Unlike other cancers, leukemia does not involve a tumor that can be surgically removed; it originates in the bone marrow. The bone marrow cannot be removed because it occupies the center of all the major bones and produces the blood cells that are needed by the rest of the body. Therefore, the treatment of leukemia focuses on destroying the abnormal leukemia cells.
The goals of leukemia treatment are to bring about a remission and to prevent a relapse. Remission is when the signs and symptoms of the cancer disappear; however, the cancer may still be in the body. A complete remission, when no signs or symptoms are apparent for a period of years, is considered a cure. The reappearance of the signs and symptoms after a remission is called a relapse. If a relapse occurs, further treatment can sometimes successfully bring about subsequent remissions.
The treatment for acute lymphocytic leukemia involves three phases that usually take between 2½ to 3½ years to complete. The intensity of the treatment and types of therapies used will vary depending upon the immunophenotype and chromosomal abnormalities present, your age, white blood cell count at the time of diagnosis, your overall health, and whether the leukemia involves other organs in your body.
The goal of the first phase of treatment, induction therapy, is to kill the abnormal blood cells. This usually requires at least four weeks of chemotherapy. Patients with ALL need to begin induction therapy as soon as possible after their diagnosis.
During consolidation therapy, the second phase, the treatment is aimed at eliminating any lingering leukemia cells in the spinal cord or brain. Radiation therapy is a crucial component to treatment during this phase to reduce the risk of a relapse.
The final treatment phase known as maintenance therapy involves much lower doses of therapies designed at preventing leukemia cells from reforming.
Children with ALL usually receive additional therapy targeted at killing abnormal cells in the central nervous system during each phase of treatment. This treatment is called central nervous system sanctuary therapy, central nervous system preventive therapy, or intrathecal chemotherapy. This therapy involves injecting chemotherapy directly into the spinal cord fluid. These direct injections kill cancer cells that can't be reached by chemotherapy drugs given by mouth or through an intravenous line.
Supportive care is an important component of leukemia treatment. Supportive care can be as simple as proper diet and extra sleep or can involve medications to control the pain and side effects of treatment. Typically, the best outcomes occur when you and your doctor work together to develop a treatment strategy that satisfies your individual needs. A clear understanding of your condition and clear communications with your doctor can help ensure that you are receiving the best possible treatment and supportive care.
This section contains more information on:
- Questions to ask
- Kinase inhibitors
- Biological therapy: monoclonal antibodies
- Radiation therapy
- Blood and bone marrow transplant
- Experimental therapy
Questions you may want to ask your doctor when selecting a treatment include:
- What subtype of leukemia do I have?
- What are the treatment options?
- What treatment do you recommend and why?
- How will the treatment affect my chance for a cure or survival?
- When will treatment begin, how long will it last, and what is the schedule?
- Does this treatment require hospitalization?
- Will I be able to go to work or school during treatment?
- How will the treatment make me feel?
- What are the side effects and risks of the treatment?
- How long could the side effects last? Could they be permanent?
- Will I need medications to control pain or other side effects?
- How do we know if it's working?
- What can I do to prepare for treatment?
In chemotherapy, anticancer drugs that damage the DNA in the blood cells are introduced into the bloodstream. Chemotherapy may also be given as palliative treatment, to relieve symptoms without the expectation of a cure, to improve a patient's quality of life. Chemotherapy may also be used as a conditioning therapy prior to a blood and bone marrow transplant.
Chemotherapy drugs can be swallowed in pill form, injected by needle into a vein or muscle, or injected under the skin. Chemotherapy regimens or treatment plans may use a single drug or a combination of drugs. Oncologists usually recommend a combination of drugs administered over a period of time for most people with leukemia. This is often more effective than a single drug, as drugs attack the cancer cells in several different ways. Doctors must also consider side effects of each drug and any potential interactions among the drugs.
The side effects of chemotherapy are caused by the damage to normal cells. Usually the side effects are temporary. Each time chemotherapy is given, the doctor is balancing destroying the cancer cells with sparing the normal cells. Often medications can be given to lessen the side effects. The cells most vulnerable to chemotherapy are those that reproduce rapidly, including the bone marrow, hair follicles, and lining of the reproductive and digestive tracts. Damage to these cells can result in:
- Hair loss
- Mouth sores
- Lowered resistance to infection due to low white blood cell counts
- Easy bruising or bleeding due to low blood platelets
- Fatigue due to low red blood cells
- Loss of appetite, nausea, and vomiting
Many of the side effects of chemotherapy are caused by low white blood cell counts. To minimize your risk of infection, it may be helpful to reduce your exposure to germs. This includes:
- Washing your hands often
- Avoiding uncooked fruits and vegetables and other foods that might carry germs
- Avoiding fresh flowers and plants because they carry mold
- Asking people to wash their hands when they come in contact with you
- Avoiding large crowds and people who are sick (wearing a surgical mask offers some protection in these situations)
Other medications, including vitamins and nonprescription medicines, can interact with chemotherapy and potentially make the drugs less effective or exacerbate their side effects. Therefore, it is important that you tell your doctor about all medicines, including vitamins, herbal or dietary supplements, and nonprescription medicines that you are taking.
Kinase inhibitors are a form of targeted drug therapy. The recent development of targeted drug therapies has dramatically improved the treatment for some types of acute lymphocytic leukemia.
Unlike traditional chemotherapies, targeted drug therapies use chemicals that work on specific cancer cells. Chemotherapies destroy both cancer and normal cells, causing a host of side effects. Targeted drug therapies tend to have fewer side effects than chemotherapy.
Currently there are only a handful of targeted drug therapies approved for leukemia treatment; however, they are a focus of much cancer research and there will likely be many more developed in the future. Examples of kinase inhibitors used to treat ALL include imatinib mesylate (Gleevec); dasatinib (Sprycel) and nilotinib are considered experimental. Kinase inhibitors can be used in combination with chemotherapy drugs.
Possible side effects of Gleevec and Sprycel include diarrhea, nausea, muscle pain, and fatigue, all of which are generally mild. Itchy skin rashes develop in about 30 percent of people on these drugs. Fluid retention can also occur. All of these side effects get worse at high doses of the drug. Patients on Gleevec or Sprycel may have a drop in their red blood cell and platelet counts or increased bleeding. Sometimes the doctor will recommend stopping the drug for a short period if the counts get too low. Eventually, normal blood-forming cells take over, and the blood counts rise back to normal. Women are advised not to become pregnant while taking either drug.
Gleevec and Sprycel are metabolized and eliminated by the liver. There are many drugs, both prescription and over the counter, as well as dietary supplements that can interfere with this process. Tell your doctor about all medicines and supplements you are taking, and check with your doctor before you start any new medicine or supplement when you are taking a kinase inhibitor.
Biological therapy, also know as immunotherapy, bolsters your immune system to help your body kill leukemia cells or slow their growth. Biological therapy can be used to treat patients with acute lymphocytic leukemia (ALL). Patients with leukemia are treated with monoclonal antibodies, special proteins that are developed in a laboratory. They are similar to the antibodies that are produced by the immune system but are created to specifically react with certain types of cancer cells.
Rituximab (Rituxan) is the monoclonal antibody used in treating patients with ALL. Other than the chance of developing fever, this drug has few side effects. Occasionally, patients with very high white blood cell counts can develop kidney problems because rituximab kills the cells so quickly that the body sometimes has trouble metabolizing all the breakdown products of the dead cells. This can overtax the kidneys.
If the leukemia has spread to other organs, radiation therapy may be necessary to treat the cancer. Radiation therapy involves either external high-energy X-rays or radiopharmaceuticals. Radiopharmaceuticals are radiation-emitting chemicals that can be swallowed, injected, or implanted in the body. Radiation therapy damages the DNA of cells, interrupting the cell division and development process.
External beam radiation is the most widely used type of radiation therapy. During treatment, the radiation is focused from the machine outside the body onto the whole body or to an area where leukemia cells have accumulated. External beam radiation therapy is like getting an X-ray but for a longer time. It usually involves daily treatments over several weeks. Several newer types of external beam radiation are making radiation therapy safer and more effective.
External beam radiation therapy is usually not the main treatment for patients with leukemia, but it is used in certain situations. In some patients, leukemia may cause the spleen to enlarge. An enlarged spleen may press on other organs in the abdomen, such as the stomach, which may result in a loss of appetite. If the symptoms are not improved by chemotherapy, radiation therapy is often a good option. Radiation therapy is also useful in treating pain from bone damage caused by leukemia cells growing in the bone marrow. Sometimes, radiation is used to treat leukemia that has spread to the brain and spinal fluid or to the testicles. Radiation therapy can also be administered in low doses to the whole body, as part of conditioning therapy to prepare the body for a blood and bone marrow transplant.
Radiation therapy attacks cancer cells that are dividing, but it can also affect dividing cells of normal tissues. It is the damage to normal cells that causes side effects. Each time radiation therapy is given, there is a delicate balance between destroying the cancer cells and sparing the normal cells. The main short-term side effects of radiation therapy are sunburnlike skin changes, fatigue, and lowered resistance to infection. Many of these side affects can be lessened by supportive care. Discuss with your doctor how to best manage your side effects.
Patients should check with their doctors before taking any vitamins or nutrition supplements during radiation treatment. Certain vitamins, such as A, E, and C, act as antioxidants and prevent the formation of ions that damage DNA in cells. Some scientists believe that high doses of antioxidant vitamins may reduce the effectiveness of radiation therapy. No studies have thoroughly tested this theory.
A blood and bone marrow transplant (BMT) is used to resupply the bone marrow with hematopoietic (blood-forming) stem cells after the body's blood cells—including the leukemia cells—have been wiped out with high doses of chemotherapy and radiation. BMT allows patients to receive the high doses of chemotherapy and radiation therapy needed to kill off leukemia cells—higher than they could normally tolerate.
Depending on the source of the stem cells, this procedure may be called a bone marrow transplant, a peripheral blood stem cell transplant, or a cord blood transplant. In a cord blood transplant, the cells come from a newborn baby's umbilical cord. The stem cells used for a BMT are most often donated by a related matched family member or an unrelated but matched donor; this is called an allogeneic transplant. A transplant from an identical twin is called a syngeneic transplant and a transplant of your own stem cells is an autologous transplant. The latter is possible if you go into remission and then save healthy bone marrow for a future transplant, in case the leukemia returns.
For people with leukemia, the first step in a BMT is "conditioning," in which they have high doses of chemotherapy, sometimes combined with radiation therapy. After conditioning, donated stem cells are infused using an IV. No surgery is required for a BMT.
A BMT is a lengthy process that includes several phases, no matter the type of transplant or the source of stem cells. Complete recovery to normal blood cell counts and a fully functional immune system may take six months to one year. During this time, one's life and family relationships will be disrupted. Side effects of BMT can be significant and vary with the phase of treatment and the type of chemo or radiation therapy and type of donor cells. Some problems may appear even a year or more after healthy cells are infused. However, a BMT is a lifesaving procedure for many people with leukemia.
Clinical trials offer patients the opportunity to receive new therapies or new combinations of known therapies to treat their leukemia. A clinical trial is one of the final stages of a long and careful cancer research process. These studies are undertaken to find out whether promising approaches to diagnosing, preventing, and treating cancer are safe and effective.
There are many ways to learn more about clinical trials. Your doctor can help you find a clinical trial that may be of benefit to you. The American Cancer Society (ACS) also provides a clinical trials matching service for patients, their family, and friends. To learn about his service you can call the ACS cancer information center at 1-800-ACS 2345 or visit their Web site. The ACS can compile a list of clinical trials that fit your medical needs based on the information you provide about your cancer type, stage, and previous treatments. You can also get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll free at 1-800-4-CANCER or by visiting the NCI clinical trials Web site at cancer.gov/clinical_trials/.
Last reviewed on 08/30/2007
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