Leukemia is cancer of blood-forming tissue such as the bone marrow. Types of leukemia are grouped by the type of cell affected and by the rate of cell growth. Leukemia is either acute or chronic.
There are many different types of leukemia. Some are fast-growing and aggressive, others are slower to progress. Leukemias are also classified based on the type of blood cells affected. The most common types of leukemia include:
Acute leukemia involves an overgrowth of very immature blood cells, also known as blasts. This condition is life-threatening because there are not enough mature blood cells to prevent anemia, infection and bleeding. A diagnosis of acute leukemia is made when there are 20% or more blasts in the bone marrow. Acute lymphoblastic leukemia (ALL) is most common during childhood and in early adulthood, although it is also diagnosed in adults 30 years old and older. Acute myelogenous leukemia (AML) occurs more often in adults.
Chronic leukemia involves an overgrowth of mature blood cells. Usually, people with chronic leukemia have enough mature blood cells to prevent serious bleeding and infection. Chronic leukemia is more common in people between ages 40 and 70 and is rare among younger people.
Myelodysplastic Syndrome (MDS) is a condition in which the bone marrow does not function normally and does not produce enough normal blood cells. The blood cells affected are white blood cells, red blood cells and platelets. Some cases of MDS may progress to acute leukemia, over time. MDS is most often found in patients nearing their 60s and 70s.
When your doctor is looking for specific types of leukemia, they will look at chromosome number and appearance, features on the bone marrow cell surface and the appearance of the bone marrow cells under a microscope.
The different types of leukemia share some common symptoms, including:
Symptoms of acute lymphoblastic leukemia may also include the presence of painless lumps under the skin in the groin, underarm or neck, and/or pain under the ribs.
The diagnosis of leukemia is based on the results of both blood and bone marrow tests, such as bone marrow aspiration and bone marrow biopsy.
Bone marrow aspiration: Before insertion of the bone marrow aspiration needle, the aspiration site is numbed with anesthesia. During this procedure, a sample of bone marrow cells is removed from the hip bone with a needle. Most people feel pressure as the needle is inserted and a few seconds of sharp pain when the bone marrow fluid is removed.
Bone marrow biopsy: With a bone marrow biopsy, a small piece of bone is removed. A biopsy may be slightly more painful, but only during the procedure.
The most effective treatment for leukemia is chemotherapy, which may involve one or a combination of anticancer drugs that destroy cancer cells. Specific types of leukemia are sometimes treated with radiation therapy or biological therapy.
Each type of leukemia is sensitive to different combinations of chemotherapy. Medications and length of treatment vary from person to person. Treatment time is usually from one to two years.
Your treatment may consist of different chemotherapy drugs and biological therapies. The short-term goal is for a complete remission (CR). A complete remission means that the bone marrow has less than 5 % blasts, the absolute neutrophil counts is over 1,000 and the platelet count is over 100,000. The long-term goal is for an extended disease-free state and cure.
A course or cycle is the period of time from the start of your chemotherapy until either the blood and bone marrow cell counts are back to normal or when you are able to receive further treatment. In some cases, the leukemia cells are destroyed only from the blood and not from the bone marrow during the first course of chemotherapy. In these cases, a second course may be needed.
If the leukemia does not respond to one or two courses of treatment, a different drug program may be used to bring on a remission. A different drug program may also be used if a relapse occurs.
A specific treatment plan is called a protocol. Each protocol is usually named by letters with each letter standing for a particular drug. A protocol may be considered either standard or experimental therapy. Your doctor will discuss with you the advantages and disadvantages of a particular type of therapy.
Once your protocol is determined, you will receive more specific information about the drug(s) that will be used to treat your leukemia. Common side effects of most chemotherapy drugs include hair loss, nausea and vomiting, decreased blood counts and infections.
Radiation therapy is used along with chemotherapy for some kinds of leukemia. Radiation therapy (also called radiotherapy) uses high-energy rays to damage cancer cells and stop them from growing. The radiation comes from a large machine.
Radiation therapy for leukemia patients may be given in two ways. For some patients, the doctor may direct the radiation to one specific area of the body where there is a collection of leukemia cells, such as the spleen or testicles. Other patients may receive radiation that is directed to the whole body. This is called total-body irradiation. This type of radiation usually is given before a stem cell transplant.
Biological therapy is sometimes used to treat leukemia. Biological therapies include growth factors, interleukins, monoclonal antibodies, etc. Some patients receive only biological therapy, while others also receive chemotherapy at the same time. You will receive more detailed information about biological therapy if it is used as a treatment for your type of leukemia.
A splenectomy is the surgical removal of the spleen. The spleen is located in the abdomen, on the left side. It acts as a filtration system for blood cells. When a patient has chronic leukemia, the spleen tends to collect leukemia cells, transfused platelets and RBCs. Frequently the spleen enlarges from storing these cells. This makes it difficult for the chemotherapy to reduce the quantity of diseased cells. If the spleen is not removed, it sometimes grows so large that it causes breathing difficulty and compresses other organs. In that case, a splenectomy may be needed.
Stem Cell Transplantation
Stem cell transplantation (SCT) is a form of treatment for leukemia patients. This type of treatment was previously referred to as a “bone marrow transplant.” This treatment consists of destroying leukemic bone marrow cells using high doses of chemotherapy and in some cases, radiation therapy. Because high-dose chemotherapy severely damages the bone marrow’s ability to produce cells, healthy stem cells are provided intravenously to stimulate new bone marrow growth.
There are two types of stem cell transplantation:
Like other leukemia treatments, SCT is highly individualized. Different factors will help your doctor decide what specific treatment to use, including the type of leukemia you have, your past response to chemotherapy treatment, the availability of stem cells for replacement, your age and the status of your leukemia.
Treatment Side Effects
The medical team carefully reviews each person’s medical history and your physician will then recommend the best chemotherapy treatment. Responses and side effects to chemotherapy may differ from person to person or from one course to the next. The seriousness of side effects is not a measure of how the leukemia is responding to the chemotherapy. Only diagnostic tests such as blood counts and bone marrow tests will give this information.
Diagnostic tests are done at different times depending on the type of leukemia you have and the type of chemotherapy drug used. For example, a complete blood count (CBC) will often be done every 24 hours for acute leukemia, but will be done only once per week or less often for chronic leukemia. A bone marrow test will be done prior to the start of chemotherapy and again in two to three weeks in acute leukemia. Depending upon the results of the bone marrow test and blood cell counts, your doctor will order further bone marrow tests. In response to the chemotherapy, the bone marrow is emptied of both normal and abnormal cells. During the time the bone marrow is “empty,” no cells are produced. Both blood and bone marrow cell counts are usually back to normal between 21 and 31 days after the first day of chemotherapy, depending on the type of chemotherapy given and the person’s response to the treatment.
In general, your white blood cell (WBC) count will fall within the first week after you start chemotherapy. As a result, you will be more prone to infection. Blood, urine, sputum, stool and throat cultures are collected to find out if an infection exists. These cultures may identify the specific organism, also known as bacteria, causing the infection. A chest x-ray will be taken because many infections occur in the lungs. If you are likely to get a specific type of infection when you are not sick such as a sinus infection, urinary tract infection or pneumonia, you have an increased chance of getting this infection each time your WBC count drops. Because of this, good personal hygiene is very important. Handwashing is the most important precaution for preventing infection. If you are unable to wash your hands after shaking hands, use a hand sanitizer.
The nursing staff will help you maintain good personal hygiene if you cannot manage it yourself (i.e., daily bathing and good mouth care). Please ask your visitors who may be sick, or think they are sick, not to visit with you while they are ill. Even wearing a mask will not completely prevent the spread of infection. Infections are treated with antibiotics given intravenously or by mouth for at least seven days. Your doctor will tell you about the antibiotic treatment in detail.
Your red blood cell count (RBC) will also decrease. This decrease can be seen by a drop in either your hematocrit or hemoglobin levels. Both will cause fatigue. You will be given a RBC transfusion as needed. As a general rule, red blood cells are transfused when your hemoglobin is at least 8.0 or lower. It is important to drink at least six to eight (8 oz.) glasses of fluids each day to flush the chemotherapy from your system. This should begin the day you start your chemotherapy and continue for four days after you have finished your treatment. If you are on IV fluids or fluid restrictions, check with your doctor or nurse before drinking this amount. As your RBC count drops, your heart may beat fast or you may feel lightheaded when you get up quickly. Report these side effects to your nurse or physician.
Another side effect of chemotherapy is a decrease in the number of platelets. If this happens, nosebleeds, bleeding gums or passing blood in the urine or stool are likely to happen. Little red dots may appear on parts of your body, especially the arms and legs. These dots are called petechiae, which means that there is bleeding from the capillaries, or small blood vessels in the skin. Platelet transfusions are usually, but not always, given when the platelet count is less than 10,000 or any time that bleeding occurs. Platelets are transfused only as needed because unnecessary transfusions may eventually cause your body to stop responding to platelet transfusions.
You must take special care of yourself when your platelet count is low. Use a very soft toothbrush to avoid irritating your gums and use an electric shaver rather than a blade for shaving. Dental flossing can be continued if you had practiced this previously but do not go down to the gum line. If you do injure or cut yourself, you can stop the bleeding by putting direct pressure to the wound for five to ten minutes. If you have vaginal bleeding, your doctor may prescribe medications such as hormones. Try not to strain during bowel movements because it may cause rectal bleeding. A stool softener can be prescribed if needed. Again, try to drink plenty of fluids to help keep your stools soft. Vigorous exercise and contact sports should be avoided. Short walks are all right. Watch your energy tolerance and recovery – “Don’t push it.” Report any bleeding to your doctor or nurse.
Other side effects you may experience are diarrhea or constipation. There are medications for each of these side effects, so let your doctor or nurse know right away if you have either of them. High fiber foods, prunes or fruit juices may help relieve constipation. It is good to drink at least eight (8 oz.) glasses of fluids each day. A dietitian will also be able to give you other food tips to help relieve these side effects.
Nausea & Vomiting
Chemotherapy can also cause nausea or vomiting. Sometimes, nausea or vomiting may be triggered by certain smells or just thinking about the hospital and about the treatment you will be receiving. Try to keep something, like dry toast or crackers, in your stomach throughout the day. A dietitian can give you other food tips that can decrease the symptoms and help you continue a healthy diet. Strong anti-nausea medications are also available. You should feel free to ask for medication if you feel queasy at any time. Some chemotherapy drugs can cause nausea for an entire day or more after treatment. Therefore, your anti-nausea medication may be continued for a day or so after chemotherapy. Some anti-nausea medications can cause drowsiness so you may need to stop driving while you are taking this medication.
Sore mouth, also called stomatitis, is a common side effect of some chemotherapy treatments. You must keep your mouth as clean as possible to prevent infection. You should rinse your mouth four times each day with a baking soda solution, especially after meals. To make the baking soda solution, mix ½ teaspoon of baking soda to eight ounces of water.
Certain mouthwashes and sprays may be prescribed to prevent infection and to make it easier for you to eat. Do not use commercial mouthwashes because they contain alcohol and may irritate your mouth. You may want to avoid foods or drinks that are tangy, salty or sweet, as they may worsen mouth soreness. Avoid extremely hot foods because they may slow the healing process in your mouth and throat.
Hair loss, both body hair and scalp hair, is a common side effect of chemotherapy. Depending upon the chemotherapy you receive, you may not lose any hair, or it may just become thinner or may completely fall out. Hair loss can have a major impact on body image.
It is natural if you do not want to eat or drink if you have a sore mouth or your stomach is upset, but it is still important that you nourish your body. Your body needs extra calories and protein when you have leukemia to build strong new cells. This is not the time to go on a weight loss diet! If you begin to lose weight, try to eat six small meals or snacks a day and add high-calorie, high-protein foods to your diet. A dietitian will be able to give you more information on these types of food and they are available at your request. A dietitian can also help a family member cope with the loss of pleasant aspects of eating, such as taste, by helping them choose the right foods and preparation style. Your appetite may be stronger in between treatments.
During chemotherapy it is also very important to drink lots of fluids. This means that you should drink at least eight (8 oz.) glasses of fluids each day. You may want to drink fluids that contain calories such as fruit juices, milk or protein supplements. Soft drinks, or carbonated beverages, may increase the intake of carbonation and result in gas or cramping. Soft drinks generally have no nutritional value and juices or energy drinks are preferable. Talk to a dietitian if you are diabetic.
If you cannot tolerate eating regular foods, there are liquid nutritional supplements available to help you get the amount of calories and protein that your body needs. The dietitian can help you choose the correct one.
If you are having difficulty eating, you may receive your nutrients through a tube in your stomach, through an intravenous (IV) line, or through intravenous hyperalimentation (IVH). Both methods can provide you with the nutrients that you need when you cannot eat enough. You will be able to speak with a dietitian if you continue having eating problems and/or weight loss.
Cancer is a journey that no one needs to take alone. There are many forms of support to help you through every stage: diagnosis, treatment and survivorship. Whether you meet with other cancer survivors like yourself, use complementary therapies or individual coping mechanisms, support is available. Listed below are just some of the ways to find help...and hope.
Getting together with other cancer patients in a support group is a valuable coping tool. Support groups are usually focused on a single disease or topic, such as breast cancer survivors or people coping with life-changing side effects from their cancer or cancer therapy. These groups allow participants to meet others like themselves and seek strength from each other. Most major cities and cancer hospitals offer support groups that meet weekly or monthly. There are also dozens of online support web sites or message boards for those who may not have access to a traditional meeting.
Complementary therapies are used in conjunction with cancer treatment, in an effort to reduce treatment side effects, ease depression and anxiety and help cancer patients take their mind off the negative aspects of their situation. Complementary therapies may include mind-body exercises like yoga, tai chi and Qi gong; visualization or guided imagery; using art or music as therapy and self-expression and traditional Eastern medicine such as acupuncture.
Staying physically active as much as possible during cancer treatment has many positive benefits. Physical activity stimulates the release of endorphins, a hormone that helps elevate mood, as well as decreasing feelings of fatigue.
Exercises for cancer patients can range from simple stretches done in the bed or chair, to more active pursuits such as walking or light gardening work. However, it’s important not to push yourself too hard. Check with your doctor before attempting any physical activity to make sure you are up to it.
Many people find it helpful to keep a journal of their cancer treatment experience. It may be as simple as recording symptoms and side effects into a notebook, or may include personal emotions and opinions about what they may be going through. Journals can be private, like a diary, or shared with loved ones and even strangers.
Increasingly, people are turning to the Internet to share their cancer journey with the world at large and to seek out others with similar experiences. Many cancer patients have begun their own web log, or “blog” to publicize their battle with cancer. Twitter, a mini-blogging technology that limits posts to 140 characters, has also proven to be a helpful tool for cancer patients to keep friends updated and reach out to others.