What is leukemia?

Leukemia is cancer of the blood cells. It starts in the bone marrow, the soft tissue inside most
bones. Bone marrow is where blood cells are made.
When you are healthy, your bone marrow makes:
White blood cells, which help your body fight infection.
Red blood cells, which carry oxygen to all parts of your body.
Platelets, which help your blood clot.
When you have leukemia, the bone marrow starts to make a lot of abnormal white blood cells,
called leukemia cells. They don't do the work of normal white blood cells, they grow faster
than normal cells, and they don't stop growing when they should.
Over time, leukemia cells can crowd out the normal blood cells. This can lead to serious
problems such as anemia, bleeding, and infections. Leukemia cells can also spread to the
lymph nodes or other organs and cause swelling or pain.
Are there different types of leukemia?
There are several different types of leukemia. In general, leukemia is grouped by how fast it
gets worse and what kind of white blood cell it affects.
It may be acute or chronic. Acute leukemia gets worse very fast and may make you feel
sick right away. Chronic leukemia gets worse slowly and may not cause symptoms for
years.
It may be lymphocytic or myelogenous. Lymphocytic (or lymphoblastic) leukemia affects
white blood cells called lymphocytes. Myelogenous leukemia affects white blood cells
called myelocytes.
The four main types of leukemia are:
Acute lymphoblastic leukemia, or ALL.
Acute myelogenous leukemia, or AML.
Chronic lymphocytic leukemia, or CLL.
Chronic myelogenous leukemia, or CML.
In adults, chronic lymphocytic leukemia (CLL) and acute myelogenous leukemia (AML) are
the most common leukemias. In children, the most common leukemia is acute lymphoblastic
leukemia (ALL). Childhood leukemias also include acute myelogenous leukemia (AML) and
other myeloid leukemias, such as chronic myelogenous leukemia (CML) and juvenile
myelomonocytic leukemia (JMML).
There are less common leukemias, such as hairy cell leukemia. There are also subtypes of
leukemia, such as acute promyelocytic leukemia (a subtype of AML).
What causes leukemia?
Experts don't know what causes leukemia. But some things are known to increase the risk of
some kinds of leukemia. These things are called risk factors. You are more likely to get
leukemia if you:
Were exposed to large amounts of radiation.
Were exposed to certain chemicals at work, such as benzene.
Had some types of chemotherapy to treat another cancer.
Have Down syndrome or some other genetic problems.
Smoke.
But most people who have these risk factors don't get leukemia. And most people who get
leukemia do not have any known risk factors.
What are the symptoms?
Symptoms may depend on what type of leukemia you have, but common symptoms include:
Fever and night sweats.
Headaches.
Bruising or bleeding easily.
Bone or joint pain.
A swollen or painful belly from an enlarged spleen.
Swollen lymph nodes in the armpit, neck, or groin.
Getting a lot of infections.
Feeling very tired or weak.
Losing weight and not feeling hungry.


To find out if you have leukemia, a doctor will:
Ask questions about your past health and symptoms.
Do a physical exam. The doctor will look for swollen lymph nodes and check to see if your
spleen or liver is enlarged.
Order blood tests. Leukemia causes a high level of white blood cells and low levels of other
types of blood cells.
If your blood tests are not normal, the doctor may want to do a bone marrow biopsy. This test
lets the doctor look at cells from inside your bone. This can give key information about what
type of leukemia it is so you can get the right treatment.
How is it treated?
What type of treatment you need will depend on many things, including what kind of leukemia
you have, how far along it is, and your age and overall health.
If you have acute leukemia, you will need quick treatment to stop the rapid growth of
leukemia cells. In many cases, treatment makes acute leukemia go into remission.
Some doctors prefer the term "remission" to "cure," because there is a chance the
cancer could come back.
Chronic leukemia can rarely be cured, but treatment can help control the disease. If you
have chronic lymphocytic leukemia, you may not need to be treated until you have
symptoms. But chronic myelogenous leukemia will probably be treated right away.
Treatments for leukemia include:
Chemotherapy, which uses powerful medicines to kill cancer cells. This is the main
treatment for most types of leukemia.
Radiation treatments. Radiation therapy uses high-dose X-rays to destroy cancer cells and
shrink swollen lymph nodes or an enlarged spleen. It may also be used before a stem
cell transplant.
Stem cell transplant. Stem cells can rebuild your supply of normal blood cells and boost
your immune system. Before the transplant, radiation or chemotherapy may be given to
destroy cells in the bone marrow and make room for the new stem cells. Or it may be
given to weaken your immune system so the new stem cells can get established.
Biological therapy. This is the use of special medicines that improve your body's natural
defenses against cancer.
For some people, clinical trials are a treatment option. Clinical trials are research projects to
test new medicines and other treatments. Often people with leukemia take part in these
studies.
Some treatments for leukemia can cause side effects. Your doctor can tell you what problems
are common and help you find ways to manage them.
Finding out that you or your child has leukemia can be a terrible shock. It may help to:
Learn all you can about the type of leukemia you have and its treatment. This will help you
make the best choices and know what to expect.
Stay as strong and well as possible. A healthy diet, plenty of rest, and regular exercise can
help.
Talk to other people or families who have faced this disease. Ask your doctor about support
groups in your area. You can also go on the Internet and find stories of people who have
leukemia.


Leukemia - Cause

Experts do not yet know what causes leukemia.
A risk factor is anything that raises your chance of getting a disease. Risk factors for some
types of leukemia include:

Smoking and tobacco use.
Being exposed to large amounts of radiation.
Being exposed to certain chemicals in the workplace.
Past chemotherapy or radiation for another cancer. (This is rare, and not all chemotherapies
raise your leukemia risk.)
Most people who get leukemia do not have any risk factors.
Most types of leukemia do not seem to run in families. But in some cases chronic lymphocytic
leukemia (CLL) does. There are also certain genetic conditions, like Down syndrome, that can
make acute myelogenous leukemia (AML) more likely.

Leukemia - Symptoms

Symptoms of leukemia depend on how much the cancer has grown and may include:
Fevers and night sweats.
Frequent or unusual infections.
Weakness and fatigue.
Headaches.
Bruising of the skin and bleeding from the gums or rectum.
Bone pain.
Joint pain.
Swelling in the belly or pain on the left side of the belly or in the left shoulder from a swollen
spleen.
Swollen lymph nodes in the armpit, neck, or groin.
Decreased appetite and weight loss because you feel full and don't want to eat.
The chronic forms of leukemia often cause no symptoms until much later in the disease.

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Leukemia - What Happens

Stem cells are made in the bone marrow. Stem cells become:
White blood cells that help your body fight infection.
Red blood cells that make sure all your body parts have the oxygen they need.
Platelets that keep you from bleeding too much.
In most cases of leukemia, there are too many abnormal white blood cells. These leukemia
cells crowd out the normal blood cells in your bone marrow and build up in your lymph nodes,
liver, and spleen. This makes it hard for your body to fight infections.

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When the leukemia cells crowd out your normal cells, your blood cannot do its job. You may
bleed or bruise easily, have more infections, and feel very tired.
Survival rates are different for each kind of leukemia. A 5-year survival rate is the percentage
of people who are still alive 5 years or more after being diagnosed. These numbers do not
necessarily show what will happen in your case. The following are estimated 5-year survival
rates:1
For acute lymphoblastic leukemia (ALL), 66% in adults and 89% in children
For acute myelogenous leukemia (AML), 23%
For chronic lymphocytic leukemia (CLL), 79%
For chronic myelogenous leukemia (CML), 53%
These numbers come from reports that were done at least 5 years ago, before newer
treatments were available. So chances of survival today are likely to be higher than these
numbers.

Leukemia - What Increases Your Risk

A risk factor is anything that makes you more likely to get a disease. Most people who have
leukemia do not have any known risk factors. But things that increase your risk of having
leukemia include:
Smoking or using other tobacco products. This risk factor is linked to some cases of acute
myelogenous leukemia (AML).2
Exposure to high levels of radiation. People who were close to atomic bomb explosions in
Japan during World War II and people who were close to the 1986 nuclear plant
accident in Chernobyl have higher rates of some kinds of leukemia.
Exposure to chemicals, such as benzene and formaldehyde. Sometimes people are
exposed to these chemicals where they work.
Chemotherapy or radiation used to treat a previous cancer.
Conditions caused by abnormal chromosomes, such as Down syndrome.
Infection with a type of HIV known as HTLV-1.
Other blood diseases, such as myelodysplastic syndromes.
Your family history. In some cases, chronic lymphocytic leukemia (CLL) runs in families.

Leukemia - When To Call a Doctor

Call your doctor to schedule an appointment if you have any symptoms, such as:
A new lump or swollen gland in your neck, under your arm, or in your groin.
Frequent nosebleeds, bleeding from the gums or rectum, more frequent bruising, or very
heavy menstrual bleeding.
Frequent fevers.
Night sweats.
Unexplained appetite loss or recent weight loss.
Feeling tired a lot without a known reason.
Swelling and pain on the left side of the belly.

Watchful Waiting
Watchful waiting is a period when your doctor is checking you regularly but not treating
you. It is also called observation or surveillance. It means that you and your doctor will
watch to see if you develop symptoms. It may be a treatment choice if you are an older
adult, depending on the stage of the leukemia and your overall health.

Watchful waiting may give as good or better results than more aggressive treatment for early
stage chronic lymphocytic leukemia (CLL). It is estimated that 1 out of 3 people who have
CLL never need treatment.3 People who have chronic lymphocytic leukemia often live for a
long time without treatment. Watchful waiting is not usually recommended for other types of
leukemia.
During watchful waiting, you will:
Have regular appointments with your doctor.
Have regular medical tests, including scans and blood tests.
Be told which symptoms to report to your doctor immediately.
Who To See
Health professionals who can evaluate symptoms of leukemia include the following:
Family medicine physician
Internist
Pediatrician
Nurse practitioner
Physician assistant
The diagnosis of leukemia will be done by a medical oncologist or hematologist. These
specialists also treat leukemia.


Leukemia - Exams and Tests

If your doctor suspects leukemia, he or she will ask about your medical history. Your doctor
also will check for enlarged lymph nodes in your neck, underarm, or groin. He or she will
also examine you to see if your liver or spleen is enlarged.
Your doctor will order blood tests, such as a complete blood count (CBC) and a blood profile.
These provide important information about the cells in your blood. They are used to look into
symptoms such as fatigue, weakness, fever, bruising, or weight loss.
If your blood work points to possible leukemia, your doctor will want to find out what kind you
might have. Your treatment plan will depend on the specific kind of leukemia that you have.
A blood test is usually enough to find signs of chronic lymphocytic leukemia (CLL).
A bone marrow aspiration and biopsy is the key to diagnosing most leukemias.
Tests that look closely at unusual cells, chromosomes, or proteins on cells can show what
type or subtype of leukemia you have. These tests can help guide treatment. Sometimes they
can help your doctor and you know whether your leukemia is likely to go into remission or
come back. In some cases, the tests can predict survival rates.
These tests include:
A test that looks for certain changes in the cell chromosomes from a sample of blood or
bone marrow (cytogenetic analysis).
A test that compares cancer cells to normal blood cells to find the specific kind of leukemia
(immunophenotyping).
A test to look for genes that are "turned on" in several subtypes of leukemia, such as acute
promyelocytic leukemia. This test is called a reverse transcription-polymerase chain
reaction test, or RT-PCR.
Your doctor may also order other tests, including:
Chest X-rays, to find out if leukemia or an infection is the cause of lung problems such as
persistent coughing, coughing up blood, chest pain, or difficulty breathing.
CT scan of the head, chest, and belly, to find out whether leukemia has spread there.
Lumbar puncture, to find out whether leukemia cells are in your cerebrospinal fluid (CSF).
MRI of the brain, to look into symptoms such as confusion, paralysis, numbness, vision
problems, vertigo, or headaches. Those symptoms could mean the leukemia has
spread to the brain.
Also, a biopsy of a lymph node or other tissues may be done to look for cancer cells.

Leukemia - Treatment Overview

The goal of treatment for leukemia is to destroy the leukemia cells and allow normal cells to
form in your bone marrow. Treatment decisions are based on the kind of leukemia you have,
its stage, and your age and general health.
Treatment for acute leukemia
Chemotherapy is the use of drugs to fight cancer. It is the usual treatment for acute
leukemia. For most people, that means receiving drugs in stages:

The goal of induction is to kill leukemia cells in the blood and bone marrow to induce
remission. During remission, there are no signs or symptoms of leukemia.
The goal of consolidation is to kill any leukemia cells that may be present even though
they don't show up in tests. If these cells regrow, they could cause a relapse.
The goal of maintenance also is to prevent any remaining leukemia cells from growing.
This may be done using lower doses of chemotherapy than those used during induction
or consolidation. This is only used in people with ALL and a few rare forms of AML.
Some types of acute leukemia spread to the brain and spinal cord. Regular chemotherapy
cannot reach those areas, because your body puts up a special barrier to protect them. A
different way of giving chemotherapy, called intrathecal chemotherapy, treats these areas
by injecting the drugs directly into your spinal canal to attack any leukemia cells there.
Radiation therapy uses high doses of radiation, such as X-rays, to destroy cancer cells.
Radiation is usually given from a machine outside the body that directs radiation to the cancer
(external radiation). Radiation is also used to treat acute leukemia that has spread to the brain
and spinal cord.
Stem cell transplant may be part of the treatment plan for people who have high-risk acute
leukemia. Most stem cell transplants for leukemia are allogeneic, meaning the stem cells are
donated by someone else. The goal of a transplant is to destroy all the cells in your bone
marrow, including the leukemia cells, and replace them with new, normal cells.
Treatment if acute leukemia gets worse
Sometimes leukemia gets worse in spite of treatments. Sometimes it gets better, or "goes into
remission." Sometimes it comes back, or "relapses." Even when that happens, there are
several treatments that may help to cure the leukemia or help you live longer:
Stem cell transplant. Donated cells from a "matched" donor can rebuild your supply of
normal blood cells and your immune system.
Chemotherapy. Sometimes medicines or doses that are different from those used during
your initial chemotherapy can help.
Clinical trials. People who have leukemia may enter a research program when they first start
treatment or if the leukemia is not getting better. These programs test new ways to treat the
disease. For more information, see www.cancer.gov/clinical_trials/ or http://clinicaltrials.gov.

Treatment of chronic leukemia
Chronic lymphocytic leukemia (CLL)
Chronic lymphocytic leukemia is not always treated right away. It usually gets worse more
slowly than acute leukemia.
Treatment choices for CLL include:
Watchful waiting. CLL usually gets worse very slowly, and you may have no symptoms for
some time. You and your doctor may decide to hold off on treatment for a while. During
this time your doctor will watch you carefully.
Radiation therapy. Radiation may be used to destroy cancer cells. It also may be used to
shrink swollen lymph nodes or a swollen spleen. Sometimes radiation is used on the
whole body to prepare for a bone marrow transplant.
Chemotherapy. Chemotherapy is the use of medicines that attack cancer cells. Many
medicines are available to fight leukemia and help you live longer.
Surgery. If the spleen starts destroying red blood cells and platelets, it may need to be
removed. This operation is called a splenectomy.
Targeted therapy with a monoclonal antibody. These antibodies can kill cancer cells, stop
their growth, or keep them from spreading.
When you have CLL, your body is not able to fight infections very well. You and your doctor
need to watch for any signs of infections, such as pneumonia or yeast infections. Early
treatment of these and other infections will help you live longer. You can sometimes prevent
certain infections or keep from getting very sick by getting a flu shot or a pneumonia vaccine.
Your doctor also may give you antibiotics to prevent infection while you are being treated for
leukemia.

Chronic myelogenous leukemia (CML)
Chronic myelogenous leukemia is treated right away.
Treatment choices for CML include:
Targeted therapy with a tyrosine kinase inhibitor, such as imatinib or dasatinib, is the first
treatment used for CML.
Chemotherapy. Chemotherapy is the use of medicines that attack cancer cells. Many
medicines are available to fight leukemia and help you live longer.
Biological therapy. This is the use of special medicines that improve your body's natural
defenses against cancer.
High-dose chemotherapy with stem cell transplant. After chemotherapy is completed, stem
cells that were previously donated and frozen are thawed and infused.
Donor lymphocyte infusion (DLI). This is a treatment that may be used after a stem cell
transplant. With DLI, a person is given more of their donor's white blood cells
(lymphocytes).
Surgery. If the spleen starts destroying red blood cells and platelets, it may need to be
removed. This operation is called a splenectomy.

Leukemia - Medications

Chemotherapy is the standard treatment for many types of leukemia. Even when a cure is not
possible, chemotherapy may help you live longer and feel better.
Chemotherapy for leukemia is usually a combination of drugs. This is because different drugs
attack leukemia cells in different ways. The combination also helps keep the leukemia cells
from becoming resistant to any one drug. Other drugs used to treat leukemia help prevent
infection and help your body grow new blood cells (such as epoetin and hematopoietic
stimulants).
Nausea and vomiting are the most common side effects of chemotherapy for leukemia. But
having chemotherapy does not mean that you have to suffer with nausea and vomiting. Your
doctor may prescribe medicines to control nausea and vomiting.

Medication Choices
Acute leukemia
Your treatment plan will include the kind of medicine that works best for the specific type or
subtype of leukemia that you have.
Acute lymphoblastic leukemia (ALL) medicines may include prednisone, methotrexate, l-
asparaginase, vincristine, and doxorubicin or daunorubicin.
Acute myelogenous leukemia (AML) medicines may include daunorubicin with cytarabine.
Idarubicin or mitoxantrone may be used instead of daunorubicin.
Acute promyelocytic leukemia (APL) medicines may include all-trans-retinoic acid (ATRA)
and chemotherapy with arsenic trioxide, idarubicin, or daunorubicin. ATRA also helps
control the risk of life-threatening bleeding from disseminated intravascular coagulation
(DIC).
Chronic leukemia
Medicines used for treatments for chronic lymphocytic leukemia (CLL) are taken orally (by
mouth) or given intravenously for limited periods of time. If there is relapse, medicines are
given again. For chronic myelogenous leukemia (CML), medicine is usually taken by mouth
for as long as needed. Treatment choices may include:
Chemotherapy for chronic lymphocytic leukemia (CLL). This may be a single medicine or a
combination of medicines. For example, you may be given a combination of
cyclophosphamide, vincristine, and prednisone. Other choices may include fludarabine
and chlorambucil, or the monoclonal antibodies rituximab and alemtuzumab.
Tyrosine kinase inhibitors for chronic myelogenous leukemia (CML). These medicines include
imatinib, dasatinib, or nilotinib. People with CML who cannot have stem cell transplants and
are unable to take tyrosine kinase inhibitors may be given interferon alfa (with or without
cytarabine), hydroxyurea, or busulfan.

Medicine for nausea and vomiting
Nausea and vomiting are common side effects of chemotherapy. These side effects usually
are temporary and go away when treatment is stopped. Your doctor will prescribe medicines
to help relieve nausea. These medicines include aprepitant, dimenhydrinate, phenothiazines,
or serotonin antagonists.
What To Think About
There are a lot of clinical trials of new medicines for leukemia. These trials have made it
possible for many people with leukemia to live longer. Ask your doctor whether you are a
candidate for participation in a clinical trial

Leukemia - Surgery

In rare cases of chronic lymphocytic leukemia (CLL), the spleen needs to be removed. This
happens when the spleen is destroying red blood cells and platelets. The operation is called a
splenectomy.
Often a swollen lymph node will be removed to confirm the diagnosis of leukemia. This
operation is called a lymphadenectomy.

Surgery is sometimes needed to place a central venous catheter into a large vein in the chest.
The catheter is a small tube that is used to give you chemotherapy and other drugs. The tube
can also be used to take samples of blood or for giving blood transfusions when needed. It
prevents the need for many needle sticks during treatment.

Leukemia - Other Treatment

The following other treatments may be used to treat leukemia:
Radiation therapy to destroy cancer cells and shrink tumors. Radiation can be applied to
one area or to the whole body. Sometimes it is used to treat leukemia that has spread
to the brain and central nervous system or to prevent this spread. It also may be used
to shrink swollen lymph nodes or to prepare your body for a bone marrow transplant.
Stem cell transplant. Transplants usually come from bone marrow or from blood. Some
transplants are autologous, meaning the stem cells come from your own body. Some
transplants are allogeneic, meaning the stem cells are donated by someone else. The
goal of a transplant is to destroy all the cells in your bone marrow, including the
leukemia cells, and replace them with new, normal cells.
Clinical trials. Clinical trials investigate new ways to treat leukemia. Many leukemia patients
are referred to clinical trials, and many trials have helped people to live longer. Ask your
doctor whether you are a candidate for a trial. He or she may be able to answer your
questions about a certain clinical trial and help you decide if it is right for you. For more
information, see www.cancer.gov/clinical_trials/ or http://clinicaltrials.gov.
People sometimes use complementary therapies along with medical treatment to help relieve
symptoms and side effects of cancer treatments. Some of the complementary therapies that
may be helpful include:

Acupuncture to relieve pain.
Meditation or yoga to relieve stress.
Massage and biofeedback to reduce pain and ease tension.
Breathing exercises for relaxation.
Mind-body treatments like the ones listed above may help you feel better. They can make it
easier to cope with cancer treatments. They also may reduce chronic low back pain, joint
pain, headaches, and pain from treatments.
Before you try a complementary therapy, it is very important to talk to your doctor about the
possible value and potential side effects. Let your doctor know if you are already using any
such therapies. Complementary therapies are not meant to take the place of standard
medical treatment, but they may improve your quality of life and help you deal with the stress
and side effects of cancer treatment.
What to think about
Many cancer patients looking for a cure are willing to try alternative treatments. Check with
your doctor before using any special diets, over-the-counter drugs, herbal products, or
unusual treatment methods that you may hear about. Some of them can make your side
effects worse or reduce the benefits of chemotherapy.