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– We demand drugs that the Czechs, Slovaks, Hungarians and even Romanians have. In Poland, we die by 20 percent more than the sick in other European countries! – say patients with lymphocytic leukemia. They just filed a petition with the health ministry. Every hour someone in Poland learns that he has leukemia, every third person that chronic lymphocytic. We talk about modern treatment with Lt. Col. Krzysztof Gawroński, MD, a specialist in internal diseases, clinical transplantology and hematology from the Department of Internal Diseases and Hematology at the Military Medical Institute.
Edyta Kolasińska – Bazan, Medonet: Are there any risk factors in leukemia, as in the case of other cancers?
Lt. Col. Krzysztof Gawroński, MD, PhD: In the case of leukemia, we still don’t know the answer. Examples include ionizing radiation, the environment, and some viruses. It is also known that undergoing chemotherapy for another cancer may result in the development of the so-called secondary myelodysplastic syndrome and consequently secondary acute leukemia. However, it should be noted that “maybe”, but does not have to be – I strongly emphasize that no one who has undergone any chemotherapy should be afraid that he is in danger of a second cancer.
And smoking? There are about 40 carcinogens in the smoke.
There are nicotine-dependent and nicotin-dependent neoplasms. Leukemias are among the latter. However, I advise against smoking and inhaling smoke due to the risk of developing nicotine-related cancers. I don’t smoke either.
The name “leukemia” (leukemia) comes from the Greek language (“leukos” – white and “haima” – blood). What does “white blood” mean?
In a nutshell, leukemia is a group of malignant neoplasms of various course and symptoms, caused by pathological clonal growth of cells of the hematopoietic system of various degrees of maturity in the bone marrow and in the lymph nodes and haematopoietic organs (liver, spleen), and at a later stage also in other tissues. As a consequence of the disease, the quantity and quality of peripheral blood cells are disturbed. It should be noted that there are many types of leukemia. We divide them into acute and chronic. Acute – lymphoblastic (ALL) and myeloid (AML), and chronic – myeloid (CML) and lymphocytic (CLL).
At the recent conference “Hematology 2016 – the latest reports from the EHA conference” you said that chronic lymphocytic leukemia does not always need to be treated, because sometimes it is enough to observe it. How it’s possible?!
There is a group of chronic lymphocytic leukemias for which patient observation is sufficient, not immediate treatment implementation. This is the case with CLL, which primarily affects the elderly. The patient is monitored until the disease progresses. At the time of diagnosis, it happens that patients have a white blood cell (specifically lymphocyte) value of more than 10, 30 or 40, but unless we find some general symptoms, we do not implement treatment.
What are the symptoms?
Fever, weight loss and heavy night sweats.
Only these three?
These patients experience many symptoms (e.g. extreme fatigue, weakness, drowsiness, or on the contrary – trouble sleeping), but these three symptoms are the signal for physicians to start treatment.
But after all, fever, weight loss and night sweats can be symptoms of many ailments?
That’s right, like the flu, right? However, if we exclude an infection, a persistent fever (above 38,3 C) regularly for 2 weeks or profuse night sweats – occurring cyclically, most often between 2-4 am (so abundant that it forces you to change clothes) may be a signal of a chronic progressive phase lymphocytic leukemia.
And then treatment is started?
Yes. I would also like to add that we do not implement the treatment when, apart from the increased value of white blood cells, there is no anemia, thrombocytopenia and when we do not find enlargement of the spleen (it is best confirmed by ultrasound examination). It should be mentioned that the patient who goes to the hematologist at the beginning undergoes a series of screening tests, on the basis of which we determine the stage of the disease. In order to optimize the treatment strategy and its monitoring in CLL patients, a number of prognostic parameters are determined. The parameter decisive for the initiation of treatment is the clinical advancement of CLL assessed according to Rai or Binet classification.
What is this about?
The Rai classification has 5 stages: “zero” – when the disease is manifested by elevated leukocytes, “first” – when leukocytosis is elevated and lymph nodes are enlarged. In the “second” stage, the spleen enlarges. In the “third” and “fourth” stages, anemia and thrombocytopenia develop. Additionally, it should be mentioned that the disease may be accompanied by haemolysis (breakdown of red blood cells); if it is not observed (i.e. not present), we still do not implement treatment.
Anemia causes many diseases. What are the symptoms of CLL patients?
It is important to know that anemia is treated differently in each type of leukemia, but since we are talking about chronic lymphocytic leukemia, I will explain it in this context.
Pretty please.
In the initial stages of CLL, there is no anemia, and if there is, then either there must be another additional cause – another disease, or we are dealing with a deficiency of the factor responsible for normal haemopoiesis (hematopoiesis), or the hemolysis I mentioned is just present, e.g. in for women of childbearing age during menstruation.
So what worries the doctor?
That the patient had an elevated number of white blood cells (was diagnosed with CLL), but at one point he developed anemia that had not been there before. It can also happen so-called a neglected patient, i.e. a patient who has been ill for a long time, or has undiagnosed or does not see a doctor – such a patient may have anemia, thrombocytopenia, etc., and this is also disturbing. The attending physician must have extensive experience – awareness and knowledge of the biology of this disease. CLL is a chronic disease, most often slowly progressive, so if a doctor notices a slight enlargement of the lymph nodes in a patient, he will not be alarmed, but a sudden deep anemia or rapid enlargement of the lymph nodes will cause great anxiety.
When is treatment initiated for CLL?
We start treatment when the patient goes through a progressive phase – moving from a lower stage to a higher one. There are also so-called prognostic-adverse factors that indicate that the disease will proceed rapidly. One is a deletion on chromosome 17 (loss of one or more nucleotide pairs from the gene DNA). Then the patient is classified as a high-risk patient and is immediately included in the treatment, even though, for example, he does not have anemia, thrombocytopenia and enlarged nodes.
What is it about?
Until a few years ago, leukemias were treated only with chemotherapy. Currently, monotherapy is being avoided and many drugs with different mechanisms of action are used simultaneously – which prevents the cancer (leukemia) cell from becoming resistant, which is the point. Drugs that are antibodies to cancer cells have appeared. These are monoclonal antibodies (most often artificially synthesized or partially artificially) directed against the CD20 receptor on the cancer cell that grows in PBL. If chemotherapy is used (cytostatics inhibit the multiplication and development of cancer cells) and at the same time we use a monoclonal antibody, this method of treatment is called chemoimmunotherapy. But I would like to point out that we are talking about starting treatment only in the case of progressive disease. If PBL is not progressing rapidly, we watch it and that’s it. We read in every American, German or British journal addressed to a hematologist that close monitoring of the patient is recommended. CLL mainly affects older people, so starting treatment (chemotherapy or chemoimmunotherapy) could simply worsen the quality of life of these people, and the role of a doctor is not to worsen the quality of life.
Monoclonal antibodies are used in the treatment of CLL, but not all new drugs are available in Poland. Why?
It should be noted that new monoclonal antibodies are not always available as “old” and “new” monoclonal antibodies can be distinguished. “New” are expensive drugs, and Poland is definitely a poorer country than, for example, the United States, Great Britain or other Western European countries.
So those who are lucky enough to be watched are lucky. How do they react to the fact that although they have leukemia, they are not yet undergoing invasive treatment?
Differently. At the beginning, the patient most often accepts a diagnosis, such as a death sentence. However, the role of the doctor (not easy!) Is to explain to the patient that observation is the best method of treatment in his case (we are talking about CLL, of course). Sometimes it is necessary to invite the family for an interview. It is important to reassure the patient …
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It’s difficult, because it has a code that chronic lymphocytic leukemia is an incurable disease.
Because it is still an incurable disease, but it is not a death sentence! With good medical supervision, you can live with it for really long years (10, 20 years and more), and the cause of death (if we mention it at all) may not be blood disease at all.