Issue link: http://viewer.e-digitaledition.com/i/753672
M a ny pat ie nt s w it h blo o d ca nce rs s h a re a n i nc re a s i ng ly hop e f u l out lo ok , a s me d ica l adva nce s of fe r more e f fe c t ive t re at me nt opt ion s. RONA, A 43-YEAR-OLD teacher and volunteer tutor, assumed her recent lack of energy was due to a case of flu that had been making the rounds at her synagogue, but when she didn't feel better after a week, she called her doctor. Rona's blood tests revealed that the cause of her fatigue was chronic lymphocytic leukemia (CLL), a type of blood cancer. She had many questions—chief among them: "What does this diagnosis mean? Is leukemia curable? What treatment options do I have?" Rona's questions are typical of those asked by individuals diagnosed with any serious disease, including the three major types of blood cancer: leukemia, lymphoma and myeloma. These diseases affect blood cells and can travel through the blood and lymphatic system, affecting other parts of the body. All three tend to weaken the immune system. Many patients with blood cancers share an increasingly hopeful outlook, as medical advances offer more effective treatment options. Targeted therapy, which uses drugs to attack specific changes that have occurred in cancer cells, is available for blood cancers, but the individual treatments that doctors recommend vary widely according to a number of factors. "Some blood cancers are clinically aggressive and make people sick quickly, while others are relatively idle and don't require medication therapy," says Alan Astrow, M.D., chief of hematology and medical oncology at New York Methodist Hospital. LOOKING AT LEUKEMIA Of the three major types of blood cancer, leukemia affects the blood most directly. Leukemia is a cancer of the white blood cells that begins in the bone marrow, where blood cells develop. White blood cells may mutate and become cancerous, which changes their behavior. They may divide quickly or die more slowly, thus accumulating in the blood and/ or bone marrow at the expense of normal cells. When leukemic white blood cells enter the bloodstream, the white blood cell count rises. The cancer cells travel throughout the body and may interfere with organ function. There are four main types of leukemia: Acute myeloid leukemia (AML) Chronic myeloid leukemia (CML) Acute lymphocytic leukemia (ALL) Chronic lymphocytic leukemia (CLL) AML, CML and CLL are most common in adults. ALL affects children more frequently, but it is also seen in adults. Acute leukemia is usually easier to cure than chronic leukemia, but patients can live for many years with the disease. "In general, acute leukemia develops rapidly and has an immediate effect on health. Chronic leukemia forms over a long period of time and often does no immediate harm," says Dr. Astrow. "A patient with chronic leukemia may not feel sick in any significant way and may not require treatment." "We don't know what causes most leukemias," Dr. Astrow continues. "Prior chemotherapy and radiation can cause certain types, and so can exposure to some chemicals, including benzene, but most people with leukemia haven't been exposed to those things." LEUKEMIA DIAGNOSIS AND TREATMENT Leukemia symptoms are related to the imbalance that the disease creates in the blood. Leukemia cells crowd out normal cells in the bone marrow so the patient doesn't have normal white blood cells to protect against infection or normal amounts of red blood cells to carry oxygen through the body or normal platelets to protect against bleeding. People who have leukemia may experience infections, bleeding or symptoms of anemia. Doctors typically diagnose leukemia by examining blood or bone marrow samples. Leukemia treatments depend on which type of disease is diagnosed and may include chemotherapy and/ or targeted drug therapy, which acts against cancerous cells and leaves normal cells largely unharmed. The chemotherapy drugs doctors use vary according to leukemia type, and emerging therapies are transforming the way that doctors treat leukemia. Imatinib mesylate (Gleevec ® ) was the first targeted drug used to treat CML and the PH+ variant of ALL, but it has largely been replaced by subsequent generation drugs. Doctors may also use stem cell transplants to replace diseased or damaged bone marrow. Stem cells can come from patients themselves, donors or umbilical cord blood. Doctors also use these transplants to treat lymphoma and myeloma. "For example, for AML, the principal options are conventional chemotherapy, which may lead to a cure but can cause significant side effects in older patients, and another type of chemotherapy called hypomethylating therapy that restores normal regulatory mechanisms in leukemic cells allowing for longer survival if not a cure," Dr. Astrow says. Treatments for CLL are evolving particularly quickly with new therapies proving to be very effective. "There have been a lot of advances in leukemia treatment during the past 40 years," Dr. Astrow says. "For chronic leukemias, in particular, the medications we have now are remarkable and have made a huge difference in how patients fare. I have patients who might have lost their lives to chronic leukemia long ago who are alive and well because of advances in medications." For Rona, the teacher who has CLL, doctors recommended infusion of a drug that will prompt her immune system to attack certain proteins on cancer cells—a treatment known as P H Y S I C I A N RE F E R R A L / / 718 . 49 9. C A RE 19