interfere with sleeping well. 

Studies have shown that CBT is as effective as drug therapies and can improve sleep in up to 70 to 80 percent of cancer patients. CBT has also been shown to decrease fatigue, anxiety and depressive symptoms while increasing  quality of life. There are many CBT methods, typically used in combination, to achieve these goals. 

Behavioral strategies include stimulus control (which focuses on connecting the subconscious with getting ready for bed, and being in bed only with sleeping) and sleep restriction (which limits time spent in bed that does not involve sleeping to increase the likelihood of being sleepy at bedtime the next night). Relaxation therapy with guided imagery and breathing exercises also helps to relieve stress and tension before bedtime.

Sleep hygiene education can be used with other CBT strategies but is not effective alone. Sleep hygiene includes relaxing before bedtime (by taking a warm bath, for example), avoiding computer or television use in the bedroom, avoiding naps during the day, creating a dark and comfortable sleeping environment, and sleeping and waking at the same time each day.

Learn how to put cancer-related insomnia to sleep.

Up All Night?

Drugs commonly used for insomnia include:

Treatment Snapshot

Cancers near the bladder, such as prostate, cervical, rectal and bladder, can increase the risk of urinary incontinence (UI). But, more often, the condition is caused by cancer treatments rather than the cancer itself.

Stress incontinence is the loss of urine due to increased pressure on the abdomen, such as that caused by coughing, laughing, exercising or lifting a heavy object. Frequent nausea and vomiting from chemotherapy can also lead to stress incontinence. If the bladder sphincter—the valve that closes tightly to hold urine in the bladder&mdash;or other bladder muscles are damaged or weakened by surgery or radiation, leaking may occur. Stress incontinence can also occur with normal aging, particularly in women who have had children, due to laxity in the ligaments that hold the bladder and uterus.

Urge incontinence is a sudden, strong urge to urinate followed by an involuntary leakage of urine. This can result from nerve damage or bladder irritation causing nerve signals, or urges, to urinate even though there may be only a small amount of urine in the bladder. Both pelvic radiation and surgery can cause nerve damage, and pelvic radiation can cause bladder irritation, as well. Peripheral neuropathy from chemotherapy may also contribute to urge incontinence.

Overflow incontinence is an inability to empty the bladder completely, causing it to overfill and leak urine. This can result from a tumor or scar tissue blocking and squeezing the urethra (the tube connected to the bladder that urine flows out of during urination), so it doesn’t open properly to release urine; or it can result from weakened bladder muscles that can’t force the urine out.

Surgeries that remove tumors or tissues near the bladder can cause UI by damaging the muscles or nerves that help control urination. Examples include surgery for gynecologic cancers (hysterectomy), prostate cancer (prostatectomy) and colorectal cancer. Radiation to the pelvic area can damage bladder muscles and nerves, irritate the bladder lining and create scar tissue, all of which can cause UI. Hormone therapies that lower estrogen can weaken the ligaments holding the bladder and cause incontinence.

Changes to diet, lifestyle and exercise habits may help in managing mild UI, whereas more invasive options, such as surgery, may be needed for severe or persistent UI. 

Alcohol and caffeine act as urine stimulants, so limiting intake of these fluids may help control urge incontinence. 

Kegel exercises can help strengthen the pelvic floor and sphincter muscles to improve urine control. Bladder training is a type of behavioral therapy that involves learning to delay urination until after feeling the urge to go and may help with urge incontinence. Double voiding—urinating and then trying again a few minutes later&mdash;may help with overflow incontinence. Biofeedback involves learning how to control pelvic and bladder muscles. Electrical stimulation therapy helps strengthen the pelvic floor muscles to improve urine control for those with stress or urge incontinence. It may also be helpful to urinate according to a time schedule rather than waiting for the urge to go, or use absorbent pads and garments for uncontrolled leakage. 

Anticholinergic drugs, such as Ditropan (oxybutynin chloride) and Detrol (tolterodine tartrate), may be used to treat urge incontinence because they affect the bladder nerves and reduce bladder muscle contractions. Use of a self-catheter several times a day may help with overflow incontinence. 

Surgical options may be most helpful for stress incontinence and include implanting an artificial urinary sphincter, creating a sling to support the bladder and urethra and injecting bulking material into tissue around the urethra to keep it closed. Surgery, however, is reserved for cases where other procedures are not effective because it can introduce other complications.

Urinary incontinence after a cancer diagnosis can be managed.