Cancer Care Basics

Section 01: Cancer

Module 02: Hematology and

Normal Laboratory Values Study
Guide
2024
Contents

The Purpose of This Study Guide ............................................................................................................................. 3

Introduction.............................................................................................................................................................. 4
Blood Basics .............................................................................................................................................................. 5
Hematopoiesis .......................................................................................................................................................... 6
Coagulation Studies .................................................................................................................................................. 8
Blood Chemistry Studies – Introduction and Electrolytes........................................................................................ 9
Blood Chemistry Studies – End Products of Metabolism ....................................................................................... 12
Blood Chemistry Studies – Iron .............................................................................................................................. 18
Blood Chemistry Studies – Glucose ........................................................................................................................ 19
Notes: ..................................................................................................................................................................... 21

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The Purpose of This Study Guide

This fillable study guide is designed to help you identify, organize and remember key information in
the course material and links to online resources so that you can increase your comprehension. Just
download it to your device and fill in the fields with the information you need. This guide will help you
recognize related concepts and make meaningful connections between topics, thus acquiring a higher
level of understanding.

In many cases, applying the concepts presented in this course on the job may require more than rote
memorization of terms and facts – critical thought and comprehension are important. As you proceed
through the summaries and questions below, try to:

1. Further condense the information presented in the module into smaller “chunks” and explain
terms and concepts in your own words to heighten retention.
2. Visualize, understand and take note of relationships among concepts and ideas.
3. Take note of examples from your current practice setting and think of how the information
would apply to a “real world” situation.

Remember, the course contains a social lounge forum in which you can share your experiences and
ideas with your peers, ask questions, or generally participate in a growing learning community.

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Introduction

five three
The average person has about ____________ litres of blood circulating in the body; __________ of the
five two
___________ litres is plasma with the remaining ___________ litres being cells.

Blood cells are classified as:

white blood cells (leukocytes) eosinophills
(1) ______________________________ (monocytes, and granulocytes:_____________________,
basophills neutrophils
___________________________, and ________________________)
red blood cells
(2) ______________________________ erythrocytes
or _____________________________cells
platelets
(3) ____________________________ thrombocytes
or _______________________________

The production of blood cells (specifically erythrocytes, granulocytes and platelets) is called
hematopoiesis bone marrow
________________________, and occurs in ______________________________________________.

In cancer and the treatment of cancer, blood cells play an essential role and we, as healthcare professionals,
need to be aware of them.

circulate
Electrolytes and other biochemical elements also ________________________ in the bloodstream and these

homeostasis
play a major role in maintaining _________________________________, and need to be monitored when

caring for patients with cancer even if they are not undergoing treatment.

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Blood Basics

liquid water
Plasma is the___________________ component of the blood and is a mixture of______________,
sugar
______________, fat
____________, protein
_______________________ salts
and_______________________.

What does the plasma carry?

blood cells
(1) _______________________________________
nutrients
(2) _______________________________________
waste products
(3) _______________________________________
antibodies
(4) _______________________________________
clotting proteins
(5) _______________________________________
chemical messengers (e.g., hormones)
(6) _______________________________________
proteins ­ help maintain body's fluid balance
(7) _______________________________________

Fill in the following table describing blood cells.

Blood Cell Other name Description

White blood cell leukocytes ­ fight infection and participate in inflammatory and immune response
­ prodcued in the bone marrow
­ five main types ­ lymphocytes, neutrophils, basophils, eosinophils and monocytes
­ differential count ­ the test which looks at the breakdown of each type of leukocytes
­ immature blood cells (blasts) ­ found in small amounts (1­5%) in the bone marrow ­
importatn in diagnosis of acute leukemia
­ normal WBC (4­10 x 10^9/L)

Red blood cell erythrocytes ­ carry oxygen from the lungs to body tissue, and
carbon dioxide from the tissue to the lungs for
removal
­ the main element, a protein called hemoglobin is
the carrier for oxygen

Platelets thrombocytes ­ essential for blood clotting along with

other factors

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Hematopoiesis

bone marrow
Blood cell development begins in the_______________________ pluripotent
with the _________________ stem
_________cell.

hematopoiesis
This highly regulated process is called ________________________ stem
and transforms the __________ cell
_________
red blood cells
into ________________________________, white blood cells
________________________________ platelets
and_________________.

the bone marrow

Most stem cells are found in ______________________________ however there is a percentage which are
circulating
found in ___________________________ blood
____________. The circulating stem cells are the ones which are
harvested for stem cell transplants.

pluripotent stem cell

The process of hematopoiesis begins with this cell. _____________________

myeloid progenitor cell

A stem cell can differentiate into a ________________________ or a lymphoid progenitor cell.

Once committed to the myeloid lineage, a cell can now become either a
erythrocyte ­ megakeryocyte progenitor
_________________________ granulocyte ­ monocyte
cell or a _______________________________________progenitor
cell.

List the cells which are granulocytes:

1) eosinophills
____________________
2) basophil
____________________
3) neutrophil
____________________

List the cell(s) which are considered agranulocytes.

monocytes
1) ____________________

What is a reticulocyte?

a young, immature red blood cell

___________________________________________________________________________________

plasma
B cell lymphocytes differentiate into ___________________ cells which are similar in appearance to
lymphocytes but are not normally found in blood.

megakeyocytes
Platelets are the end result of a _______________________ two
which breaks up. ___________third of
circulating blood
platelets are found in the __________________ stored
with the remainder ________________ in the
spleen
________________.

thousands
One megakaryocyte can produce ______________________ of platelets.
Normal platelet count ­ 130­380 x10^9/L

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Name the glycoprotein which controls the production of red blood cells.
erythropoietin
____________________________

kidney
This glycoprotein is produced in the _____________________________.

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Coagulation Studies
The prime function of coagulation mechanism is to
protect the integrity of the blood vessels while maintaining the fluid state of blood
___________________________________________________________________________________________
serious medical problems or even death may occur with the inability to stem the loss of blood
___________________________________________________________________________________________
or with the ability for normal clot to form
___________________________________________________________________________________________

stimulate formation of thrombin

Normally, the balance exists between the clotting factors that _____________________________________
delay thrombin formation
and the forces acting to _____________________________________. This balance maintains circulating blood
as a fluid
________________________. When injury occurs or blood is removed, this balance is upset, and
coagulation
_____________________ occurs.

clotting factors
Blood clotting is a cascade effect involving many _______________________ as well as essential elements such
calcium vitamin K
as _____________ and ____________________.

absorb vitamin K
The liver produces bile which is essential to __________________________________ The body uses this
blood clotting
vitamin to produce ____________________ factors. If the liver is compromised and does not produce enough
less
bile the body will then absorb less vitamin K hence producing __________ blood clotting factors.

In the following tables, please add the information you feel that you need for your practice.

Hematology Normal Range Possible Causes/Occurs in

Thrombin Time (TT) and 10­14 seconds Prolonged TT Shortened TT

Thrombin Clotting Time ­ therapy with heparin or ­ hyperfibrinogenemia
(TCT) measures the heparin like (increased level of
time needed anticoagulants fibrinogen in the blood ­
for plasma to ­ disseminated. essential for clotting)
clot when intravascular coaguation ­ elevated Hct (>55%)
thrombin is (DIC)
added ­ multiple myeloma and
fibrinolysis
­ severe liver disease

Partial Thromboplastin 22­30 seconds

Time (PTT) ­ DIC (chronic or acute)
screens for ­ hemophillia A &B
coagulation ­ heparin therapy
disorders ­ warfarin therapy
(APTT is more ­ vitamin K deficiency
sensitive version ­ hypofibrinogenmia (decreased level of fibrinogen in blood
of PTT ­ used ­ liver disease
when monitoring
heparin therapy)

APTT > 70 secs (spontaneous bleeding)

Critical Alert: ____________________________________

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 Prothrombin Time (Pro 10­14 secs increased PT:
time- PT) ­ deficiency of clotting factors
­ liver disease, liver damage
a protein produced in the ­ current anticoagulation therapy with warfarin or heparin
liver for clotting of blood ­ DIC
­ vitamin K deficiency
measures the effectiveness ­ poor fat absorption (patient with chronic diarrhea)
of both heparin and warfarin

International Normalized 0.9 ­1.2 patient taking warfarin

Ratio (INR)
higher INR ­ blood clots
warfarin ­
more slowly 2.0­3.0

Blood Chemistry Studies – Introduction and Electrolytes

patterns of abnormalities
Measurement of blood chemistry constituents is used to establish _____________________________
which may assist in the diagnosis of a condition or disease. Any blood test is not observed as a single
agent but needs to be taken into consideration with imaging studies, physical exam and patient
history.

In the following tables, please add the information you feel that you need for your practice.

Purpose Function Normal range High levels Low levels

Sodium

­ chief base in 1) maintain 136­146mmol/L ­ dehydration ­ severe burns

­ congestive heart failure
the blood osmotic pressure ­ diabetes ­ excessive fluid loss
Critical values
­ most abundant 2) maintain <90­105 ­ severe ­ tracheo (severe diarrhea/vomiting)
(90% of acid­base neuro symptoms bronchitis ­ excessive IV admin of
electrolyte fluids
electrolyte fluid) balance and vascular ­ primary (glucose­based)
­ changes in 3) transmit nerve problems aldosteronism ­ drugs (diuretics)
sodium levels impulses <125 ­ weakness ­ coma ­ edema
and dehydration ­ water intoxication
reflect changes >152 ­ ­ hypo parathyrodism
in water balance cardiovascular ­ SIADH
and renal
symptomes can be presentation of a
person with lung cancer
>160 ­ heart
failure

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Chloride

­ major anion ­ maintain 98­107mmol/L ­ dehydration ­ severe vomiting

­ exists cellular integrity ­ hyper ­ chronic resp
predominantly in * <100 ­ urinary
extracellular spaces through its excretion of chloride ventilation (resp acidosis
as part of sodium influence on is also low alkalosis) ­ salt losing
chloride/hydrochloric osmotic pressure <70 ­ ­ hyper diseases (SIADH)
acid and acid­base hyperirritability, parthyroidism ­
­ reciprocal power or and water tetany/muscular ­ kidney overhydration/water
increasing/decreasin excitability, slowed
g concentration in balance respirations, and disorders intoxication
response to conc. of hypotension due to
other anions fluid loss
­ least important >120­ weakness,
lethargy,
electrolyte to unconsciousness
measure (late) and Kussmaul
resp

Potassium

­ a principal cation of ­ nerve conduction 3.5­5.1mmol/L ­ renal failure, ­ diarhhea,

intracellular fluid ­ muscle function dehydration, vomiting, sweating
­ primary buffer ­ acid base balance obstruction and
within the cell itself ­ osmotic pressure Critical value trauma ­ starvation,
­ 90% is within the ­ controls the rate <2.5mmol/L ­ ­ cell damage malabsorption
cell and only small and force of ventricular (burns, accidents, ­ draining wounds
amounts are contraction of the fibrillation surgery, ­ renal tubular
contained in the heart (cardiac chemotherapy, acidosis
bone and the blood output) DIC) ­ damaged
­ damaged cells ­ potassium deficit >8.0 ­ muscle cells release ­ diuretic,
release potassium can be seen on irritability potassium into the antibiotics and
into the blood ECG by depression (include blood mineralocorticoid
­ 80­90% of the cell of T wave and myocardial ­ leukocytosis (in administration
potassium is peaking of P waves irritability) leukemia)
excreted in urine ­ tumour lysis
syndrome

Calcium most important in patients with metastatic disease (bone) ­ they are at increased risk for development of cancer

­ bulk of body calcium total calcium:: ­ hyperparathyroidism ­ hypoparathyroidism

(99%) is contained in 1) muscular 2.12­2.52mmol/L (due to parathyroid (due to removal of the
skeleton and teeth; act
as a huge reservoir for
contraction ionized calcium: adenoma, hyperplasia parathyroid glands;
1.14­1.28mmol/L of parathyroid glands,
maintianing blood levlels 2) cardiac function radiation)
of calcium 3) transmission of or associated ­ hyperphosphatemia
­ 1% found in the Critical Values: hypophosphatemia (due to renal failure,
circulating blood and half nerve impulses total calcium:
<1.1 ­ tetany and convulsions ­ excessive intake of laxative intake or
of that is ionized calcium 4) blood clotting > 3,25 ­ cardiotoxicity, vit. D, milk, antacids cytotoxic drugs)
arrhythmias, and coma ­ rapid
(only calcium that can be treatment indicated ­ prolonged ­ pancreatitis
used by the body, other ionized calcium: immobolization
half is protein bound <0.5 ­ tetany/life­threathening ­ vit. D deficiency
complications ­ paraneoplastic ­ low albumin levels
­ amount of protein and
albumin circulating in the
0.5­0.75­ in cases of multiple syndrome (cancer ­ alcoholism, hepatic
blood transfusions (indication
blood will affect the total to administer calcium tumours produce cirrhosis
serum calcium level >1.75­ coma parathyroid hormone

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most common causes of hypercalcemia are hyperparathyroidism and cancer
 Magnesium
­ concentrated (40­60%) in the
bone; 20% in muscle, 30% within
1) for the action of 0.74­1.03mmol/L >1.05mmol/L <0.65mmol/L
­ renal ­ movement of calcium out of
the cell itself, 1% in the serum ­ numerous enzyme
required for the used of adenosine Critical value failure/decreased bones (hypercalcemia —>
triphopshate as a source of energy systems such as abnormal calcification in
­ deficiency has significant effect
carbohydrate <0.49­ tetany function ((5% filtered
on metabolism of calcium because through glomerulus aorta and kidney)
Mg ’s importance in absorption of metabolism, protein 2.1­4.1 ­ CNS and reabsorbed in
­ hemodialysis
Ca from the intestines and in Ca’s
synthesis, nucleic ­ hypoparathyroidism
metabolism depression, renal tubules) ­ excessive loss of body
­ Mg’s measurement is used to acid synthesis and nausea, vomiting, ­ dehydration fluids
evaluate renal function, electrolyte
status and Mg metabolism contraction of fatigue ­ hypothyroidism ­ SIADH
muscular tissue 4.1­6.2 ­ coma, ­ used of antacids ­ admin of some
2) along with Na, K, ECG changes, resp containing Mg (e.g., chemotherpay and
paralysis milk of Magnesia), biotherapy agents
Ca; Mg regulates (panitubmumab and
neuromuscular 12.3 ­ complete admin of magnesium
cetubximab)
irritability and heart block salts ­ chronic renal disease
14­16 ­ cardiac ­ chronic pancreatitis
clotting mechanisms arrest

Phosphate

­ 85% of body’s total phosphorus

content is combined with Ca in the
1) required for 0.81­1.58mmol/L ­ renal insufficiency ­ hyper parathyroidism
bone; remainder in the cells generation of bone and renal failure ­ vomiting and severe
­ most of phosphorus in blood
tissue >1.45 ­ result of ­ hypo diarrhea (induced by
exists as phosphates
­ always evaluated in relation to 2) metabolism of effects of parathyroidism chemo)
calcium levels (inverse relation hypocalcemia ­
with Ca) glucose and lipids muscle cramps,
­ hypocalcemia ­ gram­neg septicemia
­ controlling factor for phosphate is
parathyroid hormone (PTH) 3) active in storage tetany, numbness ­ excessive intake of ­ hypercalcemiaof any
­ phosphate always follow glucose and transfer of and tingling, bone vit. D cause
into the cells —> when
carbohydrates are ingested, serum energy from one site and joint pain ­ bone tumours and ­ cont. admin of IV
phosphorus decreases temporaily
of body to another < 0.32 ­ weakness, metastases glucose in non­diabetic
4) maintenance of bone pain, ­ liver disease and patient
acid­base balance rhabomyolysis cirrhosis ­ hyperinsulinism
(breakdown of ­ tumour lysis ­ diabetic coma due to
striated muscle), syndrome increased carbohydrate
altered mental
status
metabolism

Pop-up in calcium information, slide 2 of 3

Define and describe Paraneoplastic Syndrome, in your own words

a group of symptoms that occurs when substances released by cancer cells or antibodies
produced by the immune system affect the normal functioning of other organs or tissues

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 In which types of cancer, is a Paraneoplastic syndrome often associated with?
hypercalcemia seen in small cell lung cancer, breast, kidney, and esophageal cancer
______________________________________________________________________________
squamous cell carcinoma of the lung, and head and neck, lymphoma, leukemia, and multiple myeloma
______________________________________________________________________________
What is the best treatment for this syndrome?

treatment of the primary tumour

______________________________________________________________________________

Blood Chemistry Studies – Enzyme Tests

protein that speeds up chemical reactions in the body

An enzyme is ______________________________________________________________________. In serum
the organ involved is working within its normal limits or is damaged
enzyme tests, we are looking to see if ___________________________________________________________
_
which can be indicated by elevation in the serum level of that test
__________________________________________________________________________________________.

Origin Function Normal range High levels Low levels

ALT Alanine aminotransferase

used to diagnose ­ liver disease no conditions which

high 17­63 IU/L cause decreased ALT
liver disease, and ­ cirrhosis
concentration in to monitor he ­ most indicated a
liver and low ­ metastatic healthy liver
course of
concentration in cancer to the liver ­ studies have shown
trreatment of liver
the heart, muscle, disease and ­ all types of that it is related to
and kidney effects of drug hepatitis increased long term
therapy mortality

ALP Alkaline Phosphatatse

­ an index of liver and liver disease

bone disease when 50­136 IU/L ­ obstructive jaundice ­ hypothyroidism
mainly in the correlated with clinical ­ space occupying ­ pernicious
bone, liver, and findings liver lesions anemia and severe
placenta, with ­ bone disease ­ level ­ cirrhosis anemias
rises in proportion to new ­ magnesium
some activity in bone cell production
bone disease
­ Paget's disease deficiency
the kidneys and ­ liver disease ­ level rises
­ metastic bone
when excretion of this
intestine enzyme is impaired as a tumours
result of obstruction in ­ primary bone
biliary tract tumours (osteogenic

must be considered with other blood studies and clinical findings

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 other
diseases/conditions
­ hyperparathyrodism
accomp. by
hypercalcemia,
hyperthyroidism
­ pulmonary & cardiac
infarctions
­ cancer of lung or
pancreas
­ ulcerative colitis,
peptic ulcer
­ chronic renal failure
­ congestive HF
AST Aspartate aminotransferase

­ in tissue of high ­ any disease 15­37 IU/L MI ­ azotemia

metabolic activity that causes liver disease (increased BUN)
­ decreasing conc in
the heart, liver, changes in ­ active and ­ chronic renal
kidney, pancreas, highly metabolic chronic hepatitis dialysis
spleen, lungs, and tissue —> rise in ­ primary or ­ vit. B6
skeletal muscle AST level metastatic deficiency
­ released into the carcinoma
circulation following ­ less specific to
injury or death of liver disorders ­ active cirrhosis
cells other diseases
­ following severe ­ hypothyroidism
cell damage, AST ­ trauma and
level will rise in irradiation and
12hrs and remain
elevated for about skeletal muscles
five days ­ to ­ pulmonary
evaluate heart and emboli, lung
liver disease infarction
­ hemolytic
anemia

LDH or LD Lactate Dehydrogenase

­ congestive HF
­ intracellular 100­205 IU/L ­ liver diseases
enzyme that is increase in associated with a
­ solid tumours, good response to
widely distributed reported value leukemias,
usually indicated cancer therapy
in tissues in the lymphomas, and
body, particularly cellular death and particular bulky
in the kidney, leakage of the disease
skeletal muscle, enzyme from the ­ lung diseases
heart, liver, brain, cell ­ musculoskeletal
diseases, muscular
and lungs damage
­ CNS disease
­ fractures (trauma ­
head injury)
­ instestinal
obstruction
CANCER CARE BASICS SECTION ONE – CANCER – MODULE 2 – HEMATOLOGY AND ­NORMAL
MI (angina
LAB VALUES
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produce elevated
LDH level)
 Blood Chemistry Studies – End Products of Metabolism

In your own words, describe the purpose of assessing the end products of metabolism.

___________________________________________________________________________________________

Bilirubin
hemoglobin
Bilirubin results from the breakdown of ________________________ which is found in
red blood cells
__________________.

liver
It is removed from the body by the _________________, which excretes it into the
bile
_________________.

A rise in the bilirubin level usually indicates ____________________________________________.

excessive destruction of RBCs/ when liver is unable to excrete normal amounts of bilirubin produced

conjugated
Direct or _______________________ in the blood
bilirubin circulates freely ______________________________
conjugated
until it reaches the liver where it is ______________ with glucuronide transferase and is then
bile
excreted in the ___________________. An increase in this type of bilirubin is indicative of
dysfunction or
_________________ blockage of the liver
______________________________________.

unconjugated
Indirect or ___________________ protein
bilirubin, which is bound to ________________, is more frequently
increased destruction of red blood cells (hemolysis)
associated with __________________________________________________________.

total
Usually only the ________________ free flowing (direct)
bilirubin, which is comprised of _______________________and
protein bound (indirect)
__________________________, is measured.
_
When is the breakdown of each subtype provided?

when total level of bilirubin is high, giving the investigator more insight to the reason for it
___________________________________________________________________________________

adult total: <3­17 umol/L

Normal range: __________________________________ and Critical: > 200umol/L
adult direct: < 2­9 umol/L
____________________________________

Elevated levels can be found in:

Total: hepatocellular jaundice, obstructive jaundice (d/t gallstones or cancer), hemolytic jaundice, congestive HF, pulmonary emboli

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­ hemorrhagic pulmonary infarcts
Direct
­ cancer of the head of the pancreas
­ choledocholithiasis
Blood Urea Nitrogen (BUN)
Urea forms in the _____________ and along with ______________, constitutes the final product in
protein _______________. The amount of urea varies directly with ________________________,
___________________________, _________________ and ________________________________.

BUN, which measures ______________________________, is used as an index of

_________________ ________________________ in the production and excretion of ____________.

Rapid protein _____________and impairment of kidney function will result in ___________BUN level.
The rate at which the BUN level rises is influenced by___________________, ___________________
and the rate at which the kidneys _______ the urea nitrogen. A markedly increased BUN is _________
evidence of severely ____________________________________________.

Normal range: _______________________________

Increased BUN level is caused by:

Creatinine
Creatinine is a byproduct in the breakdown of muscle ________________ resulting from energy
metabolism. It is produced at a ________ rate depending on the ________________ of the person
and is removed from the body by ____________ and production remains constant as long
_________________________________. A disorder of kidney function reduces _______________ of
creatinine, resulting in ______________ blood creatinine levels. This test is used to diagnose
____________________________________. It is a more specific and sensitive indicator of kidney
disease, although in chronic renal disease both BUN and creatinine are ordered as the
___________________________________ provides more information.

Normal range: Female: _____________________________Male:______________________________

Normal Bun to creatinine ratio: _____________________

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 Increased levels of serum creatinine Decreased levels of serum creatinine
Male: Male:
Female: Female:

Possible Causes: Possible Causes:

Uric Acid
Uric acid is formed from the breakdown of _______________________ and is an end product of
______________________. Uric acid is transported by the __________ from the ________ to the _________,
where it is filtered and where about ____ is _____________.

The remainder of uric acid is _______________ into the GI tract and broken down. An overproduction of uric
acid occurs when there is ________________________________________,
_________________________________________________ or an ________________________________ the
substance produced (as in renal failure).

Normal value: ___________________________________

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Causes of increased Uric Acid levels or Causes of decreased Uric Acid levels or
_________________________________ _________________________________

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Blood Chemistry Studies – Iron
Iron is necessary for the production of: ___________________________________________________________

Transferrin is: _______________________________________________________________________________

Total iron binding capacity (TIBC) correlates with ______________________________, but the relationship is
not truly linear. A serum iron test without a ________ and ______________ determination has limited value
except in the case of _________________________________.

The combined results of transferrin, iron and TIBC tests are helpful in:

1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________

Iron Study Normal Range Possible Cause for an Increase Possible Cause for a Decrease in Level
in Level

Iron

Critical alert:

Transferrin

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 TIBC

Ferritin

Blood Chemistry Studies – Glucose

Describe how glucose is formed.____________________________________________________________

___________________________________________________________________________________________

The two hormones which directly regulate glucose are: ______________________and ___________________.

Normal range: ______________________________________________________________

Hyperglycemia – possible causes Hypoglycemia – possible causes

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Clinical Relevance:

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Notes:

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