Treatment
The treatment of leukaemia is complex: it varies depending on the type of leukaemia and it is not the same for all patients.
Generally, the therapy is developed to treat the specific characteristics of the leukaemia cells that are detected, also taking into account the extent of the disease, aspects such as age and the general state of the patient.
Whenever possible a patient should be treated in a hospital that has a hematology ward that specializes in this type of disease. If this is not feasible then it is advisable that the doctor responsible for the patient coordinates the treatment strategy with a specialist centre.
Acute leukaemia requires immediate treatment, with the primary focus of the treatment to force the disease into remission (the absence of a detectable disease). Once reached, it is possible to administer more treatment cycles to prevent a possible relapse. The possibilities of a cure depend on variables such as the type of leukaemia and the age of the patient.
Patients affected by chronic leukaemia who remain asymptomatic might not need immediate treatment, but they should be periodically monitored to detect any possible progression in the disease. The disease and its symptoms can be controlled with the proper treatment but the chances of a complete cure with conventional chemotherapy are rare.
Types of Treatment
Leukaemia treatment could include:
• Chemotherapy applied intravenously or orally
• Intrathecal chemotherapy (medication applied through the spinal column with a needle, in the area known as the subarachnoid space)
• Radiotherapy
• Bone marrow or umbilical cord blood transplant
• Biological therapy
• Medication to prevent and treat nausea and other secondary effects of the treatment
• Blood transfusion (of the red blood cells or platelets)
• Antibiotics, to prevent and treat infections
Chemotherapy involves the use of medication that destroys the leukaemia cells. Depending on the type of leukaemia, it can be applied as a single form of medication, although it is more common to combine two or more drugs. Some cycles of chemotherapy are administered orally but the majority are injected intravenously. For patients who require regular injections through this method it would be necessary to attach a catheter, which consists of a flexible thin tube that is inserted into a large vein, usually in the arm, the thorax, (below the collarbone), or the neck. Through this catheter, all the medication can be administered, removing the inconvenience of repeated injections.
The medications applied intravenously or orally penetrate the blood stream and reach most of the malign cells in the body. However, these methods do not reach the cells that are present in the central nervous system, and are protected by a barrier that consists of a network of blood vessels that filters the blood between the brain and the spinal column. To reach the leukaemia cells that are present in the central nervous system, it is necessary to apply intrathecal chemotherapy, which consists of an injection of anticancer medication directly in the cerebrospinal fluid, usually applied to the lower part of the spinal column. A similar failure to reach leukaemia cells present in the testicles could mean that radiotherapy treatment would be necessary.
Image property of Terese Winslow (2007, National Cancer Institute)
Chemotherapy is administered in cycles: a period of treatment followed by a period of recuperation, before another cycle of treatment. Depending on the type of treatment its administration will require hospitalization or could be treated on an outpatient basis, as a day patient, in a consultation at a medical centre or even in the patient's home. For more information, you can consult the following web pages:
• Chemotherapy in Medline Plus
• Chemotherapy and you, resource of the National Cancer Institute
• Chemotherapy (American Cancer Society)
• Interactive presentation of the Medlin Medical Encyclopedia
Radiotherapy is used in conjunction with chemotherapy to treat certain types of leukaemia. It involves the application of elevated energy rays that attack the cancerous cells and restrict their growth.
Radiotherapy can be applied in two ways; either on the specific part of the body where the leukaemia cells have accumulated, such as the spleen or the testicles, or on the body as a whole. The latter is known as total body irradiation, and is commonly used as a preliminary step towards a hematopoietic stem cell transplant.
For more information, please consult the following web pages:
• Radiotherapy in Medline Plus
• Radiotherapy: questions and answers, resource of the National Cancer Institute.
Biological therapy (sometimes called immunotherapy, biotherapy, or biological modifier response therapy) is a new family of agents that can be used in the treatment against cancer. Biological therapy uses the body's immune system, directly or indirectly, to combat cancer and to lessen the side effects that can be caused by other cancer treatments. The most common are interferons, interleukins, stimulant factors (G-CSF, erythropoietin) and the monoclonal antibodies.
For more information:
• Biological therapy of cancer: questions and answers, resource of the National Cancer Institute.
The hematopoietic transplant is another form of treatment that can be offered to certain patients. The bone marrow of the patient, which produces the malign cells, is destroyed by administering a high dosage of chemotherapy and occasionally radiotherapy and is then replaced with a healthy bone marrow. The replacement of bone marrow can come from a donor (allogeneic transplantation), or from the patient themselves (autologous transplantation).
While traditionally, hematopoietic transplants were carried out with hematopoietic stem cells of the bone marrow (bone marrow transplant), today they are more frequently performed with stem cells obtained from the peripheral blood (venous), after stimulating the passage of hematopoietic stem cells from the bone marrow to the blood. In addition, transplants of the umbilical cord blood also serve well due to their richness in hematopoietic stem cells. The umbilical cord blood is obtained after the delivery of a newborn baby.
Download the hematopoietic guide
Stages of the treatment
There are several stages in the treatment of leukaemia:
• Induction: A combination of different chemotherapy agents are administered to halt the production of abnormal cells in the bone marrow. The objective of this stage of the treatment is to obtain a remission of the disease, which is to say, to impede the production of more leukaemia cells. This phase can last approximately a month and can be repeated if the objective is not met.
• Intensification/consolidation: chemotherapy treatment is administered even when there are no abnormal cells detected because despite the fact that they cannot be seen it is highly likely that they still remain in the organism. More treatment is administered to intensify or consolidate the induction. Sometimes the consolidation can involve an autologous or allogeneic transplant.
• Maintenance: the stage that maintains a leukaemia free bone marrow through constant low intensity chemotherapy over a longer period of time. This phase can last several years. During this period regular visits to the doctor are required to monitor the response to the treatment and any possible side effects and to check for the revival of the disease.
Supportive Treatment
Leukaemia and its treatment can provoke diverse complications and side effects. Patients usually receive supportive treatment designed to prevent or control these complications and to improve their quality of life during the treatment.
Antibiotics are often applied in order to prevent infections to which they are more easily exposed. In addition, they are advised to stay away from people who show signs of catarrhal symptoms or other infectious manifestations, as well as agglomerations.
Anaemia and hemorrhages are other problems that often require additional treatment. Transfusions of red blood cells help to fight anaemia and its effects, and platelet transfusions reduce the risk of hemorrhages.
Side effects of the treatment
It is very difficult to limit the effects of the therapy solely to the destruction of leukaemia cells. Due to the fact the healthy cells and tissue are also affected, certain side effects can materialize. These side effects are variable and depend, fundamentally, on the type, intensity and duration of the treatment. They can differ from one person to the next, and even differ between different cycles of the treatment. In general, the doctor will arrange the treatment for a patient in such a way as to avoid side effects, as much as possible.
Doctors and nurses always explain the side effects that a patient should expect, and they indicate the medication, diet and other remedies that can alleviate them. When a person is diagnosed with leukaemia, their reaction is usually one of alarm and concern, which impedes the ability to ask any questions, resolve any doubts, or listen to the explanations and comments that are offered. In these cases it is often a good idea to make a list of questions that you want to ask the doctor or to be accompanied by a family member or friend to take part in the conversation. It is not necessary to ask all the questions at one time, there will certainly exist further opportunities to consult the doctor with new questions or to obtain information.
Side effects of chemotherapy
The side effects depend on the type of medication that is administered and as with all treatments; they can vary from person to person. Generally speaking, chemotherapy affects cells in the process of multiplication, which means that it affects the neoplastic cells (which multiply rapidly) and the healthy cells that multiply faster (blood cells, scalp hair follicle cells, and cells of the digestive tract). This explains many of the symptoms experienced by patients receiving chemotherapy: reduced resistance of the organism against infections (due to the lower number of leukocytes), tiredness and malaise (due to the lack of red blood cells -anaemia-), predisposition to bruising and bleeding (due to missing platelets), loss of hair, nausea, vomiting, mouth ulcers and diarrhea. The majority of side effects disappear gradually during the period of rest between cycles of treatment.
Certain anticancer medication can affect the fertility of a patient. In women, periods can be irregular or even disappear, symptoms similar to the menopause such as hot flushes and vaginal dryness. In men, the production of sperm can be affected. Because these affects can be irreversible, men are recommended to freeze and store their sperm before beginning treatment, providing that there is enough time to do so. For children who receive anti-leukaemia treatment, there is a good chance that they will have a normal level of fertility when they reach adulthood. However, in some cases it may be impossible to reproduce, depending on the type of treatment used, the dosage administered, and the age of the patient at the moment of the treatment. Although it is possible to freeze a fertilized egg for use in the future, the technique of freezing the egg and the ovarian tissue is not sufficiently developed to offer this option to a wide range of patients who are undergoing chemotherapy.
For more information:
• National Cancer Institute document about the loss of hair.
• National Cancer Institute document about nausea and vomiting.
• The Leukaemia and Lymphoma Society document about fertility.
• Chemotherapy, Medline Plus.
• Chemotherapy and you, resource of the National Cancer Institute
Patients undergoing radiotherapy can develop symptoms of fatigue that require periods of rest. However, doctors advise patients to remain as active as possible.
Holo-cranial radiotherapy can often lead to hair loss, which can provoke scalp irritations. It is important to maintain the scalp in a clean condition and patients should follow precisely, the recommendations of their doctor. Radiotherapy can also cause nausea, vomiting, and loss of appetite. These side effects are usually temporary and doctors or nurses can recommend methods to alleviate them during the period of treatment.
However, some side effects can be more lasting. In young children who are undergoing holo-cranial radiotherapy problems related to learning and coordination have been detected. For this reason it is avoided if possible or the lowest possible dosage of radiation is applied, and only those cases in which chemotherapy is not effective on its own.
Radiotherapy applied to the genital organs can affect hormone production and the level of fertility. The majority of young adults who undergo this treatment become infertile and some require the administration of hormones.
For more information:
• Radiotherapy, resource of the American Cancer Society.
Long term controls
It is very important to carry out control checks after treatment against leukaemia. Checks normally include a complete physical examination, a blood test, a bone marrow exam, and occasionally, a cerebrospinal fluid exam in order to rule out a reappearance of the disease.
Due to side effects that can manifest several years after treatment, it is advisable for patients to undergo regular checks. In addition, patients should contact their doctors immediately if they experience any problem or change in their health no matter how minimal it may be.
Illustrations taken from the Bone Marrow Transplant Guide, by Mercè Capdevila.
