SS24 E01 MBC Matters: Understanding Blood Test Results

Research has shown that self-advocates are more likely to receive better care and have their medical questions and problems addressed. We're excited to bring you this episode, focusing on a crucial aspect of managing metastatic breast cancer—understanding blood test results. Blood tests are vital in cancer care, offering insights into our health, monitoring treatment effectiveness, and guiding our medical team's decisions. However, interpreting these results can be challenging. Joining us today is Dr. Alfredo Torres, who will help us break down the common types of blood tests, explain what the numbers mean, and discuss their impact on your treatment plan. Knowing how to interpret these results can empower you to advocate for yourself more effectively and enhance your overall care. Whether you're newly diagnosed or have been living with metastatic breast cancer for some time, this episode aims to empower you with valuable knowledge. Grab a cup of our favorite beverage and get comfortable as we dive into the mysteries of blood test results together.

Transcript

[00:00:42] Kate Pfitzer: Hello and welcome. Today we're bringing you a special podcast that we created in partnership with SHARE Cancer Support. It's an audio version of the video program from this past spring called MBC Matters Meetup: Blood Test Results, Understanding Your Laboratory Test Report. I'm Kate Vieira Pfitzer.

Victoria Goldberg and I are excited to bring you today's episode, where we'll be diving into the crucial aspect of managing metastatic breast cancer, blood test results. Blood tests are a central part of our cancer care. They provide insights into our health, monitor the effectiveness of treatments, and help our medical team make informed decisions about our care.

However, interpreting these results can often feel like deciphering a foreign language. Joining us today is Dr. Alfredo Torres to help us with that. We'll be breaking down the common types of blood tests, explain what the numbers mean, and discuss how these results impact our treatment plan. Whether you're newly diagnosed or have been living with metastatic breast cancer for some time, this episode aims to empower you with knowledge.

So grab a cup of your favorite beverage and join us as we unravel the mysteries of blood test results together. Stay tuned and let's get started.

[00:02:12] Dr. Torres: Hi, thank you, Kate, and thank you, Victoria, for having me here. Very excited to reach so many patients. My name is Alfredo Torres. I'm a medical oncologist. I worked at New York Cancer and Blood Specialists for about five years. I currently serve as the Assistant Chief Medical Officer. I have other titles. I work with the American Cancer Society on Long Island.

I sit  in their board as well, and I'm currently nominated as the chief chair for GI in OneOncology, which is a big umbrella group that we have for a community practice. I'm certified as an internal medicine. I'm certified in medical oncology and medical hematology as well. Thank you for having me.

[00:02:50] Kate Pfitzer: Dr. Torres, you are board certified in both medical oncology and hematology. Some of us have a medical oncologist and some of us have a medical oncologist hematologist. Can you explain the difference between the two? 

[00:03:03] Dr. Torres: Absolutely. I would say that  the U. S. is probably the only place in the world where you see hematology and oncology being studied togetherd

Even though you sit for two boards, during those three years of fellowship, you will get the chance to do hematology and oncology. There's rare programs that you will do oncology alone. I will say probably those are like 15-20 percent of the fellowship programs in the U. S., but most of them you will have to do both.

In terms of differences, I like to divide in three categories. You have benign hematology, malignant hematology, and then you have oncology, which is solid cancers. So, for solid cancers, an oncologist can be certified. For malignant hematology, both hematologists and oncologists will actually share the ability of treating.

And then for hematology, in benign hematology, it will be only hematologists. After you do the boards, you can maintain certification every 10 years, or you can drop one of the two. If you're, for example, an academician, you will see in big academic places that a doctor will only commit to one type of disease and can drop their second board.

So they will keep practicing as just one specialty instead of both.

Today, we want to go over some of the labs that you will probably see as a patient. You know, the labs that we commonly use for surveillance treatment of. the cancer itself and also possible side effects. One of the things that have changed recently with the Transparency Act is that most of the patients will have access to their medical information almost immediately.

That, in one hand is phenomenal because that will empower people to advocate for themselves in terms of knowing exactly what's happening and having that accessibility to their records easily. Most of the softwares right now will have a care space or will have. some sort of portal where you can access your results immediately.

But it also creates a lot of confusion and anxiety because it's not just about what the lab and the number says, it's how to interpret it and put it in the right context. Uh, I will say that two patients with the same number can tell you two different stories depending on where they are in their journey and how they feel as well.

So the interpretation of those labs is what's really important. Important not just the number itself. It's quite easy to know if a number is outside of the ranges because the ranges are usually provided by the lab. But the reality is that knowing when that value, if it's abnormal, is of clinical relevance, that becomes a little bit more challenging.

But I'm hoping that during this discussion, I can tell you at least some of the basic bloodwork that we typically see. So you, as a patient can advocate for yourself in case you're seeing any abnormalities. I will say the most commonly used lab that we see is the CBC. That stands for Complete Blood Count.

And here we are actually going to see three big numbers. The first one is the white blood cell. The white blood cell usually ranges from 4 to 10, and it can tell you a lot. When you're below that number, that's called neutropenia. When those numbers are severely down, especially if your absolute neutrophil count, ANC for short, is low, you're running a risk of having severe neutropenia.

And that makes you very immunocompromised, meaning that if you have a fever, it's quite an emergency. Actually, you need IV antibiotics the sooner possible. They're actually very, very important. We rarely have emergencies in oncology. That would be one of them. It's called neutropenic fever. So when your ANC is expected to be 0.5 or is already 0. 5 or less, and you have a fever, it's an emergency. When the white blood cell count is high, it could be that you're having an infection, but it also could be that you're having a normal response if you're having what we call growth factors. Sometimes when you're having chemotherapy, we give you an injection to avoid the neutropenia, which was what I was mentioning before, the low white blood cell count.

And when those numbers are high, it could be a perfect natural response to the growth factors working. So again, seeing the number by itself doesn't mean anything. You have to put it in the right context. So that's in the white blood cell count space. Then the second big number that we address is the hemoglobin.

So the hemoglobin in a normal woman will be 11. 5 or greater. In a man can be a gram higher and also depends on the age. But a hemoglobin when it's low, that's called anemia. The lower the hemoglobin, the more symptomatic the patient is expected to be. So, shortness of breath, tachycardia, fatigue, headaches, being pale, all of those symptoms are expected with anemia.

And the lower the number, the more symptoms you will see. However, the anemia has to be interpreted if it's something that is acute, meaning that it happened quickly. So, you're having normal anemia and then suddenly you have a big drop. Usually when that happens, patients are way more symptomatic and it probably has to do with either bleeding or a more severe reaction to chemotherapy.

Or if it's chronic, it's a more of a slow downtrend in the hemoglobin, that’s when patients are not symptomatic. And I have seen both cases of a patient, for example, with a hemoglobin of seven that is extremely short of breath, winded, and tachycardic. And a patient with a hemoglobin 0.7 that is completely normal, usually that happens when it's more chronic, so your body has time to accommodate.

The last number that we see on the CBC is the platelet count. So platelets, as we know, is a cell that is in charge of helping with clotting, and that number can fluctuate depending if the patient is on chemotherapy. We usually see the platelet count going low, that's called thrombocytopenia. Usually when you use the term penia, it means low, so neutropenia or thrombocytopenia, that means low counts.

And when we see the platelets going low, especially if they're below 50, you can start considering the possibility of having some bleeds. When that number hits below 50, we have to take into consideration if the patient is taking blood thinners or aspirin, because then that will further increase the chance of having a bleed.

So when the number is below 50, we like to hold blood thinners or anti platelet therapy. So that's for the CBC. As a hematologist oncologist, we look a little bit deeper into the subtypes of white blood cell count. That could be a little complicated. There's a rule of thumb. If you know what's happening with the white blood cell count, the hemoglobin and the platelet count, that gives you a very good overall about what's happening in the CBC.

The next test that we use is called the CMP, and that stands for Complete Metabolic Profile. The difference between the Complete Metabolic Profile and the Basic Metabolic Profile is the inclusion of the liver function tests, and we'll talk about them. In the CMP and the BMP, we look at the electrolytes and the renal function.

The electrolytes that we see are sodium, potassium, chloride, and we're also going to see the CO2 level. And we're going to see glucose and the renal function test. The renal function test is usually presented as BUN. and creatinine. Those are the things that we see. And that will tell you in the BUN and creatinine how your kidneys are functioning.

Very important to know, because a lot of chemotherapy are excreted through the kidneys, so you want to make sure that you're preserving a good renal function. That can also be an indicator of dehydration. So, for example, if you see a very high BUN with a ratio to the BUN to creatinine greater than 20 is suggestive of dehydration.

So we pay attention to that. And then sodium, potassium and chloride. You can see them being high or low pending  certain situations and they should be grossly with the normal limits in terms of the CMP. So complete metabolic profile. Like I was mentioning before, you're going to add the liver function test, LFTs for short.

The liver function tests are going to be ALT, AST, ALTFOS and total bilirubin. And they're actually very helpful to see two things. The first one, if the liver is functioning well, and that could be because of chemotherapy, because again, a big portion of the chemotherapies are processed and metabolized by the liver.

The second thing, breast cancer tends to go to the liver, so you can actually see if there's any affect on the liver. by the LFTs.  Again, you have to put in the right context, but it could be suggestive of liver dysfunction by either therapy or the disease itself. Sometimes there's an obstruction in the biliary tract, so your bilirubin can get elevated.

And alkaline phosphatase, is something that is related to the liver. and the liver functionality, but it also can be seen elevated in the setting of bone disease. So that's something that, especially in breast cancer that tends to metastasize to the bones, we pay close attention to. Other electrolytes that we follow there are calcium and magnesium.

Calcium is important, especially if you're getting a bone resorption inhibitor, XGEVA or Prolia or Zometa, depending on which one you're given as therapy. If you have metastases to the bones or if you have osteopenia or osteoporosis, these agents need calcium to build up your bones. So you can see hypocalcemia if you're in treatment with those agents.

Also, if the calcium is high, it could be an indicator that there's bone disease, meaning that the metastatic disease is going into the bones. There's a thing called malignant hypercalcemia, which is quite serious. So if the calcium level is extremely high, that could be considered also a medical emergency.

Other tests that we like to order in breast cancer are vitamin D levels. The majority of people have low vitamin D, especially in the northern parts of the U. S. where in the winter the sun exposure gets a little less. So we like to check on those. And I want to emphasize something very specific to breast cancer.

We check what we call tumor markers. So the tumor markers are labs that can help us see if there's activity of the disease happening. And the important thing about the tumor marker is not necessarily the number itself, but the trend. I think that a lab is a picture and we don't want to see a picture, something frozen on time.

We like to see a movie. So to me, the number itself doesn't tell me quite the whole story. I like to see the trend. If the trend is going up, especially if it's going up rather quickly. There's a fast doubling time. That's actually very suspicious and very worrisome for activity of the disease. And the opposite is also true.

If the numbers are going down, when a patient goes to therapy, it tells you that the patient is responding to that therapy. Those two things we take into consideration. There are other tests that we like to see when you're going through chemotherapy because you are going through processes of losing a little bit of blood, increasing the production, and then you're trying to ramp up that production in the bone marrow.

We like to check for folic acid, B12 and iron levels, which are the main components of hemoglobin. So we check an iron panel ever so often, that iron panel will have the iron. The TIBC, which is a total iron binding capacity, which if it's high, that means that you're in need of iron and we check the ferritin.

So if the ferritin is less than 100, that means that you don't have enough iron. In terms of B12 and folic acid, if they're low, we like to replace because you are going to need those vitamins in order to make sure that you have a normal production of hemoglobin that will help to expedite the recovery of the anemia.

So those are usually the main labs. If you're having medication that can have some specific side effects. For example, we have some medications that can affect your cholesterol. We like to check a lipid profile every so often, for example, every three months. Or if you have a medication that can affect your glucose, we like to check the A1C also every three months or every so often, depending on if it's controlled or not, to make sure that those labs are not getting out of hand.

Again, the most important thing when we see these labs is the interpretation of where the labs are. Sometimes one doesn't tell you the whole story. Being outside of the normal ranges is not an indicator to panic or to be extremely concerned, but to have a fair discussion with your doctor. Eventually, especially in the metastatic setting, after you go through multiple rounds of therapy, you will get more familiar with these numbers.

With the exception of hypercalcemia. and neutropenic fever, most of them are actually not an emergency. You have time to discuss with your doctor and figure out if that's something to pay attention to. The majority of the time, I tell my patients that treating and living with metastatic breast cancer is more like a marathon, not like a sprint.

Usually none of these labs are emergent. You can actually address them properly with your doctor, especially if you have a good communication with them. 

[00:15:44] Kate Pfitzer: Some of us really keep an eye on our labs and sometimes we worry about what we're seeing. Oftentimes we see our labs as normal, but they're upper high normal, or they're changing from month to month and they're going up, but they're still within normal.

And we try to be our own doctor and sort of interpret. Or at least we try to interpret what it could possibly mean. I love that you brought up the fact that interpreting is important, and it also needs to be interpreted properly because there's a lot of other factors that do come into play when we're looking at these labs.

So I'm curious, when you talk about normal and a normal range, it would be wonderful to hear your take on exactly what a normal range is. 

[00:16:28] Dr. Torres: I don't think that patients should be their own doctors, but I think that you should be your main advocator. You know yourself the best. And I have to say that as provider, we should always hear what you have to say.

You don't need to know everything, but we are a team. We have to work together. So I think that's very important. So I agree. You're not a doctor. You're not responsible to make decisions based on those numbers. But the more that you know about them, the better a conversation we can have. So that's important.

All right. So what is a normal range? A normal range is exactly what the lab designs to be within normal limits. Those labs were determined when they study thousands of people, and they did pretty much a bell curve. And you have a minimum and a maximum of normalcy on those lab values. You mentioned something very important.

There are some labs that with the normal limits, if you're actually seeing an upward trend, they could be suggestive of something actually happening. So just seeing normal ranges doesn't get you out of the woods, but most of the time it is okay to be with the normal ranges. If you're hitting those normal ranges every time you get blood work, That's usually a good indicator if things are going to be okay and they're stable and they're as expected to be.

But let's talk about some of the numbers in more detail like you mentioned. So the white blood cell, we said usually a normal range will be like four to 10. If you're below or above, that's something to address. For the hemoglobin, less than 11. 5, you're usually going to see that the patient is anemic. The lower the number, the more symptomatic and the worse it is.

And then for platelet counts, for us in hematology, we pay more attention when the platelets are starting to be below 100. When they're below 50, we say, okay, we probably need to do some medication modification if they're taking anti platelet therapy and anticoagulation, and if they're less than 30 or if they're bleeding.

then we really have to address it with something else that will be platelet transfusion or medication, depending on whatever the case will be. If you go on the CMP, when the sodium and/or potassium are abnormal, we tend to address it. It could be something as simple as the sodium is actually low for the patient to eat a little bit more salt or to hydrate better if the kidney function is a little abnormal.

But in general, we want to address the electrolytes because when they're far away from the normalcy, they can actually have problems with the heart. They could be serious. The renal function, the BUN, the creatinine that I was mentioning, usually doesn't change drastically. And when that happens, that's something more acute that is happening, like an obstruction, for example, in the bladder or the urethra.

The most common abnormal lab that we see is a difference between the BUN and the creatinine, and that usually is a sign of dehydration, which is seen after chemotherapy because of the inability to drink. maybe secondary to nausea. So I'm always emphasizing to my patients that you have to maintain adequate hydrating after chemotherapy.

And I mean, if they cannot achieve that, then I have the patients coming to see me to get hydration IV just to make sure that we're helping and preventing dehydration. Not because of the number, it's because of how people feel when they're dehydrated, then the side effects are usually worse. The liver function tests are very similar to the kidney function.

They usually don't jump too high and you actually have a lot of wiggle room because the liver is a very noble organ. And only with like 10 percent of the liver, it will still function. Well, normal would be like 30 or less, but if you're seeing that 30 to a hundred, roughly speaking, you're still fine.

There's not a lot of things to do, but if you're starting to see like the numbers being three X, five X, 10 X, the normal limit of normal, that’s not good, especially if it happens acutely. So that means that the liver is being overwhelmed either by a side effect from the medication, an infection, or a disease.

So that's something to pay attention to. For the tumor markers that we mentioned, the number itself doesn't mean much. Depending on which tumor marker and which lab we are using, that number is usually less than 30, for example, for some of the tumor markers that we follow. If you're following CEA for a non smoker, it's usually less than five, depending on the labs that you're using.

And the number itself, to me, is not super relevant. It's the trend for that number that we actually follow. Vitamin D that we touch upon is usually 30 or above. If it's less than 30, you're actually low on vitamin D. And one important one will be calcium. The calcium is usually below 10. If it's greater than 10, it's dangerous. If it's below 8, that's also not good as well. 

[00:20:42] Kate Pfitzer: So we have another question for you regarding the liver enzymes. The liver is an area of concern for those of us living with metastatic breast cancer. When you're looking at the lab results, we are wondering, Is there anything there that might trigger you to think, Oh, we need to look into this and figure out what could be causing the abnormal results and what would you do?

[00:21:07] Dr. Torres: Very good. So I teach some of the fellows that are in our program and I tell them one thing, we don't treat numbers, we treat people. So if you give me numbers. I will probably won't be able to tell what's happening, but if you tell me more information, I examined the patient, I know that patient’s history, I might have a better possibility of having a deduction about what's causing what.

For example, if I have a patient that I know is getting a therapy that is metabolized by the liver and the patient had normal liver function tests and then the week after I give the chemotherapy, those numbers went up. I can almost assure you that it was a side effect from the medication. You're telling me that a patient has liver disease and has the liver function test slowly trending up and up and up and up and then suddenly has a little bit more of a jump and that patient is taking therapy that is not what we call toxic to the liver or affects the liver.

Then I can actually say if I see the LFTs going up, the AST and the ALT going up. and that patient also has the alkaline phosphatase going up. And I do know that they have baseline liver disease. I will say, okay, this is probably more of the disease than the medication. When you have the two situations, when you have liver dysfunction, because the patient has a baseline metastatic disease to the liver, but you also have a medication that is affecting the liver.

You have to see when did the patient started the medication, what doses is the patient taking, and you have to see if the patient has any new medication that was included on their arsenal, you know, even over the counter stuff or herbal stuff. Just to give you an example. I had a patient recently. She was doing great.

She was taking a medication that was toxic to the liver, but she was doing great for months, three, four months doing phenomenal. The LFT suddenly had a jump and I couldn't make a lot of sense out of it. So I started asking her if she took anything and she actually went on a portal and saw there was a medication.

that she read was great for the therapy and she didn't tell me. It was an over the counter medication and her liver enzymes 10x from where she was. I had to hold the medication. I told her not to take the medication. So you have to get the story. And sometimes it is hard. We have other ways of complementing that information.

We do physical exam. We ask you a couple questions, which I highly value, and I think you get a lot of information. And then lastly, we actually can do imaging as well to see if we can sort out what's what. On a patient that comes to me and shows me a lab result, only a lab result without anything else will be a little challenging.

You will need more information. That's why the interpretation is important. 

[00:23:38] Victoria Goldberg: I just wanted to jump in for a second. Yes. You're using some acronyms that maybe people don't know what they mean, including me. LFT, I think the other one was AST, wasn't the right, did I say the right thing? What do they stand for and what do they measure?

[00:23:56] Dr. Torres: Very good. So I think when I was reviewing the CMP, which is a complete metabolic profile, I mentioned what LFTs are. LFTs is actually a short acronym for liver function test. In general, if you consider all of them in the liver function test, you have what we call the AST and ALT. They're part of the liver enzymes.

You actually can see bilirubin and there's another way of mentioning AST and ALTs. GGT, which is also functionality of the liver. And you have bilirubin and alkaline phosphatase. The short way that we refer to is ALKphos as well. So those are what we call liver function tests. The AST stands for Aspartate Aminotransferase.

[00:24:38] Victoria Goldberg: And we'll be using that on our regular life. Thank you.. 

[00:24:44] Dr. Torres: Oh, yeah So that's,  and the ALT is alanine transaminase, by the way, but we never use those names. We use ASD and ALT for, for short. 

[00:24:54] Victoria Goldberg: I think we will stick to those. That's a lot easier. So I want to go to another acronym that's very widely used and you mentioned it.

And we all, as if we are experts in this, we all say, Oh, our CBCs. So most of us, and I don't know if it's true for every regiments, but for people who are doing IV chemo and IV targeted therapies, we get our CBCs every time before the treatment. And I think. People who are on the pill get it a little less often, maybe once a month.

And I wanted to ask you, the other tests that you had mentioned, how often are those prescribed? How often do you do the other two tests that you talked about? And should they be done on a regular basis or only if there is something wrong with the CBCs? 

[00:25:48] Dr. Torres: So CBC, which is complete blood count and CMP, which is a complete metabolic profile or a basic metabolic profile, which is a CMP without the liver function tests or LFTs, they should be done quite routinely, especially if the patient is on therapy.

Most of the protocols for chemotherapy, they tell you how often you have to do them, but I will say in an active patient, usually once a month, we tend to run those tests. That's a gross estimate, but for some chemotherapies, you actually need to do it a little bit sooner. For tumor markers, every three months, it will be sufficient for A1c aka glycated hemoglobin, which is the one that we use for diabetes or to see how the glucose or sugar is the same as lipid profile.

We tend to do them every three months if the medication that we're using can cause some reaction to the lipids, which is a cholesterol. or to the sugar, which is the glucose. I remember something that I wanted to communicate as well. Knowing the numbers and knowing what normal parameters is important, but I say more importantly, it's actually to know what to do with them.

So for example, a lot of the medications that we give, they could be what we call nephrotoxic, meaning toxic to the kidney, or a lot of them could be toxic to the liver. So when we see the renal function test being abnormal, and when we see the liver function test being abnormal, if that's a consequence, of the medication that we're giving, we have to adjust that medication.

There's actually protocols that say you have to dose reduce the medication if you're seeing X or Y or Z organ being affected. But also it is a job of the oncologist. But I want to make sure that people can advocate for themselves. They have to say if my renal function is being compromised or my liver function is being compromised, are any of my other therapies, my hypertension medication,

my diabetes medication, my blood thinners, do I have to modify any of them? And sometimes the answer is no, but I think it's very important for the patient if they're going through a threshold in terms of the functionality of that organ to communicate with the doctor saying, listen, I think we need to revise my medication list, make sure that there's nothing that needs to be modified.

That is very important. What to do with those results is probably more important than knowing if something is abnormal or not. If you see something in red, start advocating for yourself. Say, do I have to review any of my other medication? Also, over the counter medications, even though you don't have to get a prescription and they could be deemed as natural, they can definitely, definitely modify your renal function and your liver function test.

So before you start anything, just communicate with your doctor. You will be surprised that most of the people are willing to incorporate what we call holistic or alternative medication if they're not interacting or if they're not posing any threats to the patient. So that's also very important as well.

[00:28:38] Victoria Goldberg: So the key here is listen to your doctor, talk to to your doctor, have an open communication. But I wanted to go back to the three numbers. We like numbers. The three numbers, they seem to be the most important ones that we get from the CBC, right? And that's the red counts, the white cell counts, and the platelets.

So I want to ask you about a topic that's very dear to my heart, the anemia. As far as I know, and correct me if I'm wrong, all anemia is not the same. There are different types of anemia. Can you go quickly over that so people would understand that not everything is related to iron depletion? 

[00:29:19] Dr. Torres: Correct. So as a hematologist, the first lab that we check when we have an anemia patient is actually the reticulocyte count.

The reticulocyte count is actually the baby red blood cell to kind of like name it a sort. The way that I explain that is that when you have the bone marrow and you have to start ramping up the production to respond to anemia because your body being so smart saying the hemoglobin is low, we have to ramp up the production, it's going to spill like a couple of baby red blood cells into the bloodstream.

That's actually good. When we see those numbers, when we see the reticulocyte count being high, that means that your bone marrow is working well. So when your marrow is working well, the anemia is usually secondary to hemolysis, which is an out immune phenomenon of your own body destroying your red blood cells or bleeding, even though you cannot see it.

Sometimes you can bleed through the stool and not see it. All right. You can see sometimes dark stool or red stool, but that sometimes you actually, the stool is normal and you can still be bleeding. So that is actually anemia, but with a normal functioning marrow. Now, going back to the reticulocyte count, if you don't see it in the bloodstream, that means that your marrow is not producing enough red blood cells.

And when that happens, we check a second number called MCV. That stands for Mean Corpuscular Volume. That is actually the difference in size between the cells, the red blood cells. And that can tell you quite a nice story. So when the MCV is low, that's actually iron deficiency or a thalassemia. The iron deficiency, by the way, it's the most common anemia.

That's why patients or people automatically reflect to thinking about iron deficiency when they see anemia. It is the most common one. But it's not the only one. Now, when that MCV is normal, meaning that it's between 80 to 100, that is what we call normocytic anemia. And it's usually secondary to anemia of chronic disease, more commonly renal dysfunction.

And when that MCV is greater than 100, we call that macrocytic anemia. It's usually B12, folic acid deficiency, alcohol, and there's other diseases as well, like MDS that could be part of that. So we use that to kind of like help us sort out what type of anemia the patient is having. 

[00:31:30] Victoria Goldberg: Thank you so much.

You've explained it so well that now I actually understand it. But I have a question and you mentioned that it's not about the numbers. It's about what to do with these numbers. So what do you do when you are anemic? As far as I know, and I might not be right about this, that the blood transfusion is the only way to fix it.

Maybe not. And how often is it safe to do blood transfusions? 

[00:31:56] Dr. Torres: I always talk to my patients. Diagnosis, staging, then treatment. You mentioned it before, and we kind of like went through a very brief overview of what anemias are. All anemias are not the same. I want to know why. The anemia is happening. I want to see if I can actually fix that underlying issue.

If I can do that, then I will address the underlying issue. Okay. By the way, transfusions are not the only way that we can use for anemia. So I'm going to talk very basically. B12 and folic acid deficiency, you get vitamins. Iron deficiency, I'll give you iron. If you have problems with your kidney function or if it's secondary to chemotherapy, I can give you an injection that is called EPO, erythropoietin analogs, that does the same thing that the kidney does to bring the hemoglobin up.

Okay? So there's things that can be done and there's more things of course, but you know, I just want to keep it a little short. Now, transfusions, if the hemoglobin is below seven or there is vital sign compromise, meaning your blood pressure is too low, your oxygenation is going low, then that patient needs actually transfusions.

Having a lot of transfusion is not necessarily bad, but we try to avoid it because the more transfusions that you get, the harder it is for you to find compatible blood. Your body will start seeing a lot of antibodies and then it will be harder for for you to actually get compatible blood. So we try the best as possible within our means.

to avoid really low levels of anemia. If we have to modify the chemotherapy, if we have to dose interrupt and we have to actually postpone one cycle and move it up a little, or if we have to give you growth factors, such as like the one that I was mentioning for the kidney, like the EPO analog, we can do all that to actually try to maintain a better level of hemoglobin.

It is fairly normal to see a little bit of anemia. We call that malanemia during therapy. Okay. So your hemoglobin is 9 10. You should be functional. You should be feeling okay. You are not in transfusion territory. 

[00:33:54] Victoria Goldberg: Okay. Well, that's wonderful. It's good to know because 20 years ago when I had my early stage cancer, I told Kater that I got a procreate shot at the time that they used to give, but I think they don't do it anymore.

Right. That was 

[00:34:08] Dr. Torres: bad. We don't do it for early stage, but we do it for metastatic. And that is a very important topic. The reason for that is that there is some thought that in the early stage that can stimulate the growth of the tumor. But in the metastatic setting, it's okay, and it's approved. Okay, so that's a great question.

All the EPO analogs, including Procrit, are safe to use in the metastatic setting. You only discuss pros and cons with the patient, but, but yes, we use it. 

[00:34:35] Kate Pfitzer: I'd like to finish up with a topic of communication. You talked a lot about communication, how important it is to have good patient doctor communication.

When a patient sees their results on the portal and they're abnormal, what are the next steps on the oncology side? What do oncologists typically do when they see this abnormal result? 

[00:34:56] Dr. Torres: In an ideal world, and we're not living in a perfect world, by the time that you get those results, we already went through them, okay?

And they're publicly released. If there were to be an emergency, there are systems that are checking balances to minimize the possibility of any of those labs slipping through, okay? So when we see them, we get alerted, especially if it's a critical lab. So there's Normal, abnormal, and then critical. So when we have a critical lab, then we get notified and we have to address it right away.

It is New York state law that whenever the lab releases a critical value, a doctor has to be notified. If it's not critical, we usually have time to actually sit down and review it. If we see, if you're having an appointment to come and see me soon, we can do it in person. If it's something that is still abnormal and needs to be addressed sooner, you should be expecting a phone call from your physician or the nurse.

And whenever none of those things are happening, you always can advocate and call the number that you have to contact your physician office and ask them, listen, I'm concerned about this lab. Is there something that I need to address? And again, it goes back in full circle in terms of advocating for yourself.

Fortunately, medicine in the U. S. is short staff. Not just from a medical standpoint, but also nurses and front desk. It is tough for us to handle the volume sometimes, so nothing is perfect. There's only one of you that takes care of you, and I have to take care of 6, 000 patients. I do my best not to miss anything, but we're human, so always advocate for yourself.

That's always a message as well. 

[00:36:26] Victoria Goldberg: That is such an important message. We want to reiterate it again. Advocate for yourself, but do keep an open conversation with your doctor. 

[00:36:39] Kate Pfitzer: We know that you're human and we know that oncologists are very busy. I want to ask you this specific question because we hear it all the time.

Sometimes communication is hard and sometimes patients have questions and they feel dismissed. For example, they'll go to the oncologist and ask, Hey, you know, I'm a little worried my blood test is abnormal. They'll kind of say, Oh, oh, oh, it's okay, it's okay. I won't really answer that question. I would love to hear your advice on how a patient could maybe ask the right question to their provider so they actually get the answer that they need and they don't feel dismissed.

[00:37:18] Dr. Torres: That's a very smart question. I think. A doctor and a patient, they have a relationship and that relationship needs to be built. There's different personalities and, and different ways, but I think as a general rule of thumb, if you are polite and you ask politely and you say, I need to get an answer about X, Y, and Z, for example, doctor, Why do you think that my liver function test is progressively getting worse?

Every time that we check, the number keeps getting higher. I know that you mentioned in the past that it's normal, but why you might think that that's happening? I want to pick your brain, an open question, instead of saying, is this okay? Because you give them an easy way out of saying, is this normal? Yes or no?

The same thing we get in training for medical school. If we want to get information from you, I won't ask you a yes or no question. That's called a closed question. I will ask an open question. It's like, I'll say, how are you feeling? What has changed since the last time I saw you? If I want to get information, I'll do open ended questions.

So I think an open ended question to your provider could be a solution. It's like, why do you think this is happening? My fatigue has been getting worse over the past couple of days. What is the main culprit or what can I do to try to fix those liver function tests? Do you think that there's anything that I could be eating differently or is something related to any of the medications?

But open ended questions I think is the way to go. 

[00:38:33] Kate Pfitzer: So much to talk about still and liquid biopsy is on the top of everyone's mind. So if you're up to it, we would love to have you back. Dr. Torres, we want to thank you. So much for generously sharing your time and your expertise with us today. We really, really appreciate it.

[00:38:51] Dr. Torres: It was an honor sharing with you guys. And then I got, like I mentioned, anything that I can do to help spread knowledge, make them feel empowered about their disease and to live with metastatic breast cancer and enjoy their life and make sure that they keep moving forward. I'm more than happy to help.

[00:39:07] Victoria Goldberg: Thank you so much. And I think Kate and I feel a lot more empowered right now. Thank you so much.

[00:39:18] Kate Pfitzer: Thanks for listening. This episode was produced by me, Kate Vieira Fitzer, host and metastatic breast cancer program director, along with Victoria Goldberg, executive producer of Our NBC Life. Original music and sound design was created by our associate producer, Connor Kensley. Many thanks to our program assistant, Miranda Gonzalez, and Christine Benjamin, Vice President of Patient Support and Education at Share Cancer Support.

You can find more episodes of RMBC Life wherever you get your podcasts. Be sure to subscribe, rate, and review us. Check out our blog and full episode notes on our website at rmbclife. org. And follow us on Facebook, Instagram, X, and YouTube at RMSDLive.