Risk Factors

Several factors influence the risk of developing leukemia:

• Radiation: People exposed to very high levels of radiation are much more likely than others to get acute myeloid leukemia, chronic myeloid leukemia, or acute lymphocytic leukemia.
• Smoking: Smoking cigarettes increases the risk of acute myeloid leukemia.
• Benzene: Benzene is used widely in the chemical industry. It's also found in cigarette smoke and gasoline. Exposure to benzene in the workplace can cause acute myeloid leukemia. It may also cause chronic myeloid leukemia or acute lymphocytic leukemia.
• Chemotherapy: Cancer patients treated with certain types of cancer-fighting drugs sometimes get acute myeloid leukemia or acute lymphocytic leukemia later in life. For example, being treated with drugs known as alkylating agents or topoisomerase inhibitors is linked with a small chance of later developing acute leukemia.
• Myelodysplastic syndrome and certain other blood disorders: People with certain blood disorders in which the bone marrow does not make enough healthy blood cells are at increased risk of acute myeloid leukemia.
• Human T-cell leukemia virus type I (HTLV-I): People with HTLV-I infection, avirus that infects T cells (a type of white blood cell), are at increased risk of a rare type of leukemia known as adult T-cell leukemia. Although the HTLV-I virus may cause this rare disease, adult T-cell leukemia and other types of leukemia are not contagious.

Symptoms

People with chronic leukemia may not have symptoms. The doctor may find the disease during a routine blood test. People with acute leukemia usually go to their doctor because they feel sick.

Some common symptoms of chronic or acute leukemia include the following:

• Swollen lymph nodes that usually don't hurt (especially lymph nodes in the neck or armpit)
• Fevers or night sweats
• Frequent infections
• Feeling weak or tired
• Bleeding and bruising easily (bleeding gums, purplish patches in the skin, or tiny red spots under the skin)
• Swelling or discomfort in the abdomen (caused by a swollen spleen or liver)
• Weight loss for no known reason
• Pain in the bones or joints

Other health problems may also cause these symptoms. A person with any of these symptoms should see a health care provider so the problem can be diagnosed and treated as early as possible.

Screening and Diagnosis

Doctors sometimes find leukemia after a routine blood test. If symptoms suggest leukemia, the doctor will ask for personal and family medical history. The doctor may order one or more of the following tests:

• Physical exam: Doctors check for swollen lymph nodes, spleen, or liver.
• Blood tests: Doctors check for specific substances in the blood that indicate cancer is present.
• Cytogenetics: Doctors look at the chromosomes of cells from samples of blood, bone marrow, or lymph nodes. If abnormal chromosomes are found, the test can help determine the type of leukemia.
• Lumbar puncture (spinal tap): Doctors may remove a sample of cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). A laboratory checks the fluid for cancer cells.
• X-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Biopsy: The doctor removes tissue to look for cancer cells. A biopsy is the only sure way to know whether leukemia cells are in the bone marrow. There are two ways a doctor can obtain bone marrow. Some people will have both procedures during the same visit:
  • Bone marrow aspiration: The doctor uses a thick, hollow needle to remove samples of bone marrow.
  • Bone marrow biopsy: The doctor uses a very thick, hollow needle to remove a small piece of bone and bone marrow.

Staging

If the biopsy shows leukemia cells, it is important to know the stage (extent) of the disease to plan the best treatment. Staging may involve having more tests.

• Tests Used to Stage Chronic Lymphocytic Leukemia (CLL)
  • Stages of CLL
• Tests Used to Stage Chronic Myeloid Leukemia (CML)
  • Phases of CML
• Tests Used to Stage Acute Leukemias
  • Stages of Acute Lymphocytic Leukemia
  • Stages of Acute Myeloid Leukemia

Tests Used to Stage Chronic Lymphocytic Leukemia (CLL)

• Bone marrow aspiration and biopsy: This is the removal of bone marrow, blood, and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist then views these tissue samples under a microscope to look for abnormal cells.
• X-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body, such as the lymph nodes.
• Magnetic resonance imaging (MRI): This procedure uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body.
• CT scan: Doctors often use CT scans to take pictures of tissue inside the body. An x-ray machine linked to a computer takes several pictures. The pictures may show whether cancer has spread to lymph nodes or other areas in the body.
• Blood chemistry studies: Doctors take a blood sample to measure the amounts of certain substances in the blood. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in a specific organ or tissue.
• Antiglobulin test: Doctors take a sample of blood to find out if there are any antibodies on the surface of red blood cells or platelets. These antibodies may react with and destroy the red blood cells and platelets.

Stages of Chronic Lymphocytic Leukemia (CLL)

Stage 0: There are too many lymphocytes in the blood, but there are no other symptoms of leukemia. Stage 0 chronic lymphocytic leukemia is indolent (slow-growing).

Stage I: There are too many lymphocytes in the blood and the lymph nodes are larger than normal.

Stage II: There are too many lymphocytes in the blood, the liver or spleen is larger than normal, and the lymph nodes may be larger than normal.

Stage III: There are too many lymphocytes in the blood and there are too few red blood cells. The lymph nodes, liver, or spleen may be larger than normal.

Stage IV: There are too many lymphocytes in the blood and too few platelets. The lymph nodes, liver, or spleen may be larger than normal and there may be too few red blood cells.

Refractory CLL: Refractory CLL is cancer that does not get better with treatment.

Tests Used to Stage Chronic Myeloid Leukemia (CML)

• Cytogenetic analysis: For this test, cells in a sample of blood or bone marrow are viewed under a microscope to look for certain changes in the chromosomes such as the Philadelphia chromosome.
• Bone marrow aspiration and biopsy: This is the removal of bone marrow, blood, and a small piece of bone by inserting a needle into the hipbone or breastbone. A pathologist views the bone marrow, blood, and bone under a microscope to look for abnormal cells.

Phases of Chronic Myeloid Leukemia (CML)

There is no standard staging system for CML. Instead the disease is classified by phase.The number of blast cells in the blood and bone marrow and the severity of symptoms ?determine the phase of the disease.

Chronic phase: In chronic phase CML, fewer than 10% of the cells in the blood and bone marrow are blast cells.

Accelerated phase: In accelerated phase CML, 10% to 19% of the cells in the blood and bone marrow are blast cells.

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

Relapsed CML: In relapsed CML, the amount of blast cells increases after a remission.

Tests Used to Stage Acute Leukemias

• X-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Lumbar puncture (spinal tap): Doctors may remove a sample of cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). A laboratory checks the fluid for leukemia cells.
• Ultrasound: This procedure uses high-energy sound waves bounced off internal tissues or organs to make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
• CT scan: Doctors often use CT scans to take pictures of tissue inside the body. An x-ray machine linked to a computer takes several pictures. The pictures may show whether cancer has spread to lymph nodes or other areas in the body.

Stages of Acute Lymphocytic Leukemia (ALL)

There is no standard staging system for ALL.The disease is classified as untreated, in remission, or recurrent.

Untreated ALL: The ALL is newly diagnosed and has not been treated except to relieve symptoms such as fever, bleeding, or pain.

• The complete blood count is abnormal.
• More than 5% of the cells in the bone marrow are blasts (leukemia cells).
• There are signs and symptoms of leukemia.

ALL in remission: The ALL has been treated.

• The complete blood count is normal.
• Only 5% or fewer of the cells in the bone marrow are blasts (leukemia cells).
• There are no signs or symptoms of leukemia in the brain and spinal cord or elsewhere in the body.

Recurrent acute lymphoblastic leukemia (ALL): This is cancer that has recurred (come back) after going into remission. Leukemia cells may come back in the blood, bone marrow, or other parts of the body.

Stages of Acute Myeloid Leukemia (AML)

There is no standard staging system for AML. The disease is described as untreated, in remission, or recurrent.

Untreated AML: In untreated AML, the disease is newly diagnosed. It has not been treated except to relieve symptoms such as fever, bleeding, or pain, and the following are true:

• The complete blood count is abnormal.
• At least 20% of the cells in the bone marrow are blasts (leukemia cells).
• There are signs or symptoms of leukemia.

AML in remission: AML in remission occurs when the disease has been treated and the following are true:

• The complete blood count is normal.
• Less than 5% of the cells in the bone marrow are blasts (leukemia cells).
• There are no signs or symptoms of leukemia in the brain and spinal cord or elsewhere in the body.

Recurrent AML: This is cancer that has recurred (come back) after it has been treated. Leukemia cells may come back in the blood or bone marrow.

Treatment

At Huntsman Cancer Institute (HCI) leukemia is treated by a team of specialists, including hematologic oncologists (doctors who specialize in cancers of the blood), medical oncologists, nurses, dietitians, social workers, and other professionals.

People with leukemia have many treatment options:

• Watchful waiting
• Chemotherapy
• Targeted therapy
• Biological therapy
• Radiation therapy
• Bone marrow/Blood stem cell transplant
• Clinical trials

If the spleen is enlarged, the doctor may suggest surgery to remove it.

A patient may receive more than one type of treatment. The treatment that's right for each patient depends on many factors:

• The type of leukemia (acute or chronic)
• The patient's age
• Whether leukemia cells were found in the cerebrospinal fluid
• Certain features of the leukemia cells
• The patient's symptoms and general health.

People with acute leukemia need to be treated right away. The goal of treatment is to destroy cancer cells until there are no signs and symptoms of leukemia in the body (called remission). After people go into remission, more therapy may be given to prevent cancer from coming back (called a relapse or recurrence). This type of therapy is called consolidation therapy or maintenance therapy.

Watchful waiting

People who choose watchful waiting put off having cancer treatment until they have symptoms. Doctors sometimes suggest watchful waiting for people with chronic leukemia. People with chronic leukemia may not require cancer treatment for a long time. By putting off treatment, they can avoid the side effects of chemotherapy or radiation therapy.

If this option is used, the doctor will check the patient regularly, about every three months. The patient will receive treatment if symptoms occur or get worse.

Chemotherapy

Many people with leukemia are treated with chemotherapy. Chemotherapy uses drugs to destroy leukemia cells. Depending on the type of leukemia, the person may receive a single drug or a combination of two or more drugs. Learn more about this treatment in our introduction to chemotherapy video.

Targeted therapy

People with chronic myeloid leukemia and some with acute lymphoblastic leukemia may receive drugs called targeted therapy. Targeted therapies use drugs that block the growth of leukemia cells. For example, a targeted therapy may block the action of an abnormal protein that stimulates the growth of leukemia cells.

Biological therapy

Some people with leukemia receive drugs called biological therapy. Biological therapy for leukemia is treatment that improves the body's natural defenses against the disease.

One type of biological therapy is called a monoclonal antibody. One kind of monoclonal antibody carries a toxin that kills the leukemia cells. Another kind helps the immune system destroy leukemia cells.

For some people with chronic myeloid leukemia, the biological therapy is a drug called interferon. It is injected under the skin or into a muscle and can slow the growth of leukemia cells.

Radiation therapy

Radiation therapy uses high-energy rays to kill leukemia cells. People receive radiation therapy at a hospital or clinic.

Some people receive radiation from a large machine aimed at the spleen, the brain, or other parts of the body where leukemia cells have collected.

Bone marrow/Blood stem cell transplant

Some people with leukemia receive a bone marrow/blood stem cell transplant. A transplant allows the patient to be treated with high doses of drugs, radiation, or both. The high doses destroy both leukemia cells and normal blood cells in the bone marrow. After receiving high-dose chemotherapy, radiation therapy, or both, the patient receives healthy stem cells through a large vein. New blood cells develop from the transplanted stem cells. The new blood cells replace the ones that were destroyed by treatment.

Stem cell transplants take place in the hospital. Stem cells may come from the person's own body or from someone who donates their stem cells:

• Autologous stem cell transplant: This type of transplant uses a patient's own stem cells. Before getting high-dose chemotherapy or radiation therapy, a person's stem cells are removed. The cells may be treated to kill any leukemia cells present. The stem cells are frozen and stored. After receiving high-dose chemotherapy or radiation therapy, the stored stem cells are thawed and returned to the patient.
• Allogeneic stem cell transplant: This type of transplant uses healthy stem cells from a donor. A patient's brother, sister, or parent may be the donor. Sometimes the stem cells come from a donor who isn't related. Doctors use blood tests to learn how closely a donor's cells match the patient's cells.
• Syngeneic stem cell transplant: If the patient has an identical twin, this type of transplant uses stem cells from the healthy twin.

Learn more in our video about HCI's Blood and Marrow Transplant program.

Clinical trials

These studies discover and evaluate new and improved cancer treatments. Patients are encouraged to talk with their doctors about participating in a clinical trial or to ask any questions regarding research studies. For more information, also visit HCI's clinical trials website.

Support

When you or someone you love is diagnosed with cancer, concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, employment, or how to continue normal daily activities.

Here's where you can go for support:

• Your health care team can answer your questions and talk to you about your concerns. They can help you with any side effects and keep you informed of all your treatments, test results, and future doctor visits.
• The Cancer Learning Center has hundreds of free brochures and more than 3,000 books, DVDs, and CDs available for checkout. You can browse the library, perform Internet research, or talk with a cancer information specialist. Call 801-581-6365 or toll free 1-888-424-2100, or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
• Our Patient and Family Support Services professionals offer HCI patients and their families emotional support and resources for coping with cancer and its impact on daily life.
• The Linda B. and Robert B. Wiggins Wellness-Survivorship Center offers support groups, classes, and activities aimed to increase the quality of life and well-being of HCI patients and their families.