Types of Leukaemia
Leukaemia occurs in several forms. Some forms appear suddenly and progress rapidly over days to weeks: they are called acute leukaemia. Others are less apparent and progress slowly over month to years: they are called chronic leukaemia. Leukaemias are named according to the type of white blood cells involved. The myeloid leukaemias are those, which involve the granulocytes; the lymphoid leukaemias are those, which involved the lymphocytes.
Acute Lymphoid Leukaemia (ALL)
Acute lymphoid leukaemia is most common in children and accounts for only a small percentage of adult leukaemias. It affects immature lymphocytes. Normal lymphocytes are responsible for fighting infection: when bacteria or viruses attack the body, lymphocytes respond by producing anti-bodies or special lymphocyte killer cells. When you have acute lymphoid leukaemia, the lymphocytes cannot function properly, and you may develop a serious infection. In addition, the disease causes many abnormal lymphocytes to be produced, crowding out the normal red blood cells and platelets.
Chronic Lymphoid Leukaemia (CLL)
This leukaemia also affects the lymphocytes, but develops more slowly than acute lymphoid leukaemia. This disease affects adults and does not occur in children. The disease progresses slowly, so the normal cells are not crowded out as rapidly as in the acute form of the disease. If you have chronic lymphoid leukaemia, you may not feel any symptoms until the later stages of the disease.
Acute Myeloid Leukaemia (AML)
This leukaemia mainly affects adults, but can occur in children and adolescents. Acute myeloid leukaemia mainly affects the myeloid cells known as granulocytes. This disease creates an excessive number of young myeloid cells and a shortage of mature myeloid cells. The young myeloid cells can block blood vessels.

Chronic Myeloid Leukaemia (CML)
Chronic myeloid leukaemia can occur at any age but is uncommon below the age of 20 years. It stops myeloid cells from functioning properly. It occurs in two stages: first, there is a slow multiplication of abnormal cells. Then, it can quickly change into an acute stage.What causes Leukaemia?The causes of leukaemia are not known. Some factors appear to influence its development. These risk factors only explain a very small number of leukaemia cases. Having one or more of these factors does not mean that you will definitely develop leukaemia. If you are concerned about any of these factors you should talk to your doctor.
Genetic factors: Down’s syndrome children and children with some other rare congenital abnormalities have an increased risk of acute leukaemia. Genetic factors may play a role in the development of chronic lymphoid leukaemia. Chronic lymphoid leukaemia is more common in men and seems to run in families.
Radiation: leukaemia occurs at higher than average rates among people exposed to intense radiation. These include survivors of atomic bomb explosions in Japan, people exposed to radiation after the Chernobyl nuclear plant disaster, and people who received large amounts of radiation necessary for treatment of certain medical conditions in the past.
Chemicals: workers exposed to benzene have an increased risk of acute myeloid leukaemia. Smoking appears to increase risk of acute myeloid leukaemia.
Country of origin: in certain areas of the world, such as south-west Japan, parts of Africa and the Caribbean, a particular type of leukaemia can be spread among local residents by a virus known as HTLV (Human T Cell Leukaemia Lymphoma Virus).
Diagnosis
People with symptoms of leukaemia will have blood tests and bone marrow tests, which can confirm whether or not the disease is present. The symptoms of leukaemia are similar to symptoms of some other common conditions. If you are concerned about your symptoms you should consult your doctor. Symptoms of acute LeukaemiaThe symptoms of acute leukaemia usually appear quite suddenly as this type of leukaemia develops quickly. Weakness, tiredness and looking ‘washed out’ may be due to reduced numbers of red blood cells.
Prolonged bleeding, for example, heavy nosebleeds, or bruising easily, may be due to a decrease in platelets. A tendency to get infections and associated high temperatures may be due to your white blood cells not functioning properly. Pain in the bones and joints may also occur.
Symptoms of chronic leukaemia
The symptoms of chronic leukaemia develop over months or years. They are similar to those of acute leukaemia but also include enlargement of the lymph nodes, spleen and liver. Anaemia may be a symptom of chronic myeloid leukaemia. Most people with chronic lymphoid leukaemia are not even aware that they have the disease and may only be diagnosed during an examination for another medical problem. Chronic myeloid leukaemia usually progresses slowly at first but may change to a more active phase and become more like an acute leukaemia after several years.
What doctors and other health professionals will I see?
Your general practitioner will refer you for initial tests to confirm whether or not you have cancer. If a diagnosis of cancer is made, he or she will also refer you to a specialist who will advise you about treatment options. Specialists and health workers who care for people with leukaemia include:
Surgeons: who are responsible for biopsies and other surgical procedures
Haematologists: diagnose and treat people with blood diseases
Medical oncologists: who are responsible for chemotherapy
Radiation oncologists: who are responsible for radiotherapy
Dieticians: who recommend the best diets to follow while you are in treatment and recovery
Nurses: who assist you through all stages of your hospitalisation and cancer experience.
Social workers and occupational therapists: who will advise you on support services available and help you to resume normal activities.
How leukaemia is diagnosed
Leukaemia can be diagnosed by examining samples of your blood and bone marrow under a microscope. A lymph node biopsy may also be recommended. Blood tests and bone marrow tests are also ways of checking progress, so they will continue during and after treatment.
Blood test
Leukaemia is suspected if a blood test shows large numbers of abnormal white blood cells and low numbers of red blood cells, platelets and normal white blood cells.

Bone Marrow BiopsyA
bone marrow biopsy is usually needed to diagnose the type of leukaemia. A small amount of fluid is collected from the bone marrow with a syringe and a small core of bone marrow is removed. The samples are then examined under a microscope. Having a bone marrow biopsy may be painful, so a local anaesthetic is always used. You may also be given a sedative, to increase your comfort during the procedure.
Lymph node biopsy
If you have an inflamed lymph node, your doctor may recommend a biopsy to see if this is related to leukaemia. Tissue is removed from the affected lymph node for examination under a microscope. You may have a local or general anaesthetic, depending on where the affected node is. The procedure could be done while you are an outpatient, or during a brief stay as an inpatient.

Lumbar puncture (‘spinal tap’)
Your doctor may recommend a lumbar puncture to check for leukaemic cells in the fluid, which surrounds the brain and spinal cord. In a lumbar puncture, a fine needle is put into a space between bones in your lower back and some fluid extracted from around your spine. This is then examined under a microscope. A local anaesthetic is used to reduce the pain and discomfort felt during this procedure. Some people worry about having this procedure: you may choose to have a sedative if you wish. Discuss this with your doctor.

Treatment
In recent years, a lot of progress has been made in the treatment of acute leukaemia, particularly acute lymphoid leukaemia. The main treatment used is chemotherapy. For some people, stem cell transplantation may be a further option. People with chronic lymphoid leukaemia may not need treatment for many years but have regular checkups and blood tests to monitor the disease. People with chronic myeloid leukaemia, in its early stages, are usually given moderate doses of chemotherapy or interferon injections.

Chemotherapy
Chemotherapy is the treatment of cancer using anti-cancer (cytotoxic) drugs. The aim is to kill cancer cells while doing the least possible damage to normal cells. The drugs work by stopping cancer cells from dividing and multiplying. Chemotherapy drugs are commonly taken intravenously, that is, they are injected into a vein. To avoid having repeated injections, a long-lasting intravenous catheter is usually used. The drugs can then be added to a fluid drip attached to the catheter. When moderate doses are required, chemotherapy drugs may be given in tablet form or as simple injections under the skin. Chronic lymphoid leukaemia and chronic myeloid leukaemia are usually treated in this way. If chronic myeloid leukaemia changes to a more active phase after several years, stronger chemotherapy may be given.
For some people, chemotherapy for acute leukaemia will mean spending several weeks in hospital. Others may be able to stay at home but will need regular hospital visits for checkups and further treatments.
Three different phases of chemotherapy are used to treat acute leukaemia – induction therapy, consolidation therapy and continuation therapy.

Induction therapy
Treatment begins with induction therapy, which usually lasts for four to six weeks. This is a phase of vigorous treatment aimed at destroying as many abnormal white blood cells as possible to obtain a remission.
You are said to be in remission when your blood and bone marrow show no detectable signs of leukaemia.
Patients with acute lymphoid leukaemia will receive extra therapy after remission is achieved. As microscopic collections of leukaemia cells may have spread to the spinal fluid, anti-cancer drugs are injected directly into the fluid around your spine. Radiotherapy may also be given. In children, the use of radiotherapy is avoided wherever possible because of its potential side effects, which may affect their growth and development.
Consolidation therapy
After remission has been achieved, ongoing therapy is used to prevent the return of the leukaemia (called a relapse). The goal of this second phase of treatment is to kill any undetected cancer cells that may have survived the first treatment. Different anti-cancer drugs are used to try to overcome possible resistance by the leukaemia cells to any one drug.

Continuation therapy
Continuation therapy is the final stage of treatment for childhood acute lymphoid leukaemia. It is given over a longer period of time (two or three years), but its aim is the same: to destroy remaining cancer cells. In acute myeloid leukaemia, however, the role and duration of continuation chemotherapy is still being studied.
In general, this phase of treatment is not as intense as the first two phases. It may sometimes be replaced by stem cell (bone marrow) transplantation.
Side effects of chemotherapy
The most important effect of chemotherapy is that it kills leukaemia cells. However, it may have side effects. Normal cells are better able to renew themselves after chemotherapy than leukaemia cells, but some normal cells that multiply rapidly (like hair cells) may be affected by chemotherapy. Reactions vary with different drugs, with different people and from one course of treatment to the next. Doses of chemotherapy which are moderate, such as those, used for treatment of chronic leukaemia, usually cause few side effects.
The most common side effects are nausea and vomiting, feeling off-colour and tired, hair loss, diarrhoea, constipation and a sore mouth. If normal blood cells are affected, there may also be problems with infection and bleeding.
Remember that measures are always taken to either prevent or control any reactions. Ask your doctor or nurse for information on your specific chemotherapy. Ask for advice on any possible reactions you may experience and the best ways for you to cope with them.
Stem cell (bone marrow) transplantation
This treatment allows you to have higher doses of chemotherapy than usual; this may increase your chance of being cured. For younger patients with acute leukaemia who have achieved remission this treatment significantly increases the change of long-tern remission and possible cure. Stem cell transplantation is rarely used as the initial treatment for children with acute lymphoid leukaemia because excellent results are usually achieved with chemotherapy. Stem cells are early-stage blood cells that develop in bone marrow (the soft tissue inside bones). High doses of chemotherapy can harm stem cells. Stem cells, infused into you just like a blood transfusion, can rescue your bone marrow from the effects of the treatment.
There are two sources of stem cells: autologous, where you act as your own donor and allogenis, where someone else (usually a tissue-matched family member, but sometimes a matched, unrelated person) donates. If you act as your own donor, the stem cells will be collected before you receive high-dose chemotherapy. This may be when you are recovering from another course of treatment with chemotherapy plus growth factor injections, or after injections of a growth factor alone. The growth factor stimulates the bone marrow to produce large numbers of stem cells for collection.
Autologous stem cells are commonly collected from the bloodstream in a process called apheresis. Blood is taken by syringe from a vein (usually in your arm) or from a small tube going through a vein the neck or chest. The blood is then passed through a machine that can separate the blood cells by spinning them at very high speed. A computer is used to separate the stem cells, which are placed in a collection bag, and the remaining blood cells are returned to your body. An anticoagulant is used in the process and this may cause a tingling in your fingers or lips. Let the nurse know if this happens and adjustments can be made. Sometimes, stem cells are collected directly from the bone marrow in a procedure done in an operating theatre under general anaesthetic.
The transplantation of stem cells takes place after the completion of high-dose chemotherapy. The cells find their way into the bone marrow spaces and engraft, eventually resulting in the restoration and production of normal blood cell numbers. The length of time this takes determines how long you will be in hospital. Specific information about the type of transplant you will be having should be available from your doctor or nurse.
Side effects of stem cell transplantation
While you are having treatment, you will be prone to infections, may bruise and bleed more easily, and may become weak, with little energy. Other possible side effects include mouth infection and ulcers, nausea, vomiting, diarrhoea or bleeding from the bladder. Let your nurse and doctor know if you experience any of these symptoms so that they can be treated.
Immunotherapy with interferonInterferon is a protein that is normally produced by the body and has anti-cancer effects. It is often used in the treatment of chronic myeloid leukaemia. Interferon is given by daily injection under the skin. Side effects of interferon treatmentInterferon can cause flu-like symptoms (fever, chill and sweats) one to two hours after the injection. Some people have the injection before they go to bed, so these symptoms do not interfere too much with day-to-day life. Other side effects include tiredness, loss of appetite and muscle pain.
All-trans-retinoic acid
This form of vitamin A is used to treat a type of acute myeloid leukaemia called acute promyelocytic leukaemia. It is usually used with chemotherapy and has shown markedly improved results in these patients. Some people experience headaches, dry skin, dry mouth and bone pain while taking this treatment.Palliative treatmentPalliative treatment is treatment that relieves or soothes pain and other distressing symptoms of illness. Palliative care is available for all people who experience pain and distress associated with cancer, whatever their stage of cancer treatment. It is a particularly important type of treatment for people with advanced cancer, who cannot be cured but can expect to live without undue pain and distress. Palliative care includes pain relief using painkilling drugs and other measures. Pain is usually well controlled with oral medication.
General practitioners, specialist and specialist palliative care teams in hospital all play important roles in palliative treatment for people with early and advanced cancer.

Prognosis/Outlook
For most people, remission may last for several years before new problems arise. During remission, they will be able to lead a normal life. Younger adults who achieve remission are potentially curable with high-dose chemotherapy and stem cell transplantation. Most children with acute lymphoid leukaemia can expect to be completely cured and many former patients are now adults with children of their own. The outlook is also excellent for children with acute myeloid leukaemia. For most people, chronic leukaemia can be controlled and a normal lifestyle enjoyed for long periods of time. Many people want to know about the risk of their leukaemia returning or relapsing. As everyone is different it is not possible to give definite answers. Factors such as the particular type of leukaemia you have, your symptoms and your age all affect your prognosis, so it is best to discuss your situation with your doctor.
Making decisions about treatment
Sometimes it is difficult to make decisions about what is the right treatment for you. You may feel that everything is happening so fast that you do not have time to think things through. Some people find that waiting for test results and for treatment to begin is very difficult. While some people feel they are overwhelmed with information, other may feel that they do not have enough. You need to make sure that you understand enough about your illness, the possible treatment and side effects to make your own decisions. If you are offered a choice of treatments, you will need to weigh up the advantages and disadvantages of each treatment. If only one type of treatment is recommended, ask your doctor to explain why other treatment choices have not been advised.
Some people with more advanced cancer will always choose treatment, even if it only offers a small chance of cure. Others want to make sure that the benefits of treatment outweigh any side effects. Still others will choose the treatment they consider offers them the best quality of life. Some may choose not to have treatment but to have any symptoms managed as they arise in order to maintain the best possible quality of life.
Talking with doctors
You may want to see your doctor a few times before making a final decision on treatment. The first consultation when you are told you have cancer is usually stressful and you may not remember very much. It is often difficult to take everything in, and you may need to ask the same question more than once. You always have the right to find out what a suggested treatment means for you, and the right to accept or refuse it.
Before you see the doctor, it may help to write down your questions. There is a list of questions to ask your doctor at the end of this section, which may assist you. Taking notes during the session can also help. Many people like to have a family member or friend to go with them, to take part in the discussion, take notes, or simply listen. Some people find it is helpful to tape record the discussion.
Talking with others
Once you have discussed treatment options with your doctor, you may want to talk them over with family or friends, with nursing staff, the hospital social worker or chaplain, or your own religious or spiritual adviser. Talking it over can help to sort out what course of action is right for you.
A second opinion
You may want to ask for a second opinion from another specialist. This is understandable and can be a valuable part of your decision-making process. Your specialist or local doctor can refer you to another specialist and you can ask for you records to be sent to the second-opinion doctor. You can still ask or a second opinion even if you have already started treatment or still want to be treated by your first doctor.
Taking part in a clinical trial
You doctor may suggest that you consider taking part in a clinical trial. Clinical trials are a vital part of the search to find better treatments for cancer. Doctors conduct clinical trials to test new or modified treatments and see if they are better than existing treatments. Many people all over the world have taken part in clinical trials that have resulted in improvements to cancer treatment. However the decision to take part in a clinical trial is always yours.
If your doctor asks you to take part in a clinical trial, make sure that you fully understand the reasons for the trial and what it means for you. Before deciding whether or not to join the trial, you may wish to ask your doctor:
What treatments are being tested and why?
What tests are involved?
What are the possible risks or side effects?
How long will the trial last?
Will I need to go into hospital for treatment?
What will I do if any problems occur while I am in the trial?
If you decide to join a randomised clinical trial, you will be given either the best existing treatment or a promising new treatment. You will be chosen at random to receive one treatment or the other, but it will always be the best treatment available.
If you do join a clinical trial, you have the right to withdraw at any time. Doing so will not jeopardise your treatment for cancer. It is always your decision to take part in a clinical trial. If you do not want to take part, your doctor will discuss the best current treatment choices with you.
Recovery and follow-up care
After the completion of your treatment, you will need to have regular check-ups. Your doctor will decide how often you will need check-ups, as everyone is different. They will gradually become less frequent if you have no further problems. If the disease flares up, or relapses, it can often be treated successfully. The treatment used for the relapse is often different from the first treatment.
Seeking Support
When you are first diagnosed with cancer, you may feel a variety of emotions, such as fear, sadness, depression, anger or frustration. It may be helpful to talk about your feelings with your partner, family members or friends, or with a hospital counsellor, social worker, psychologist or your religious or spiritual advisor.
Sometimes you may find that your friends and family do not know what to say to you: they may have difficulty with the feelings as well. Some people may feel so uncomfortable that they avoid you. They may expect you to ‘lead the way’ and tell them what you need. This can be very difficult to bear and can make you feel very lonely. You may feel able to approach your friends directly and tell them what you need. You may prefer to ask a close family member or a friend to talk with other people for you.DietA balanced nutritious diet will help you to keep as well as possible and cope with the cancer and any side effects if treatment. Depending on the kind of treatment you have had, you may have special dietary needs. A dietician can help to plan the best food