Leukemia

Topic Overview

What is leukemia?

Leukemia is cancer of the blood cells. It starts in the bone marrow, the soft tissue inside most bones. Bone marrow is where blood cells are made.

When you are healthy, your bone marrow makes:

• White blood cells, which help your body fight infection.
• Red blood cells, which carry oxygen to all parts of your body.
• Platelets, which help your blood clot.

When you have leukemia, the bone marrow starts to make a lot of abnormal white blood cells, called leukemia cells. They don't do the work of normal white blood cells, they grow faster than normal cells, and they don't stop growing when they should.

Over time, leukemia cells can crowd out the normal blood cells. This can lead to serious problems such as anemia, bleeding, and infections. Leukemia cells can also spread to the lymph nodes or other organs and cause swelling or pain.

Are there different types of leukemia?

There are several different types of leukemia. In general, leukemia is grouped by how fast it gets worse and what kind of white blood cell it affects.

• It may be acute or chronic. Acute leukemia gets worse very fast and may make you feel sick right away. Chronic leukemia gets worse slowly and may not cause symptoms for years.
• It may be lymphocytic or myelogenous. Lymphocytic (or lymphoblastic) leukemia affects white blood cells called lymphocytes. Myelogenous leukemia affects white blood cells called myelocytes.

The four main types of leukemia are:

• Acute lymphoblastic leukemia, or ALL. ALL is the most common leukemia in children. Adults can also get it.
• Acute myelogenous leukemia, or AML. AML affects both children and adults.
• Chronic lymphocytic leukemia, or CLL. CLL is the most common leukemia in adults, mostly those who are older than 55. Children almost never get it.
• Chronic myelogenous leukemia, or CML. CML occurs mostly in adults.

What causes leukemia?

Experts don't know what causes leukemia. But some things are known to increase the risk of some kinds of leukemia. These things are called risk factors. You are more likely to get leukemia if you:

• Were exposed to large amounts of radiation.
• Were exposed to certain chemicals at work, such as benzene.
• Had some types of chemotherapy to treat another cancer.
• Have Down syndrome or some other genetic problems.
• Smoke.

But most people who have these risk factors don't get leukemia. And most people who get leukemia do not have any known risk factors.

What are the symptoms?

Symptoms may depend on what type of leukemia you have, but common symptoms include:

• Fever and night sweats.
• Headaches.
• Bruising or bleeding easily.
• Bone or joint pain.
• A swollen or painful belly from an enlarged spleen.
• Swollen lymph nodes in the armpit, neck, or groin.
• Getting a lot of infections.
• Feeling very tired or weak.
• Losing weight and not feeling hungry.

How is leukemia diagnosed?

To find out if you have leukemia, a doctor will:

• Ask questions about your past health and symptoms.
• Do a physical exam. The doctor will look for swollen lymph nodes and check to see if your spleen or liver is enlarged.
• Order blood tests. Leukemia causes a high level of white blood cells and low levels of other types of blood cells.

If your blood tests are not normal, the doctor may want to do a bone marrow biopsy. This test lets the doctor look at cells from inside your bone. This can give key information about what type of leukemia it is so you can get the right treatment.

How is it treated?

What type of treatment you need will depend on many things, including what kind of leukemia you have, how far along it is, and your age and overall health.

• If you have acute leukemia, you will need quick treatment to stop the rapid growth of leukemia cells. In many cases, acute leukemia can be cured. Some doctors prefer the term 'remission' to 'cure,' because there is a chance the cancer could come back.
• If you have chronic lymphocytic leukemia, you may not need to be treated until you have symptoms. But chronic myelogenous leukemia will probably be treated right away. Chronic leukemia can rarely be cured, but treatment can help control the disease.

Treatments for leukemia include:

• Chemotherapy, which uses powerful medicines to kill cancer cells. This is the main treatment for most types of leukemia.
• Radiation treatments. Radiation therapy uses high-dose X-rays to destroy cancer cells and shrink swollen lymph nodes or an enlarged spleen. It may also be used before a stem cell transplant.
• Stem cell transplant. Donated stem cells can rebuild your supply of normal blood cells and boost your immune system. Before the transplant, radiation or chemotherapy is used to destroy cells in bone marrow and make room for donated cells.
• Biological therapy. This is the use of special medicines that improve your body's natural defenses against cancer.

For some people, clinical trials are a treatment option. Clinical trials are research projects to test new medicines and other treatments. Often people with leukemia take part in these studies.

Some treatments for leukemia can cause side effects. Your doctor can tell you what problems are common and help you find ways to manage them.

Finding out that you or your child has leukemia can be a terrible shock. It may help to:

• Learn all you can about the type of leukemia you have and its treatment. This will help you make the best choices and know what to expect.
• Stay as strong and well as possible. A healthy diet, plenty of rest, and regular exercise can help.
• Talk to other people or families who have faced this disease. Ask your doctor about support groups in your area. You can also find people online who will share their experiences with you.

Frequently Asked Questions

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	Cancer: Controlling nausea and vomiting from chemotherapy

Cause

Experts do not yet know what causes leukemia.

A risk factor is anything that raises your chance of getting a disease. Risk factors for some types of leukemia include:

• Smoking and tobacco use.
• Being exposed to large amounts of radiation.
• Being exposed to certain chemicals in the workplace.
• Past chemotherapy or radiation for another cancer. (This is rare, and not all chemotherapies raise your leukemia risk.)

Most people who get leukemia do not have any risk factors.

Most types of leukemia do not seem to run in families. But in some cases chronic lymphocytic leukemia (CLL) does.¹ There are also certain genetic conditions, like Down syndrome, that can make acute myelogenous leukemia (AML) more likely.

Symptoms

Symptoms of leukemia depend on how much the cancer has grown and may include:

• Fevers and night sweats.
• Frequent or unusual infections.
• Weakness and fatigue.
• Headaches.
• Bruising of the skin and bleeding from the gums or rectum.
• Bone pain.
• Joint pain.
• Swelling in the belly or pain on the left side of the belly or in the left shoulder from a swollen spleen.
• Swollen lymph nodes in the armpit, neck, or groin.
• Decreased appetite and weight loss because you feel full and don't want to eat.

The chronic forms of leukemia often cause no symptoms until much later in the disease.

What Happens

In most cases of leukemia, there are too many abnormal white blood cells. These leukemia cells crowd out the normal blood cells in your bone marrow and build up in your lymph nodes, liver, and spleen. This makes it hard for your body to fight infections.

Your white blood cells help your body fight infection. Your red blood cells make sure all your body parts have the oxygen they need. Your platelets keep you from bleeding too much. When the leukemia cells crowd out your normal cells, your blood cannot do its job. You may bleed or bruise easily, have more infections, and feel very tired.

Chemotherapy or radiation that is used to treat other cancers, such as breast cancer or Hodgkin's lymphoma, can sometimes cause leukemia months or years later.² (This is rare.)

Survival rates are different for different kinds of leukemia. A 5-year survival rate is the percentage of people who are still alive 5 years or more after being diagnosed. But keep in mind that everyone is different. These numbers do not necessarily show what will happen in your case. Researchers are continuing to develop new and better treatments for leukemia. The 5-year survival rates are:

• For acute myelogenous leukemia (AML), as low as 5% to 10% for older people who have worse types of AML or as high as 75% for young people. Your survival rate will depend upon your age, overall health, and the type of AML.
• For chronic lymphocytic leukemia (CLL), about 75%, depending on your age, overall health, and other factors.³
• For chronic myelogenous leukemia (CML) in people who receive a bone marrow transplant, over 70%. (This applies to people age 50 or younger who are treated in the first year after diagnosis. Transplants are not as successful for older people or for people who have had CML for more than a year.)⁴
• For CML in newly diagnosed people taking imatinib (Gleevec), over 85%.⁵

The leukemia-free period for acute lymphoblastic leukemia (ALL) depends on age. In general, children are more likely than adults to have a long leukemia-free period with treatment.

What Increases Your Risk

A risk factor is anything that makes you more likely to get a disease. Most people who have leukemia do not have any known risk factors. But things that increase your risk of having leukemia include:

• Smoking or using other tobacco products. This risk factor is linked to some cases of acute myelogenous leukemia (AML).⁶
• Exposure to high levels of radiation. People who were close to atomic bomb explosions in Japan during World War II and people who were close to the 1986 nuclear plant accident in Chernobyl, have higher rates of some kinds of leukemia.
• Exposure to chemicals, such as benzene and formaldehyde. Sometimes people are exposed to these chemicals where they work.
• Chemotherapy or radiation used to treat a previous cancer.
• Conditions caused by abnormal chromosomes, such as Down syndrome.
• Infection with a type of HIV known as HTLV-1.
• Other blood diseases, such as myelodysplastic syndromes.
• Your family history. In some cases, chronic lymphocytic leukemia (CLL) runs in families.¹

When To Call a Doctor

Call your doctor to schedule an appointment if you have had any symptoms for longer than 2 weeks, such as:

• A new lump or swollen gland in your neck, under your arm, or in your groin.
• Frequent nosebleeds, bleeding from the gums or rectum, more frequent bruising, or very heavy menstrual bleeding.
• Frequent fevers.
• Night sweats.
• Unexplained appetite loss or recent weight loss.
• Feeling tired a lot without a known reason.
• Swelling and pain on the left side of the belly.

Watchful Waiting

Watchful waiting is a period when your doctor is checking you regularly but not treating you. It is also called observation or surveillance. It means that you and your doctor will watch to see if you develop symptoms. It may be a treatment choice if you are an older adult, depending on the stage of the leukemia and your overall health.

Watchful waiting may give as good or better results than more aggressive treatment for early stage chronic lymphocytic leukemia (CLL). It is estimated that 1 in 3 people who have CLL never need treatment.⁷ People who have chronic lymphocytic leukemia often live for a long time without treatment. Watchful waiting is not usually recommended for other types of leukemia.

During watchful waiting, you will:

• Have regular appointments with your doctor.
• Have regular medical tests, including scans and blood tests.
• Be told which symptoms to report to your doctor immediately.

Who To See

Health professionals who can evaluate symptoms of leukemia include the following:

• Family medicine physician
• Internist
• Pediatrician
• Nurse practitioner
• Physician assistant

The diagnosis of leukemia will be done by a medical oncologist or hematologist using a bone marrow aspiration and biopsy. These specialists also treat leukemia.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

If your doctor suspects leukemia, he or she will ask about your medical history. Your doctor also will check for enlarged lymph nodes in your neck, underarm, or groin. He or she will also examine you to see if your liver or spleen is enlarged.

Your doctor will order blood tests, such as a complete blood count (CBC) and a blood profile. These provide important information about the cells in your blood. They are used to look into symptoms such as fatigue, weakness, fever, bruising, or weight loss.

If your blood work points to possible leukemia, your doctor will want to find out what kind you might have. Different kinds of leukemia need different kinds of treatment.

• A blood test is usually enough to find signs of chronic lymphocytic leukemia (CLL).
• A bone marrow aspiration and biopsy is the key to diagnosing most leukemias.

Unusual cells, chromosomes, or proteins on cells can tell what type of leukemia you have, such as acute lymphoblastic leukemia (ALL), acute myelogenous leukemia (AML), or chronic myelogenous leukemia (CML), or even a subtype. It is important to know if you have a subtype of a leukemia. Different subtypes get better with different kinds of treatment.

Your doctor may also order other tests, including:

• Chest X-rays, to find out if leukemia or an infection is the cause of lung problems such as persistent coughing, coughing up blood, chest pain, or difficulty breathing.
• CT scan of the head, chest, and belly, to find out whether leukemia has spread there.
• Lumbar puncture, to find out whether leukemia cells are in your cerebrospinal fluid (CSF).
• MRI of the brain, to look into symptoms such as confusion, paralysis, numbness, vision problems, vertigo, or headaches. Those symptoms could mean the leukemia has spread to the brain.

Also, a biopsy of a lymph node or other tissues may be done to look for cancer cells.

Treatment Overview

The goal of treatment for leukemia is to destroy the leukemia cells and allow normal cells to form in your bone marrow. Treatment decisions are based on the type and subtype of leukemia you have, its stage, and your age and general health.

Treatment for acute leukemia

Chemotherapy is the use of drugs to fight cancer. It is the usual treatment for acute leukemia. For most people, that means receiving drugs in three stages:

• Induction. The goal of this stage is remission. Remission is a period in which the leukemia cells have been destroyed and are replaced with healthy cells. Induction is done with high doses of powerful drugs which may be given over a period of time from about a week to a month, depending on the type of leukemia. Then it takes several weeks for your body to start growing new blood cells. You probably will stay in the hospital during this time. This can take a month or longer.
• Consolidation. Even when tests show no leukemia cells can be found, there may still be some left. The goal of consolidation is to kill any cells that are left. Consolidation often involves the same drugs given in the induction stage, but the schedule and doses may be different. For example, you may receive the drugs in one or two 5-day cycles spread over 1 to 3 months.
• Maintenance. The goal of this stage is to prevent leukemia cells from growing back. During maintenance you are given lower doses of drugs over the course of 2 to 3 years. If your type of leukemia has a high risk of coming back (relapse), this stage might include a stem cell transplant. The maintenance stage is not used for all types of leukemia, but is a common part of treatment for acute lymphoblastic leukemia (ALL).

Some types of acute leukemia spread to the brain and spinal cord. Regular chemotherapy cannot reach those areas, because your body puts up a special barrier to protect them. A different way of giving chemotherapy, called intrathecal chemotherapy, treats these areas by injecting the drugs directly into your spinal canal to attack any leukemia cells there. Radiation is also used to treat acute leukemia that has spread to the brain and spinal cord.

Stem cell transplant is often used as an initial treatment for people with high-risk acute leukemia. Most stem cell transplants for leukemia are allogeneic, meaning the stem cells are donated by someone else. The goal of a transplant is to destroy all the cells in your bone marrow, including the leukemia cells, and replace them with new, normal cells.

Treatment if acute leukemia gets worse

Sometimes leukemia gets worse in spite of treatments. Sometimes it gets better, or "goes into remission." Sometimes it comes back, or "relapses." Even when that happens, there are several treatments that may help to cure the leukemia or help you live longer:

• Clinical trials. People who have leukemia may enter a research program when they first start treatment or if the leukemia is not getting better. These programs test new ways to treat the disease. For more information, see www.cancer.gov/clinical_trials/ or http://clinicaltrials.gov.
• Stem cell transplant. Donated cells from a "matched" donor can rebuild your supply of normal blood cells and your immune system. (A matched donor is usually a family member. But many people have family members whose stem cells are not a close enough match.) Stem cells can be from bone marrow, from the bloodstream, or from umbilical cord blood. If you have a matched donor, drugs and radiation are used to destroy the cells in your bone marrow and make room for donated cells. If you have a relapse after a transplant, a transfusion of more of your donor's white blood cells may put you back into remission.
• Drugs. Sometimes different drugs or different doses than those that were used during your initial chemotherapy can help.
• Repeating the induction stage. Sometimes the same drugs that put leukemia into remission in the first place will work again.

Treatment of chronic leukemia

Unlike acute leukemia, chronic leukemia is not always treated right away. It usually gets worse more slowly than acute leukemia. This is especially true for chronic lymphocytic leukemia (CLL).

Treatment choices for chronic leukemia include:

• Watchful waiting. Treatment is often not needed in the early stages of CLL. CLL usually gets worse very slowly, and you may have no symptoms for some time. You and your doctor may decide to hold off on treatment for a while. During this time your doctor will watch you carefully. It is estimated that 1 in 3 people who have CLL never need treatment.⁷
• Stem cell transplant. Most stem cell transplants for leukemia are allogeneic, meaning the stem cells are donated by someone else. The goal of a transplant is to destroy all the cells in your bone marrow, including the leukemia cells, and replace them with new, normal cells.
• Biological therapy. This is the use of special drugs that improve your body's natural defenses against cancer. One such drug that doctors often use to treat CLL is a monoclonal antibody.
• Radiation therapy. Radiation may be used to destroy cancer cells. It also may be used to shrink swollen lymph nodes or a swollen spleen. Sometimes radiation is used on the whole body to prepare for a bone marrow transplant or to treat CLL.
• The first treatment used for chronic myelogenous leukemia (CML) is the medicine imatinib (Gleevec).
• Clinical trials, which are used to find out whether a medicine or treatment is safe and effective. People who have chronic leukemia are often referred to clinical trials for their treatment. For more information, see www.cancer.gov/clinical_trials/ or http://clinicaltrials.gov.
• Chemotherapy. Chemotherapy is the use of drugs that attack cancer cells. A variety of drugs is available to fight leukemia and help you live longer.
• Treatment of infections. When you have chronic leukemia, your body is not able to fight infections very well. You and your doctor need to watch for any signs of infections, such as pneumonia, yeast infections, and shingles. Early treatment of these and other infections will help you live longer. You can sometimes prevent certain infections or keep from getting very sick by getting a flu shot or a pneumonia vaccine. Your doctor also may give you antibiotics to prevent infection while you are being treated for leukemia.

If you have chronic lymphocytic leukemia (CLL), your doctor may want to check you regularly for other types of cancer. People who have CLL have a higher chance than normal of getting a second cancer.

Treatment if chronic leukemia gets worse

If you have chronic myelogenous leukemia (CML) that gets worse or relapses, there is still much hope. Imatinib (Gleevec) may be combined with other drugs to treat the disease. A new drug called dasatinib (Sprycel) is now available for people whose CML is not helped by imatinib. Other new drugs are also being tested in clinical trials.

If you have a relapse after a bone marrow transplant, a transfusion of more of your donor's white blood cells may put you back into remission.

Palliative care

If leukemia gets worse, you may want to think about focusing on palliative care for your treatment. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different from treatment to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life-not just in your body but also in your mind and spirit.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

Even if your treatment is going well, it's a good idea to plan ahead. Talk to your family and your doctor about health care and other legal issues that arise near the end of life. Put your health care choices in writing (with an advance directive or living will). This is important, if a time comes when you can't make and communicate these decisions. Think about your treatment options and which kind of treatment will be best for you. You may also want to choose a health care agent to make and carry out decisions about your care if you become unable to speak for yourself.

For more information, see the topics Writing an Advance Directive and Choosing a Health Care Agent.

A time may come when your goals may change from treating an illness to maintaining your comfort and dignity. Your doctor can address questions or concerns about maintaining your comfort when cure is no longer an option. Hospice care professionals can provide palliative care in the comfortable surroundings of your own home.

For more information, see the topics Palliative Care, Hospice Care and Care at the End of Life.

What to think about

When leukemia has been in remission for a long time, the word "cure" is often used. Your doctor may use the term "remission" instead of "cure" when talking about the effectiveness of your treatment. Although many people who have leukemia are successfully treated, the term remission is used because cancer can return (recur). It is important to discuss the possibility of recurrence with your doctor.

Clinical trials play a very important part in the treatment of leukemia. Clinical trials test the latest drugs and other new treatments. They have made it possible for many people with leukemia to live longer. People who are in clinical trials get all the recommended treatments for their cancer and are closely watched. Talk to your doctor about whether there is a clinical trial that might be good for you. For more information, see www.cancer.gov/clinical_trials/ or http://clinicaltrials.gov.

Prevention

There is no known way to prevent most types of leukemia. Most people with leukemia do not have known risk factors. A risk factor is anything that raises your chances of getting a disease.

Some types of leukemia may be prevented by avoiding high doses of radiation, exposure to the chemical benzene, smoking and other tobacco use, or certain types of chemotherapy used to treat other types of cancer.⁸

Home Treatment

During treatment for any stage of leukemia, there are things you can do at home to help manage the side effects of leukemia or its treatment. Home treatment may be all that is needed to manage the following common problems. If your doctor has given you instructions or medicines to treat these symptoms, be sure to use them. Eating a balanced diet and getting enough sleep and exercise may help you feel better.

• Home treatment for nausea or vomiting includes watching for and treating early signs of dehydration, such as having a dry mouth, sticky saliva, and reduced urine output with dark yellow urine, and feeling lightheaded when you stand up. Your doctor also may prescribe medicines to control nausea and vomiting. For more information on how to deal with these side effects, see:

  Cancer: Controlling nausea and vomiting from chemotherapy.

• Home treatment for diarrhea includes resting your stomach and being alert for signs of dehydration. It is important to drink plenty of water to keep yourself hydrated. Check with your doctor before using any over-the-counter drugs for diarrhea.
• Home treatment for constipation includes gentle exercise along with drinking enough fluids and eating a diet that is high in fiber. Check with your doctor before using a laxative. Ask your doctor whether there are any foods that you should avoid while you are receiving chemotherapy. Many people are told not to eat fresh fruits and vegetables and to eat only well-cooked meat. Bacteria on fresh fruits and vegetables are not always washed off easily. Bacteria that live inside meats are not always killed unless the meat is cooked well. When your immune system is weakened by leukemia treatment, you are more likely than other people to get sick from these bacteria.
• Home treatment for fatigue includes making sure you get extra rest while you are receiving chemotherapy or radiation therapy. Let your symptoms guide you. You may be able to keep your usual routine and just get some extra sleep. Fatigue is often worse at the end of treatment or just after treatment is completed.
• Home treatment for sleep problems includes establishing a sleep routine that will let you get the rest you need.
• Eating well during treatment for leukemia includes making sure you get the nutrition you need to prevent weight loss and conserve your strength. You may find it helpful to talk with a registered dietitian (RD) to make sure you're eating a balanced diet during your treatment.

Dealing with your emotions

If you have recently been diagnosed with leukemia, you may have many different emotions. Most people feel some denial, anger, and grief. Some people may feel depressed or "blue." Other people may have fewer emotions. There is no "normal" or "right" way to react. There are many steps you can take to help with your emotional reaction to leukemia. Some people find that talking with family and friends helps. Other people find that spending time alone is what they need.

If your reaction is interfering with your ability to make decisions about your health, it is important to talk to your doctor. Your cancer treatment center may offer psychological or financial services. You may also contact your local chapter of the American Cancer Society to help you find a support group. Talking with other people who may have had similar feelings can be very helpful.

There are other emotional issues you may face:

• The diagnosis of leukemia and the need for treatment can be very stressful. You may be able to reduce your stress by expressing your feelings to others. Learning relaxation techniques may also help you reduce your stress.
• Your feelings about your body may change. Adapting to your changed body image may involve talking openly about your concerns with your partner and discussing your feelings with your doctor. Your doctor may also be able to refer you to groups that can offer additional support and information.
• Hair loss. This is emotionally distressing for some people. Not all cancer drugs cause hair loss, and some people have only mild thinning that is noticeable only to them. Ask your doctor whether you should expect hair loss with the drugs you will receive.

If leukemia or its treatment causes pain, there are many ways to relieve it. If your doctor has given you instructions or medicines for pain, be sure to use them. Home treatment for pain, such as a nonsteroidal anti-inflammatory medication, or an alternative therapy, such as biofeedback, may improve your physical and mental well-being. Be sure to discuss any home treatment with your doctor.

Medications

Chemotherapy is the standard treatment for many types of leukemia. Even when a cure is not possible, chemotherapy may help you live longer and feel better.

Chemotherapy for leukemia is usually a combination of drugs. This is because different drugs attack leukemia cells in different ways. The combination also helps keep the leukemia cells from becoming resistant to any one drug. Other drugs used to treat leukemia help prevent infection and help your body grow new blood cells.

Nausea and vomiting are the most common side effects of chemotherapy for leukemia, and the most feared. But having chemotherapy does not mean that you have to suffer with nausea and vomiting. Your doctor may prescribe medicines to control nausea and vomiting. There are also things you can do at home. For more information on these side effects, see:

Cancer: Controlling nausea and vomiting from chemotherapy.

Medication Choices

Acute leukemia

Different types of leukemia are best treated with different kinds of medicine.

• Acute lymphoblastic leukemia (ALL) drugs include prednisone, vincristine, daunorubicin, L-asparaginase or pegaspargase, methotrexate, and cyclophosphamide. Imatinib (Gleevec) and nelarabine (Arranon) are sometimes used to treat ALL. Dasatinib (Sprycel) is a newer drug for treating some ALL that has not improved with other drugs.
• Acute myelogenous leukemia (AML) drugs include daunorubicin, idarubicin, cytosine arabinoside, and mitoxantrone.⁹ Gemtuzumab (Mylotarg) may be given to people whose AML has relapsed. It helps your body destroy cancer cells.
• Acute promyelocytic leukemia (APL) drugs include all-trans-retinoic acid (ATRA) and chemotherapy with arsenic trioxide, idarubicin, or daunorubicin. ATRA helps control the risk of life-threatening bleeding from disseminated intravascular coagulation (DIC). Later treatment can include ATRA with or without methotrexate and 6-mercaptopurine. Or if a first round of ATRA and chemotherapy does not work, arsenic trioxide may be used.⁹
• To treat leukemia in the brain or prevent it from spreading to the brain and central nervous system, methotrexate and cytarabine/cytosine arabinoside are injected into the spinal canal. This is called intrathecal chemotherapy.

Supportive treatments during cancer treatment include:

• Antibiotics and immunoglobulins help to prevent or fight infections. This is important when you do not have enough normal white blood cells to fight infections on your own.
• Transfusions of red blood cells and platelets.
• Epoetin and hematopoietic stimulants help your body make new blood cells.
• Allopurinol to prevent kidney problems and gout.
• Saline or steroid eyedrops for relief during treatment with cytarabine/cytosine arabinoside.

Chronic leukemia

Treatments for chronic lymphocytic leukemia (CLL) are usually given intravenously for limited periods of time. If there is relapse, medicines are given again. For chronic myelogenous leukemia (CML), medicine is usually taken by mouth for the rest of your life. Treatment choices may include:

• Chemotherapy for chronic leukemia can involve a single drug or a combination of drugs. For example, you may be given a combination of cyclophosphamide, vincristine, and prednisone. Other drug choices include fludarabine, chlorambucil, hydroxyurea (hydroxycarbamide), cytarabine, busulfan, rituximab, and alemtuzumab.
• Allopurinol may be given to prevent kidney problems and gout.
• Dasatinib (Sprycel) blocks the growth of cancer cells. It can be used for CML that has not been helped by imatinib or other drugs.
• Imatinib (Gleevec) blocks the growth of cancer cells. It is often given to people who have CML. Nilotinib (Tasigna) may be given to people who cannot take imatinib.
• Immune globulin (IG) helps prevent infections. It is sometimes used for people with chronic lymphocytic leukemia (CLL), because CLL weakens the immune system. Bendamustine hydrochloride (Treanda) is sometimes given to slow the progression of CLL.

Medication for nausea and vomiting

Nausea and vomiting are common side effects of chemotherapy. These side effects usually are temporary and go away when treatment is stopped. Your doctor will prescribe drugs to help relieve nausea. These may include:

• Aprepitant (Emend), which is used in combination with ondansetron and dexamethasone as part of a 3-day program.
• Dimenhydrinate, such as Dramamine.
• Metoclopramide, such as Reglan and Octamide.
• Phenothiazines, such as promethazine and prochlorperazine.
• Serotonin antagonists, such as ondansetron (Zofran), granisetron (Kytril or Sancuso), or dolasetron (Anzemet). These drugs work best when they are combined with corticosteroids such as dexamethasone.

What To Think About

There are a lot of clinical trials of new drugs for leukemia. These trials have made it possible for many people with leukemia to live longer. Ask your doctor whether you are a candidate for participation in a clinical trial. For more information, see www.cancer.gov/clinical_trials/ or http://clinicaltrials.gov.

Surgery

In rare cases of chronic lymphocytic leukemia (CLL), the spleen needs to be removed. This happens when the spleen is destroying red blood cells and platelets. The operation is called a splenectomy.

Often a swollen lymph node will be removed to confirm the diagnosis of leukemia. This operation is called a lymphadenectomy.

Surgery is sometimes needed to place a central venous catheter into a large vein in the chest. The catheter is a small tube that is used to give you chemotherapy and other drugs. The tube can also be used to take samples of blood or for giving blood transfusions when needed. It prevents the need for many needle sticks during treatment.

Other Treatment

The following other treatments may be used to treat leukemia:

• Radiation therapy to destroy cancer cells and shrink tumors. Radiation can be applied to one area or to the whole body. Sometimes it is used to treat leukemia that has spread to the brain and central nervous system or to prevent this spread. It also may be used to shrink swollen lymph nodes or to prepare your body for a bone marrow transplant. In rare cases, total body radiation is used to treat chronic lymphocytic leukemia (CLL).
• Stem cell transplant. Transplants usually come from bone marrow or from blood. Some transplants are autologous, meaning the stem cells come from your own body. Some transplants are allogeneic, meaning the stem cells are donated by someone else. The goal of a transplant is to destroy all the cells in your bone marrow, including the leukemia cells, and replace them with new, normal cells.
• Clinical trials. Clinical trials investigate new ways to treat leukemia. Many leukemia patients are referred to clinical trials, and many trials have helped people to live longer. Ask your doctor whether you are a candidate for a trial. He or she may be able to answer your questions about a certain clinical trial and help you decide if it is right for you. For more information, see www.cancer.gov/clinical_trials/ or http://clinicaltrials.gov.

What to think about

Many cancer patients looking for a cure are willing to try alternative treatments. Check with your doctor before using any special diets, over-the-counter drugs, herbal products, or unusual treatment methods that you may hear about. Some of them can make your side effects worse or reduce the benefits of chemotherapy.

Other Places To Get Help

Organizations

References

Citations

1. Kipps TJ (2006). Chronic lymphocytic leukemia and related diseases. In MA Lichtman et al., eds., Williams Hematology, 7th ed., pp. 1343-1383. New York: McGraw-Hill.

2. Kebriaei P, et al. (2008). Management of acute leukemias section of Acute leukemias. In VT DeVita Jr et al., eds., DeVita, Hellman, and Rosenberg's Cancer: Principles and Practice of Oncology, 8th ed., vol. 2, pp. 2232-2265. Philadelphia: Lippincott Williams and Wilkins.

3. American Cancer Society (2008). Cancer Facts and Figures 2008. Atlanta: American Cancer Society. Available online: http://www.cancer.org/docroot/STT/content/STT_1x_Cancer_Facts_and_Figures_2008.asp.

4. National Comprehensive Cancer Network (2006). Chronic myelogenous leukemia, version 1.2006. Available online: http://www.nccn.org/professionals/physician_gls/PDF/cml.pdf.

5. Druker BJ, et al. (2006). Five-year follow-up of patients receiving imatinib for chronic myeloid leukemia. New England Journal of Medicine, 355(23): 2408-2417.

6. Liesveld JL, Lichtman MA (2006). Acute myelogenous leukemia. In MA Lichtman et al., eds., Williams Hematology, 7th ed., pp. 1183-1236. New York: McGraw-Hill.

7. Johnston JB (2004). Chronic lymphocytic leukemia. In JP Greer et al., eds., Wintrobe's Clinical Hematology, 11th ed., vol. 2, pp. 2429-2463. Philadelphia: Lippincott Williams and Wilkins.

8. Greer JP, et al. (2004). Acute myeloid leukemia in adults. In JP Greer et al., eds., Wintrobe's Clinical Hematology, 11th ed., vol. 2, pp. 2097-2142. Baltimore: Williams and Wilkins.

9. National Comprehensive Cancer Network (2006). Acute myeloid leukemia. Clinical Practice Guidelines in Oncology, version 1. Available online: http://www.nccn.org/professionals/physician_gls/PDF/aml.pdf.

Other Works Consulted

• Appelbaum FR (2008). The acute leukemias. In L Goldman, D Ausiello, eds., Cecil Medicine, 23rd ed., pp. 1390-1397. Philadelphia: Saunders.

• Faderl S, Kantarjian HM (2007). Chronic myelogenous leukemia and other myeloproliferative disorders. In DC Dale, DD Federman, eds., ACP Medicine, section 12, chap. 17. New York: WebMD.

• Gilliland DG, Raffel GD (2008). Molecular biology of acute leukemias section of Acute leukemias. In VT DeVita Jr et al., eds., DeVita, Hellman, and Rosenberg's Cancer: Principles and Practice of Oncology, 8th ed., vol. 2, pp. 2221-2231. Philadelphia: Lippincott Williams and Wilkins.

• Kantarjian H, O'Brien S (2008). The chronic leukemias. In L Goldman, D Ausiello, eds., Cecil Medicine, 23rd ed., pp. 1397-1408. Philadelphia: Saunders.

• Shanafelt TD, Gertz MA (2007). Chronic lymphoid leukemias and plasma cell disorders. In DC Dale, DD Federman, eds., ACP Medicine, section 12, chap. 15. New York: WebMD.

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