Leukemia

About Leukemia

In this section, you or a loved one can find out more about medical treatments for leukemia. We also provide practical advice about leukemia and offer tips on how to tap into your support network. Read on and you’ll find answers to some of your questions as well as links to resources with more information. Being informed is an important first step towards becoming an active decision-maker in your care plan.

What is Leukemia?

About 1 in 53 Canadian men and 1 in 72 Canadian women are expected to develop leukemia during their lifetime. An estimated 22,510 Canadians are living with, or are in remission from leukemia.

Leukemia is a cancer that originates in blood stem cells. Before going into detail about this particular type of cancer, it’s important to understand the basics:

Cell – the body is made of up millions of cells. Each cell contains genes that are basically a set of instructions that tell the cell how to grow, work, reproduce and die.
Stem cells – are basic “starter” cells that later become different types of cells that do different jobs.
Cancer – is a disease that affects the set of instructions (genes) in certain cells; as a result, the instructions can be changed and the cells become cancer cells. These abnormal cancer cells often live longer than normal cells. In many types of cancer, cells may grow too much, form lumps or malignant tumours, and potentially spread (metastasize) to other parts of the body. Leukemia may or may not metastasize.

Blood cells are made in the bone marrow (the soft, spongy substance in the centre of bones). Bone marrow contains immature blood stem cells that can grow into all 3 types of mature blood cells (red blood cells, white blood cells and platelets). Doctors may do a bone marrow test in people who have or may have leukemia. Knowing the characteristics of the cells in the bone marrow helps doctors identify the type of leukemia.

In leukemia, stem cells do not develop into mature blood cells and remain immature. These immature cells are called blast cells. Over time, the blast cells build up and crowd out normal blood cells so that they can't do their jobs. After leukemia is diagnosed, these blast cells may be referred to as “leukemia cells”.

There are many different types of leukemia and a variety of treatments specific to the type of leukemia are available. Knowing the type of leukemia you have will both help you understand what is happening to your blood cells as well as the treatments available for your leukemia. Treatments vary with the type of leukemia.

There are 4 main types of leukemia; these vary by the stem cell type affected and how fast the condition develops.

Blood stem cells develop into either lymphoid stem cells or myeloid stem cells:

Myeloid stem cells are responsible for the development of red blood cells, platelets and two types of white blood cells, the granulocytes and monocytes
Lymphoid stem cells are responsible for the development of lymphocyte white blood cells

The diagram below shows how basic stems cells develop into either myeloid stem cells or lymphoid stems cells.

Normal development of Blood Cells

A leukemia that develops quickly, over days or weeks, is defined as acute, whereas, one that develops slowly, over months or years, is defined as chronic.

The main types of leukemia are:

Acute lymphocytic leukemia (ALL)
Chronic lymphocytic leukemia (CLL)
Acute myelogenous leukemia (AML)
Chronic myelogenous leukemia (CML)

Within these 4 types, there are many subtypes of leukemia that are differentiated by subtle variations. These subtypes will not be discussed here, for more information on the subtypes of leukemia, visit the Canadian Cancer Society website.

The most common types of leukemia in adults are AML and CLL.

Finding out you have leukemia can leave you feeling devastated and overwhelmed, so it's crucial to reach out for help and information from people who are close to you and to your healthcare team. Along with obtaining the best possible medical support and treatment, it is important to make your emotional and physical wellbeing a priority, to ask for help and support when you need it, and to nurture relationships with compassionate people who enrich your life. You don't have to do it alone – there are many ways to manage your daily life with your healthcare team, family and friends, as you will see in the following sections.

What causes leukemia?

For most people with ALL, AML, CLL or CML there are no clear causes for these diseases. Leukemia is more prevalent in men than women and the risk of developing leukemia increases with age. Some of the factors that increase the risk of someone developing leukemia include:

Family history of leukemia
High doses of radiation
Previous treatment with chemotherapy or radiation therapy (the combination of both increases the risk of either treatments used alone)
Exposure to chemicals such as benzene or formaldehyde
Genetic syndromes (leukemia is more likely in children who have these conditions)
- Down syndrome
- Fanconi anemia
- Alaxia-telangiectasia
- Bloom syndrome
Smoking cigarettes

About cancer stages

In order to prescribe treatment, doctors need to know the extent or “stage” of cancer in the body. For leukemia, there are different staging systems depending on the type of leukemia you have.

Diagnostic tests for all types of leukemia

The following tests are used to diagnose leukemia. The results of these tests may also help doctors identify the leukemia stage.

Diagnostic tests	Staging and other tests
Medical history and physical examination	Blood chemistry tests
Complete blood count (CBC)	Chest x-ray
Blood chemistry tests	CT scan
Bleeding and clotting factors	Magnetic resonance imaging (MRI)
Cytochemistry	Ultrasound
Immunophenotyping
Cytogenetic and molecular studies
Bone marrow aspiration and biopsy
Lumbar puncture
Lymph node biopsy

The method used to identify leukemia stages varies by type of leukemia

ALL is a type of cancer that starts in the stem cells of the blood. Since ALL is an acute leukemia, it starts suddenly and develops quickly within days or weeks.

For ALL, there is no standard staging system. The disease can be described as untreated, in remission, recurrent or relapsed.

Untreated: In newly diagnosed ALL, the condition itself has not been treated; however, some signs and symptoms such as fever, bleeding or pain may have been treated. At this stage, the complete blood count is abnormal, about 25% of the bone marrow cells are immature white blood cells called blasts and the patient may have symptoms of leukemia.
Remission: The ALL has been effectively treated. At this stage, the complete blood count is normal, and blast cells account for less than 5% of bone marrow cells. There are no signs or symptoms of leukemia in the body. When a patient is in partial remission, less than 25% of the bone marrow cells are blast cells.
Relapsed (also called recurrent): The ALL has come back following a period of remission. With recurrent disease, more than 25% of bone marrow cells are blast cells.
Refractory: ALL did not respond to treatment.

Your doctor will choose your treatments based on your ALL subtype and your risk factors.

For AML, there is no standard staging system. The disease can be described as untreated, in remission or relapsed.

Untreated: In newly diagnosed AML, the condition itself has not been treated, however, some signs and symptoms may have been treated. At this stage, blast cells may be found in the patient’s blood sample. At least 20%-30% of bone marrow cells are blasts and the patient may have symptoms of leukemia.
Remission: The AML has been treated. At this stage, the number of blood cells (neutrophils and platelets) have recovered (without blood transfusion) and blast cells account for less than 5% of bone marrow cells. There are no signs or symptoms of leukemia in the body. When a patient is in partial remission, less than 25% of the bone marrow cells are blast cells.
Relapsed (also called recurrent): The AML has come back following a period of remission. AML relapse may be defined as 5% or more blast cells in the bone marrow (not due to other causes).
Refractory: AML did not respond to treatment.

With CLL, the stage of the disease is established based on blood cell counts and amount of lymphoid tissues involved. Lymphoid tissues include cells and organs that make up the lymphatic system, which includes white blood cells (such as lymphocytes), bone marrow, thymus, spleen, and lymph nodes.

Staging systems consider factors such as elevation of your blood and marrow leukemic lymphocyte counts, lymph nodes' size and distribution, spleen's size, extent of the decrease in blood platelet counts and extent of anemia.

Two different staging systems can be used, the Rai and the Binet. The Rai system is most commonly used in Canada.

The Rai staging system has levels 0 to IV:

Stage 0 (Low risk 0): There are too many lymphocytes in the blood; however, the numbers of red blood cells and platelets are normal and the lymph nodes and spleen are not enlarged.
Stage I (Intermediate risk I): There are too many lymphocytes in the blood, the numbers of red blood cells and platelets are normal and the spleen is not enlarged. The lymph nodes are enlarged.
Stage II (Intermediate risk II): There are too many lymphocytes in the blood; however, the numbers of red blood cells and platelets are normal. The lymph nodes may be enlarged and the spleen and/or liver are enlarged.
Stage III (High risk III): There are too many lymphocytes in the blood, and there are fewer red blood cells than normal. The number of platelets is normal and the lymph nodes, spleen or liver may be enlarged.
Stage IV (High risk IV): Too many lymphocytes are in the blood but too few platelets. The number of red blood cells may be low and the lymph nodes, spleen or liver may be enlarged.

The Binet system has 3 levels, A, B and C. Stages A and B generally correspond to Rai stages 0, I and II while stage C corresponds to Rai stages III and IV. The Binet system also includes relapsed and refractory disease and considers the risk level and number of areas of lymphatic tissue that are enlarged. The Binet system is not detailed here, for more information on the Binet system, visit the Canadian Cancer Society website.

It’s important to keep in mind that people with CLL may not require treatment right away and some people may never require treatment. Your doctor’s decision to start treatment depends on whether or not you have signs or symptoms that indicate progressive disease. These signs and symptoms are called treatment indications. See the section on Treatment - Watchful Waiting for a listing of the indications.

CML is grouped into phases based on blood cell counts and symptoms, instead of stages. There are 3 phases: chronic, accelerated and blast crisis.

Chronic Phase: Less than 5% of the cells in the blood and bone marrow are blast cells. The patient has either no symptoms or very mild symptoms.
Accelerated Phase: 10% to 19% of the cells in the blood and bone marrow are blast cells. Symptoms include fever, poor appetite, weight loss, and enlarged spleen. When CML is in the accelerated phase, it can quickly go to the blastic phase. This is referred to as a blastic crisis.
Blast Crisis: 20% or more of the cells in the blood and bone marrow are blast cells. The leukemia has spread to tissues and organs outside the bone marrow. Symptoms include fever, malaise, an enlarged spleen, poor appetite, weight loss, fatigue, shortness of breath, abdominal pain and bone pain. The white blood cell counts and platelet counts become abnormal which can lead to bleeding and infection.

For more information on CML disease phases, visit the Canadian Cancer Society website.

In addition to the phases mentioned above, CML can also be in remission (blood counts return to normal), relapsed (number of blast cells in the blood and bone marrow increase following treatment and remission) or refractory (the leukemia does not respond to treatment).

Multiple myeloma, usually referred to as myeloma, is a cancer of the plasma cells found in the bone marrow. A plasma cell is a type of immune cell that produces antibodies used to fight infection.

There are two systems generally used to stage active myeloma: the revised International Staging System (R-ISS) and the Durie-Salmon staging system.

For more information about the staging of multiple myeloma, visit the Canadian Cancer Society website or download the patient handbook on the Myeloma Canada website.

About 1 in 53 Canadian men and 1 in 72 Canadian women are expected to develop leukemia during their lifetime.²
Leukemia is a type of blood cancer. In Canada, the number of people living with, or in remission from blood cancer rose by 25% from 2014 to 2016.²
An estimated 6,200 Canadians were diagnosed with leukemia in 2017.¹
There are no obvious reasons why some people get acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), CLL or chronic myeloid leukemia (CML) and others don’t.³
Risk factors for developing certain types of leukemia include: previous cancer treatment with certain types of chemo and radiation therapy, genetic disorders, exposure to certain chemical such as benzene, smoking and a family history of leukemia.³
Although CLL (chronic lymphocytic leukemia) is called a leukemia, it is actually a form of lymphoma.⁴
More than 2,200 people in Canada are diagnosed with CLL each year.⁴

References:

What are the effects of leukemia?

A prognosis is the doctor’s best estimate of how disease will affect a person and how that person will likely respond to treatment. The prognosis for people with leukemia varies with the type of leukemia and other factors.

Examples of factors which affect the prognosis include age, chromosome changes, white blood cell count, response to chemotherapy and early relapse.

You may have come across survival statistics regarding leukemia. Keep in mind that survival statistics are general estimates and must be interpreted carefully. These statistics are based on the experience of groups of people and; therefore, cannot be used to predict an individual’s specific chances of survival. When certain types of leukemia are diagnosed and treated early, the likelihood of successful treatment is better.

Your doctor can explain the statistics for leukemia and what they may mean for you.

Signs and symptoms will vary depending on the type of leukemia. With chronic leukemia (for example CLL and CML), patients often say that they do not feel well in general and frequently the diagnosis is confirmed during routine blood tests. When a patient has acute leukemia (such as ALL and AML) leukemia symptoms may suddenly arise over a period of days or weeks.

Common symptoms of leukemia include:

Fever
Chills
Persistent fatigue
Weakness
Frequent or severe infections
Losing weight without dieting
Swollen lymph nodes, enlarged spleen or liver
Easy bleeding and/or bruising
Recurrent nosebleeds
Tiny red spots in your skin (known as petechiae)
Excessive sweating (especially at night)
Bone pain or tenderness

ALL symptoms

ALL symptoms include:

Aches in arms, legs or back
Bruises for no clear reason
Enlarged lymph nodes
Fever without an obvious cause or a lasting, low-grade fever
Headaches
Pale skin
Pinhead-size red spots under the skin (called petechiae)
Prolonged bleeding from minor cuts
Shortness of breath during normal physical activity
Tiredness or no energy
Vomiting
Unexplained weight loss

CML symptoms

If you have CML, sometimes you won’t have any symptoms. Often people with CML only learn of their condition after a routine physical or blood test.

Possible CML symptoms:

Tiredness or no energy
Shortness of breath during basic everyday activity
Pale skin
Discomfort or a "dragging" feeling on the upper left side of your stomach (caused by an enlarged spleen)
Night sweats
An inability to tolerate warm temperatures
Unexplained weight loss

AML symptoms

AML symptoms include:

Pale skin
Black-and-blue marks (bruises) with no clear cause
Pinhead-size red spots under the skin (called petechiae)
Prolonged bleeding from minor cuts
Slow healing of cuts
Tiredness or no energy
Shortness of breath during normal physical activity
Mild fever or night sweats
Swollen gums
Frequent minor infections, such as perianal sores (sores around the anus)
Loss of appetite and weight loss
Aches or discomfort in bones or joints such as knees, hips or shoulders

CLL symptoms

CLL symptoms generally develop over time. In fact some people with CLL have no symptoms. An elevated white blood cell count found through a blood test is the most common initial reason a doctor will suspect CLL.

Possible CLL symptoms:

Tire more easily, and/or feel short of breath due to anemia (low red blood cell count)
Lose weight due to decreased appetite and/or increased use of energy
Fever, chills and night sweats
Have enlarged lymph nodes and spleen
Have infections of the skin, lungs, kidneys or other part of the body

Are there other associated symptoms?

Repeated infections can occur in patients with leukemia. Kidney failure or impaired kidney function, as well as a decreasing number of neutrophils (a type of white blood cell), are also known complications. Leukemia treatments can have serious side effects.

Support means everything

When you have cancer, you may need different types of support at different times.

Although you may find it hard to ask for help, the fact is that having help often makes it easier to cope with leukemia. Keep in mind that your family and friends, even co-workers, may really want to help but they aren’t sure what to do. Knowing that you need something done (for example walking your dog) allows your loved ones to feel useful. Keep in mind that receiving and giving help are both gifts.

Other sources of support are people who have gone through what you’re going through. These people understand how you feel, they can tell you what to expect, how they coped, and give you hope for the future. You can get in touch with people in your situation through organized support programs. If you’re interested in an organized support program ask your doctor or other member of your healthcare team for more information. Contacting the Canadian Cancer Society, Survivornet or the Leukemia & Lymphoma Society of Canada can also give you access to people and resources. For those of you with CLL, you can also contact the CLL Patient Advocacy group or Lymphoma Canada.

Your healthcare team is also a key source of support for you. Although the people on your team are all professionals, they are also human beings so it’s important to build a good relationship with them with open honest communication.

Family and friends want to be there for you. Some people know what to do and say without you saying anything. Others want to help but aren’t sure how. In these cases, you can take the first step by starting the conversation and tell the other person exactly what you need help with. You shouldn't assume that the other person will know how to help. In other cases, someone may say, “Let me know if I can do anything.” You can answer by saying specifically what you need help with.

Here are some tips and helpful insights we’ve learned from patients:

Ask those closest to you to learn about your condition. This will help them understand your symptoms better and how you feel about them. It may give them new ideas about how to make things easier for you in your day-to-day life. This awareness alone will make you all more comfortable dealing with leukemia. Mutual understanding often arises from education – friends and relatives can read this or other websites, look up reliable sources of information in libraries, or go with you to some of your appointments. Websites for the Leukemia & Lymphoma Society of Canada, the CLL Patient Advocacy group, Lymphoma Canada or Myeloma Canada are excellent sources of information.
Let them know you need their support. This could be just their listening when you need to talk – even about things not directly related to your leukemia. Nourish your important personal relationships – share how you are feeling physically and emotionally. There will be times when you experience more pain and limitations, and are frustrated.
Always be open and honest about your needs. It’s best to give others a very clear idea of how they can help you. Here are some examples of what you may ask of your friends and family:
- Help with housework such as cooking, cleaning, shopping and yard work
- Water your house plants and garden
- Mow the lawn
- Bring in your mail
- Take care of your pets
- Drive you to your medical appointments or treatments
- Drive a child to or from school or other activities
- Pick up a prescription at the pharmacy
- Look up information about your condition or other topics
- Be the contact person who keeps others updated on your condition

People with cancer can experience a range of emotions. Although some of these feelings are difficult to deal with, there are positive feelings as well. Some cancer patients find that they begin to appreciate life in a new way.

Leukemia is different for every patient, with treatment tailored to each individual case. The key is to closely follow your healthcare team’s instructions for the steps and medications to take. Be persistent in following your treatment. Keep notes and communicate regularly with your doctor about the effects of your treatment. If you feel there’s a problem with your treatment, or are experiencing any side effects, talk to your doctor right away about these concerns. Don’t hold back from asking questions. Be pro-active and involved in the decision-making about your health.

Here are some tips on how to get the most out of your appointment with people on your healthcare team:

Be open and honest about how you’re feeling
If you want a loved one to talk with your healthcare team either with you or on your behalf, it helps to choose one person to play this role. This will help avoid having many people asking your healthcare team the same questions
Write down any questions you have and bring the list with you
Take notes
Ask who you should call if something happens between scheduled appointments
Try not to become hostile or angry during your appointment, this can affect how your healthcare team communicates with you

Lifestyle options

For most people, regardless of having cancer or not, exercise, healthy eating and good sleep habits are recommended. A healthy lifestyle can lead to enhanced quality of life for most people.

Talk to your doctor before making any lifestyle changes.

Many doctors encourage physical activity during cancer treatment and recovery.

Benefits of exercise after cancer treatment can include:

Increased energy level
Less fatigue, anxiety and depression
Reduction of stress
Improvement in cardiovascular fitness
Better self-esteem
Improved quality of life
Stimulate your appetite
Reduce side effects like nausea, fatigue and constipation
Help you sleep

Even though adding regular exercise to your life may be challenging, it’s important to remember that exercise can also help maintain your endurance as well as strength and flexibility. Make sure to discuss any plans for new physical activities with your healthcare team. If you experience any health problems while exercising, be sure to seek medical attention.

Planning your exercise program

After being diagnosed, check with your doctor before starting an exercise program, some programs may not be appropriate for you. This is the case even if you exercised regularly before your diagnosis. If your doctor says it’s okay to exercise, it could also be a good idea to meet with a physical therapist or another healthcare professional with experience in exercise. These experts can help you develop an exercise program that is right for you.

General safety precautions include:

Don’t exercise if you have anemia or other blood problems (for example, abnormal sodium or potassium levels).
Avoid public places, such as gyms, if you have low white blood cell counts or a weakened immune system.
Avoid uneven surfaces or any weight-bearing exercises that could cause falls or injury.
If you have osteoporosis, arthritis, nerve damage or cancer that has spread to the bone, do not use heavy weights or exercise that puts too much stress on the bones.
Avoid swimming pools if you are receiving radiation therapy as chlorine can irritate skin in the treatment area.

For general information about exercise, you can go to the Public Health Agency of Canada Physical Activity’s webpage.

Going through cancer therapy can take its toll on your body. After your treatment, living a healthy lifestyle is a good way to regain strength and endurance, manage stress, deal with fatigue, sleep problems and solve weight issues.

Managing fatigue

Patients may describe fatigue as feeling tired, weak, worn-out, heavy, slow, or no energy. Fatigue can be a symptom of a low red blood cell count (anemia). Red blood cell counts may be lower when the bone marrow is affected by leukemia or its treatments. Fatigue can also occur due to poor nutrition, sleep problems, anxiety or depression.

Make sure to discuss your fatigue with your healthcare team. They may suggest or prescribe one or more treatments such as nutritional supplements, blood transfusion, iron pills or other medications.

Cancer-related fatigue may not be completely relieved by sleep and rest. This type of fatigue generally diminishes after cancer treatment ends but patients may continue to experience it months and even years later.

Here are some approaches to coping with fatigue. Make sure to discuss any changes to your lifestyle with your doctor:

Exercise can help patients with cancer feel better and have more energy. Refer to our section on exercise.
A schedule of activity, rest and proper sleep time. Changes in daily routine makes the body use more energy so keeping to a regular schedule can improve sleep and increase day-time energy levels.
Talk to a counselor about how you feel. Bottled up feelings and emotions can make fatigue worse.

For people with cancer, along with everyone else, a good diet is important for your body to regain its strength. Patients can consult Canada’s Food guide for help in making healthy food choices after having received cancer treatment.

People’s responses to food during their leukemia treatment can vary. Some people continue to have a strong appetite and enjoy eating. Other people have trouble eating. Side effects from your treatment or emotions like anxiety can make eating a challenge. Here are some suggestions to help you eat during your treatment:

Present your food in an attractive way on the plate.
Try to make mealtimes relaxed and pleasant.
Experiment with a variety of food.
If you are having trouble maintaining your weight, consider eating several small snacks, such as cereal, cheese, fruit or yogurt, throughout the day.
Keep in mind that eating difficulties are temporary.

A dietician can also help you make a meal plan that fits with your health needs and food preferences.

Supplements

The best way to get the vitamins and minerals you need is by eating a healthy, well-balanced diet, which should provide the amounts needed to stay healthy. However, taking regular-strength multivitamins and/or mineral supplements tailored appropriately for your age group and condition may be helpful, but you should check with your doctor before taking any supplements.

Both prior to and after your leukemia treatment, you’ll likely experience overwhelming emotions such as feelings of anxiety or depression.

Ways of coping with these emotions include physical activity, good nutrition, balancing being active with rest and communicating honestly regarding your fears and concerns.

Getting support from other people can help you manage your emotional health. Family, friends, religious or spiritual groups, cancer support groups, on-line support forums and counselors are all options. Which people or group(s) are best suited to you is a personal decision. Your level of comfort with the support setting is very important. If you prefer talking with one person at a time, a counselor or trusted friend might be the best choice. If you prefer talking with other leukemia patients who are experiencing the same thing you are experiencing, then a peer-support group run by a local clinic may be the best option for you. Many cancer support programs are offered through local hospices. Try contacting the Leukemia & Lymphoma Society of Canada, the CLL Patient Advocacy group, Lymphoma Canada or Myeloma Canada.

Complementary therapy options for cancer

During your interactions with family and friends, and perhaps support groups, you may hear about various complementary and alternative therapies for cancer. These therapies, used for cancer in general, may include vitamins, herbs, special diets, and acupuncture among other things.

If you are considering any complementary or alternative therapies, talk to your doctor first. The decision to use a complementary or alternative therapy is a personal choice; however, it’s important that your doctor knows about these therapies because they could have some effects on the treatment prescribed by your doctor(s).

Here are some examples of complementary therapies:

Acupuncture
Aromatherapy
Art therapy
Ayurvedic medicine (traditional approach that originated in India)
First nations healing
Massage
Naturopathic medicine
Traditional Chinese medicine

Medical treatments

Your healthcare team will discuss your treatment options with you. The following factors are considered when choosing treatment for leukemia:

Type of leukemia
Overall health
Age
Chromosomal abnormalities

Treatment options also vary with the type of leukemia:

ALL

Chemotherapy
Targeted therapy for patients who are Philadelphia chromosome positive (Ph+)
Radiation therapy
Stem cell transplantation
Supportive therapy

AML

Chemotherapy
Stem cell transplantation
Donor lymphocyte infusion
Radiation therapy
Supportive therapy
- Oral Targeted therapy: FLT3 inhibitor midostaurin

CLL

Watch and wait
Chemotherapy
Chemoimmunotherapy
Monoclonal antibodies
Targeted therapy
Splenectomy
Radiation therapy
Supportive care

CML

Targeted therapy
Stem cell transplantation
Donor lymphocyte infusion
Biologics
Chemotherapy
Surgery
Radiation
Supportive

Multiple myeloma

Observation
Radiotherapy ± surgery
Chemotherapy
High-dose chemotherapy with stem cell transplantation
Corticosteroids such as dexamethazone or prednisone, often in combination with chemotherapy
Immunomodulatory agents
Proteasome inhibitors (PIs)
Monoclonal antibodies

In addition to all the treatment options mentioned above, your doctor may recommend that you enroll in a clinical trial.

Depending on the stage of your cancer and the treatment option(s) prescribed, you may have one or more of the following specialists on your healthcare team:

Dietitian
General practitioner
Medical oncologist
Occupational therapist
Oncologist
Pathologist
Pharmacist
Physiotherapist
Psychologist
Radiation oncologist
Radiation therapist
Radiologist
Surgeon
Surgical oncologist

Other healthcare professionals may also be involved, such as nurses and social workers.

Stem cell transplantation means stem cells from a healthy person (the donor) are transferred to the patient with leukemia.

If you have ALL, your healthcare team will develop a treatment plan based on your needs. Options include:

Chemotherapy

Chemotherapy is the main treatment for ALL, it can be given over a long period, usually about 2 to 3 years.

The treatment typically consists of 2 parts:

Induction therapy which generally involves treatment with 2 or more chemotherapy drugs (some are swallowed, others injected)
Post-remission (consolidation and maintenance) and central nervous system prophylaxis. Without these post-remission treatments, your cancer may return

Central nervous system prophylaxis is used to keep the cerebrospinal fluid from being infiltrated by leukemia.

Targeted therapy (Ph+) definePh+

One in five adults and a small percentage of children with ALL are Ph+. This means they have a particular chromosomal abnormality.

For patients with leukemia cells with the Philadelphia chromosome (Ph+ ALL), a targeted therapy drug called tyrosine kinase inhibitor (TKI) will be given as part of the chemotherapy.

Radiation therapy

Radiation therapy can also be offered, mainly to prevent ALL spread to the central nervous system, to relieve pain if the leukemia has spread to bones, prior to a stem cell transplant, or to shrink a tumour that is pressing against vital organs.

Stem cell transplant

In the post-remission stage of treatment, a stem cell transplant may be offered to patients with ALL; however, both the transplant and the chemotherapy drugs used prior to the transplant can lead to serious side effects. For this reason, this treatment approach is an option only for some patients.

Supportive therapy

ALL treatment routinely results in complications. In these instances, your healthcare team may consider these options:

Blood transfusions, when there are low blood cell counts in your system
Antibiotics, antivirals or antifungals for infections
Growth factors, to stimulate white blood cell production
Leukapheresis, to remove excess white blood cells
Drugs to treat tumour lysis syndrome

Side effects

Side effects can occur with ALL treatments, particularly chemotherapy and stem cell transplantation:

Low blood cells counts
Infection
Graft versus host disease (this means the stem cell donor’s immune cells mistakenly attack the patient’s normal cells)
Kidney stones
Anemia
Mouth sores
Diarrhea
Hair loss
Nausea and vomiting
Fatigue
Loss of appetite

f you have AML, your healthcare team will develop a treatment plan based on your needs which could contain a variety of therapy options:

Chemotherapy

Chemotherapy is the main treatment used in AML. Patients are treated in two phases: induction, and following remission, consolidation/maintenance.

AML spreads to the central nervous system in only 5% of cases, so generally, no preventive treatment is given. Should it happen, chemotherapy is directly applied to the cerebrospinal fluid and with systemic chemotherapy (with this the medication[s] circulate in the bloodstream).

Targeted therapy

Targeted therapy is treatment that involves drugs or other substances that target specific molecules involved in cancer cell growth. An additional benefit of targeted therapy drugs is that they limit harm to normal cells (unlike chemotherapy).

One targeted therapy currently available in Canada is drug midostaurin. This drug can be added to the chemotherapy regimen for people with leukemia cells that have a certain genetic mutation called FLT3. About a third of people with AML have the FLT3 mutation.

Stem cell transplant

During remission, a stem cell transplant may be offered to patients with AML; however, both the transplant and the chemotherapy drugs used prior to the transplant can lead to serious side effects. For this reason, this treatment approach is an option only for some patients.

Donor lymphocyte infusion

If a relapse happens after a stem cell transplant, the donor’s lymphocyte blood cells will be given to the patient through one or multiple treatments.

Radiation therapy

In various circumstances, radiation therapy may be offered, mainly to any AML that has spread to the central nervous system, to relieve pain if the leukemia is in the bones, in anticipation of a stem cell transplant, or to treat a buildup of leukemia cells (blasts) outside the bone marrow.

Supportive therapy

AML treatment routinely results in complications. In these instances, your healthcare team may consider these options:

Blood transfusions, when there are low blood cell counts in your system
Antibiotics, antivirals or antifungals for infections
Growth factors, to stimulate white blood cell production
Leukapheresis, to remove excess white blood cells
Drugs to treat tumour lysis syndrome

Side effects

Side effects can occur with AML treatments, particularly chemotherapy and stem cell transplantation:

Low blood cells counts
Infection
Graft versus host disease (this means the stem cell donor’s immune cells mistakenly attack the patient’s normal cells)
Kidney stones
Fatigue
Temporary hair loss
Nausea and vomiting
Diarrhea
Rashes
Mouth sores

If you have CML, your healthcare team will develop a treatment plan based on your needs. Options include:

Targeted therapy

Targeted therapy is used for CML when the leukemia cells have the Philadelphia chromosome (called Ph-positive, or Ph+, CML).

Tyrosine kinase inhibitors (TKIs) are a standard treatment for most patients with CML. Other drugs can be combined with TKIs.

The following TKIs are used to treat CML:

Imatinib
Dasatinib
Nilotinib
Bosutinib
Pontatinib

Stem cell transplant

In the chronic phase of the disease, stem cell transplants are rarely used due to the high level of risk. If the CML develops resistance to treatment with targeted therapy or biological therapy, stem cells may be used to treat the condition.

Donor lymphocyte infusion

If a relapse happens after a stem cell transplant, a donor’s lymphocyte blood cells will be given to the patient through one or multiple infusions.

Biological therapy

Biological therapy with interferon alfa was a main treatment for CML. Now it is usually offered to patients with CML whose cancer has developed resistance to targeted therapy.

Chemotherapy

Chemotherapy is used in CLM in preparation for a stem cell transplant, or for patients with CLM that has developed resistance to targeted therapy.

Surgery

A splenectomy (removal of the spleen) may be performed if the spleen is enlarged and painful for the patient. This may also improve blood cell counts.

Radiation therapy

In various circumstances, radiation therapy may be offered, to shrink an enlarged spleen should chemotherapy be ineffective, to treat a painful buildup of leukemia cells (blasts) outside the bone marrow, treat CML that has expanded beyond the bone marrow, or to treat the whole body before a stem cell transplant.

Supportive therapy

CML treatment routinely results in complications. In these instances, your healthcare team may consider these options:

Blood transfusions, when there are low blood cell counts in your system
Antibiotics, antivirals or antifungals for infections
Growth factors, to stimulate white blood cell production
Leukapheresis, to remove excess white blood cells
Drugs to treat tumour lysis syndrome

Side effects

Side effects can occur with CML treatments:

Heart problems
Flu-like symptoms
Prolonged fatigue
Weight loss
Diarrhea
Depression
Mouth sores

In a case where you have CLL, your healthcare team will develop a treatment plan based on your needs and risk level. Options include:

Watchful waiting

If the CLL is stable with no apparent symptoms, your condition will be monitored for any signs of progression. If the disease progresses, treatment will be started.

Treatment is started only if you have at least one of the following treatment indications:

Your bone marrow is unable to keep up with your body's need for healthy blood cells –as indicated by anemia (low red blood cell counts) and/or low platelet counts
Massive spleen, progressive spleen enlargement, or an enlarged spleen together with symptoms
Massive lymph nodes, progressive lymph node enlargement or large lymph nodes cause symptoms
Increase in number of white blood cells of more than 50% over a 2-month period or double in number in less than 6 months;
Low numbers of red blood cells or platelets that do not increase with standard treatments
‘B’ symptoms, which means having any one or more of the following CLL-related symptoms or signs:
- Unintended weight loss of 10% or more within the last 6 months
- Tiredness (fatigue)
- Having fevers higher than 38°C for 2 or more weeks without signs of infection
- Heavy night sweats for longer than 1 month without any sign of infection

Chemotherapy

Chemotherapy, alone or in combination with other drugs, can be used to treat CLL. It is used to control the blood cell counts, increase numbers of red blood cells and platelets, and to shrink the swollen spleen and lymph nodes.

A lot of chemotherapy drugs are injected by needle directly into a vein (intravenous or IV infusion). However some drugs are taken by mouth (capsules or pills).

Standard chemotherapy drugs for CLL, used alone or in combination include:

Fludarabine
Cyclophosphamide
Bendamustine
Chlorambucil
Doxorubicin
Vincristine

Combining chemotherapy drugs with monoclonal antibodies is also used to treat CLL. Common combination regimens include:

Fludarabine, cyclophosphamide, and rituximab (FCR)
Chlorambucil and obinutuzumab
Bendamustine and rituximab (BR)

Targeted therapy and monoclonal antibodies

This type of therapy may be used for intermediate-risk and high-risk CLL. Targeted therapy drugs act on specific particles on the cancer cell surface that are involved in sending signals to tell the cell to grow or divide. Targeted therapies help stop these signals and therefore control the growth and spread of cancer cells.

Targeted therapies are often available in pill form. This allows patients to take their medication at home.

Targeted therapy is generally included as part of first line treatment. However some of the targeted drugs can also be used when CLL is hard to treat (for example after other treatments have been tried).

The drugs ibrutinib, idelalisib and venetoclax are oral targeted therapies available in Canada for the treatment of patients with CLL.

Targeted therapies include monoclonal antibody therapies. A monoclonal antibody can attach itself to a cancer cell and kill the cell. Monoclonal antibodies obinutuzumab and rituximab target the CD20 protein on the surface of certain cells; these monoclonal antibodies can be used with or without chemotherapy.

Antibody therapy is generally given in combination with chemotherapy drugs, which is called 'chemoimmunotherapy'. Similar to many chemotherapy drugs, antibody therapies are injected via needle directly into a vein (IV infusion) or under the skin (subcutaneous).

Surgery

A splenectomy (removal of the spleen) may be performed if the spleen is enlarged and painful for the patient. This may lead to improved blood cell counts.

Radiation therapy

In various circumstances, radiation therapy may be used to shrink an enlarged spleen should chemotherapy be ineffective, to treat a painful buildup of leukemia cells (blasts) in the bone marrow, or to shrink enlarged lymph nodes. Sometimes the enlarged lymph node, spleen or other organ is blocking the function of a neighbouring body part.

Supportive therapy

CLL treatment routinely results in complications. In these instances, your healthcare team may consider these options:

Blood transfusions, when there are low blood cell counts in your system
Infusions of immunoglobulins that can prevent recurring infections
Antibiotics, antivirals or antifungals for infections
Growth factors, to stimulate white blood cell production
Leukapheresis, to remove excess white blood cells
Drugs to treat tumour lysis syndrome

Stem cell transplantation

Since they divide rapidly stem cells can be killed off by chemotherapy and radiation therapy. Sometimes patients with CLL receive chemotherapy given in very high doses, often followed by whole-body irradiation. However, this series of treatments can potentially destroy all stem-cells and leave the patient at very high risk for infection.

To deal with this problem, the patient receives a “rescue” with stem-cells from a donor – this is referred to as stem cell transplantation.

Side effects

With respect to side effects, it is important to understand that:

Not all patients will experience side effects or the same side effects or intensity of the same side effects
Side effects are not always severe and can be mild
Different treatments have different side effects
Effective treatments that can reduce side effects or prevent them from happening altogether exist

Side effects can occur with CLL treatments, particularly chemotherapy and monoclonal antibody treatment:

Extreme fatigue
Infections
Hair loss
Nausea and vomiting
Diarrhea
Constipation
Mouth sores
Aches and pains
Low blood pressure
Low blood counts
Anemia

Disclaimer

Please note that the information on this Web site should not be used as a substitute for seeking medical advice or treatment from a physician. You should not use this information to diagnose or treat a medical condition or health problem. Speak to your health care provider if you have any questions about your medical condition, symptoms or treatment options.

CLL resources

Lymphoma Canada

The Mission of Lymphoma Canada: Empower patients and the lymphoma community through education, support, advocacy, and research. Lymphoma Canada provides, at no cost and in both official languages: Electronic and print materials on the Hodgkin lymphoma, non-Hodgkin lymphoma and CLL, peer and caregiver support groups, educational forums and advocacy on behalf of patients. Lymphoma Canada also funds Canadian research.

CLLPAG

CLLPAG is a volunteer-run patient organization. Their mission is to advocate and provide education to improve access to health care that will extend the lives of Canadians affected by Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL).

The Leukemia & Lymphoma Society of Canada

The mission of LLSC is to cure leukemia, lymphoma, Hodgkin's disease and myeloma, and improve the quality of life of patients and their families. Their strategy to achieve the mission is based on three areas of focus: research, patient support and advocacy.

The Canadian Cancer Survivor Network

The Canadian Cancer Survivor Network was created by a group of Canadians concerned about cancer. Their mission is to promote health by conducting educational activities for cancer patients, caregivers, and survivors on the physical and financial impacts, and other relevant topics, associated with managing cancer; to promote health by providing individuals living with and survivors of cancer, and their caregivers, with access to related counselling, information, or support group programs; to advance education by organizing and participating in conferences and speaking engagements to the public on topics related to cancer; to advance education by conducting research on cancer patients’ and survivors’ physical, emotional, and financial well-being and disseminating the results of the research to the public; to undertake activities ancillary and incidental to the attainment of the above charitable purposes.

AML Resources

The Leukemia & Lymphoma Society of Canada

The mission of LLSC is to cure leukemia, lymphoma, Hodgkin's disease and myeloma, and improve the quality of life of patients and their families. Their strategy to achieve the mission is based on three areas of focus: research, patient support and advocacy.

The Canadian Cancer Survivor Network

MM Resources

Myeloma Canada

Myeloma Canada is a non-profit, charitable organization created by, and for people impacted by multiple myeloma, a relatively unknown cancer of the plasma cells. Exclusively devoted to the Canadian myeloma community, Myeloma Canada has been making myeloma matter since 2005. Their mission is to improve the lives of Canadians impacted by myeloma by accelerating access to better care through awareness, education, advocacy, community engagement and clinical research.

The Canadian Cancer Survivor Network

OncoQuébec

OncoQuébec is a Web application developed by Q-CROC that allows users to search for oncology clinical trials by filters or keywords. It provides the most complete and up-to-date information on clinical trials that are recruiting and conducted by different sponsors across Quebec hospitals.

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