Leukemia Treatment in the Greater Philadelphia Area

As with most other cancers, many types of leukemia show no obvious symptoms early in the disease. Because of this, doctors sometimes find leukemia after a routine blood test. If you have symptoms that suggest leukemia, your doctor will try to find out what’s causing the problems. Some of the symptoms of leukemia are similar to non-cancerous blood conditions such as:

• Anemia
• Bruising easily
• Excessive fatigue
• Unexplained night sweats

Tests, especially blood tests will be run to determine the cause of the symptoms.

If your doctor suspects that you may have leukemia, more blood tests will be run as well as bone marrow tests to see if the abnormal cells are in the bone marrow -- the source of blood cells.

Bone marrow can be obtained for testing in two ways. Some people will have both procedures during the same visit:

Bone Marrow Aspiration

The doctor uses a thick, hollow needle to remove samples of bone marrow.

Bone Marrow Biopsy

The doctor uses a very thick, hollow needle to remove a small piece of bone and bone marrow.

In chronic lymphocytic leukemia (CLL), the leukemia cells may spread from the blood and bone marrow to other parts of the body, such as the lymph nodes, liver, and spleen. It is important to know whether these cells have spread in order to provide the patient with the best leukemia treatment options.

The most commonly used staging and classification systems used by doctors to describe CLL are the Rai system and the Binet System. 

Sometimes, doctors break these stages into “risk groups” that help them determine when to begin treatment: 

• Low risk: Stage 0
• Intermediate risk: Stages I and II
• High risk: Stages III and IV

In acute myeloid leukemia (AML), treatment is planned based on the subtype of AML rather than its stage. The two main systems used to classify AML subtypes are the French-American-British (FAB) classification and the newer World Health Organization (WHO) classification.

French-American-British (FAB) Classification

Under this classification, AML is divided into subtypes M0 through M7, based on the type of cell the leukemia develops from and how mature the cells are. This was based largely on how the leukemia cells looked under the microscope after routine staining.

• M0: Undifferentiated acute myeloblastic leukemia
• M1: Acute myeloblastic leukemia with minimal maturation
• M2: Acute myeloblastic leukemia with maturation
• M3: Acute promyelocytic leukemia (APL)
• M4: Acute myelomonocytic leukemia
• M4 eos: Acute myelomonocytic leukemia with eosinophilia
• M5: Acute monocytic leukemia
• M6: Acute erythroid leukemia
• M7: Acute megakaryoblastic leukemia

Subtypes M0 through M5 all start in immature forms of white blood cells. M6 AML starts in very immature forms of red blood cells, while M7 AML starts in immature forms of cells that make platelets.

Unlike the FAB classification system, the WHO classification system takes into account many of the factors that are now known to affect the prognosis (outlook) that can better classify acute myeloid leukemia. 

The WHO system divides AML into several groups, including: 

• AML with certain genetic abnormalities (gene or chromosome changes)
• AML with myelodysplasia-related changes
• AML related to previous chemotherapy or radiation
• AML not otherwise specified (this includes cases of AML that don’t fall into one of the above groups)
• Myeloid sarcoma (also known as granulocytic sarcoma or chloroma)
• Myeloid proliferations related to Down syndrome
• Undifferentiated and biphenotypic acute leukemias (leukemias that have both lymphocytic and myeloid features), which are sometimes called mixed phenotype acute leukemias (MPALs)

You can learn about these groups in detail, as well as their prognostic factors by visiting the American Cancer Society website. > 

In this type of blood cancer, the disease is classified by phase: chronic phase, accelerated phase, or blastic phase. These phases, along with the results from diagnostic tests, are important in planning treatment. 

The number of blast cells in the blood and bone marrow and the severity of signs or symptoms determine the phase of the disease. The three phases of chronic myeloid leukemia are: 

Chronic Phase

fewer than 10% of the cells in the blood and bone marrow are blast cells.

Accelerated Phase

10% to 19% of the cells in the blood and bone marrow are blast cells.

Blastic Phase

20% or more of the cells in the blood or bone marrow are blast cells. When tiredness, fever, and an enlarged spleen occur during the blastic phase, it is called a blast crisis.

Sometimes, CML can relapse (return) after it has been treated. In relapsed CML, the number of blast cells increases after remission.

Doctors have found that cytogenetic tests, flow cytometry, and other lab tests provide more detailed information about the subtype of ALL and the patient’s prognosis than traditional staging methods. These tests help divide ALL into groups based on the gene and chromosome changes in the leukemia cells.

The WHO system divides ALL into several groups, which include:

B-Cell ALL

B lymphocytes, or B cells, are a type of white blood cell that plays a large role in protecting your body from infection (humoral immunity) by making antibodies against antigens.

T-Cell ALL

T cells play a central role in cell-mediated immunity. They are vital in hosting an immune response against pathogens.

Visit the American Cancer Society website for more details regarding B-Cell and T-Cell ALL groups.>

People with chronic lymphocytic leukemia who do not have symptoms may be able to put off having cancer treatment. By delaying treatment, they can avoid the side effects of treatment until they have symptoms.

If you and your doctor agree that watchful waiting is a good idea, you’ll have regular checkups (such as every 3 months). You can start treatment if symptoms occur.

Although watchful waiting avoids or delays the side effects of cancer treatment, this choice has risks. It may reduce the chance of controlling leukemia before it gets worse.

You may decide against watchful waiting if you don’t want to live with untreated leukemia. Some people choose to treat the cancer right away.

If you ever begin to have concerns about watchful waiting, it’s important to discuss your feelings with your oncologist. In many cases, a different approach is available. 

Radiation therapy is the use of high-energy x-rays to destroy cancer cells. The most common type of radiation therapy used to treat leukemia is external radiation therapy, which uses a machine outside the body to send radiation toward the area of the body with cancer. 

Radiation therapy may be used for leukemia that has spread, or may spread, to the brain and spinal cord. It might also be used to relieve symptoms and improve quality of life (called palliative therapy).

Many people with leukemia are treated with chemotherapy. Chemotherapy uses drugs to destroy leukemia cells.

Depending on the type of leukemia, you may receive a single drug or a combination of two or more drugs. You may receive chemotherapy in several different ways:

• Orally:
  Some drugs are pills that you can swallow.
• Intravenously:
  Into a vein (IV): The drug is given through a needle or tube inserted into a vein.
• Through a catheter (a thin, flexible tube):
  The tube is placed in a large vein, often in the upper chest, which is useful for patients who need many IV treatments. The health care professional injects drugs into the catheter, rather than directly into a vein. This method avoids the need for many injections, which can cause discomfort and injure the veins and skin.
• Into the cerebrospinal fluid:
  If the pathologist finds leukemia cells in the fluid that fills the spaces in and around the brain and spinal cord, the doctor may order intrathecal chemotherapy. The doctor injects drugs directly into the cerebrospinal fluid in one of two ways:
• Into the spinal fluid: The doctor injects the drugs into the spinal fluid.
• Under the scalp: Children and some adult patients receive chemotherapy through a special catheter called an Ommaya reservoir. The doctor places the catheter under the scalp and then injects the drugs into the catheter. This method avoids the pain of injections into the spinal fluid.

Intrathecal chemotherapy is used because many drugs given by IV or taken by mouth can’t pass through the tightly packed blood vessel walls found in the brain and spinal cord. This network of blood vessels is known as the blood-brain barrier.

Chemotherapy is often given in cycles. Each cycle has a treatment period followed by a rest period.

Treatment may take place in a clinic, at the doctor’s office, or at home. Sometimes, a hospital stay is needed. 

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue’s environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Targeted therapies used for leukemia treatment include:

Monoclonal Antibodies

Monoclonal antibodies are immune system proteins made in the laboratory to treat many diseases, including cancer. As a cancer treatment, these antibodies can attach to a specific target on cancer cells or other cells that may help cancer cells grow. The antibodies are able to then kill the cancer cells, block their growth, or keep them from spreading.

Kinase Inhibitors

This treatment blocks certain proteins, which may help keep leukemia cells from growing and may kill them.

Because not all cancer cells have the same target, tests to identify factors like the genes and proteins involved in your leukemia might be needed. Your oncologist might also recommend combining targeted therapy with another treatment option. 

Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. 

Some biological therapies, such as monoclonal antibodies, are given by IV infusion. This substance binds to the leukemia cells, killing them or helping the immune system destroy them. Others might be injected under the skin or into a muscle. It can slow the growth of leukemia cells.

Depending on your particular situation, you may have your treatment in a clinic, at the doctor’s office, or in the hospital. Your oncologist may also administer other drugs at the same time to prevent side effects.