If you have been diagnosed with a blood cancer you may be asked to take part in a clinical trial. Clinical trials are research studies that help determine whether a new treatment is safe, effective and works better than the current treatment. Each study is designed to answer specific questions and to find better ways to screen, diagnose, prevent, or treat a disease or condition.
Active monitoringÂ (watch & wait) consists of on-going monitoring of your condition. This is commonly used at times when the condition is detectable, but is not causing symptoms or side effects that warrant treatment. It is more commonly used in chronic conditions which require intermittent treatment with long periods between treatments.
Corticosteroids are hormones produced naturally by the body. They can also be made in the laboratory. These drugs play an important role in the management of blood conditions. Prednisone and dexamethasone are examples of corticosteroids commonly used in the treatment of blood conditions. These drugs work by directly killing cancer cells as well as enhancing the effects of chemotherapy.
Chemotherapy literally means therapy with chemicals. Many chemotherapy drugs are also called cytotoxics (cell toxic) because they kill cells, especially ones that multiply quickly like cancer cells. Chemotherapy is the main form of treatment given for cancer. The dose, timing and types of the drugs used will vary depending on the particular disease involved, age and general health, and the treatment protocol (plan of treatment) being followed.
Chemotherapy is usually given as a combination of drugs (combination chemotherapy). Each drug acts together to target the cancer in a different way, and also has different side effects. Therefore a combination may be more effective than a single drug in controlling your disease and the side effects are kept to a minimum. Chemotherapy is usually given in several cycles (or courses) with rest periods in between. This is to allow the body time to recover from the side effects.
Chemotherapy is given in many different ways in the treatment of blood cancers. Some drugs are given in tablet form (orally) or are injected into a vein (intravenously or IV) in the hand or arm. For some types of blood cancers, chemotherapy may also be given intrathecally (into the spinal fluid) to prevent or treat any CNS disease.
If you are having several cycles of chemotherapy your doctor may recommend that a central venous catheter (also called a central line) is inserted. A central venous catheter is a special line inserted through the skin, into a large vein in the arm, neck or chest. Once in place, chemotherapy and any other IV drugs can be given through the line and blood tests can usually be taken from the line, without the need for frequent needle pricks. There are several different kinds of central lines used; some are intended for short term use while others remain in place for months and even years. These lines require special care to prevent infection. If necessary, the nurses at your treatment centre will teach you how to look after your line.
In most cases you don’t need to be admitted to hospital for chemotherapy, which is usually taken at home or given in the hospital’s day treatment centre. Sometimes, depending on the type of chemotherapy being given and your general health, you may need to be admitted to the ward for a short while.
There are a variety of initial chemotherapy approaches. In general some approaches are better tolerated with lower response rates overall, but excellent responses in some individuals. Others, especially combination therapies, have more side effects but better overall response rates. The choice of treatment for you depends on your and your doctors’ preferences and the behaviour of your cancer cells.
Radiotherapy is a type of treatment that uses high energy x-rays to kill cancer cells and shrink tumours. Radiotherapy is generally regarded as local therapy because it only destroys cancer cells in the treated area.
The radiation field is the area of the body which is being treated. Common fields include the mantle field (treating the lymph nodes of the neck, chest and armpit), the upper abdominal field (abdomen and sometimes spleen), the pelvic field (hips and groin) and the spine. ‘Involved Field Radiotherapy’ is the term sometimes used to describe radiotherapy being given to a local area. The area of normal tissue encompassed by the radiotherapy field is kept to the smallest area possible to avoid affecting the normal tissues.
Before you start radiotherapy, the Radiation Oncologist (doctor who specialises in treating people with radiotherapy) will carefully calculate the correct dose of radiation therapy for you. The area or areas of your body that need to be treated will be marked with tiny ink dots on your skin using a special indelible pen.
Radiotherapy is usually given in small doses (also known as fractions) each weekday (Monday to Friday) over a week or more in the radiotherapy department of the hospital. You do not need to be admitted to hospital for this treatment, but if you live far away you may need to organise closer accommodation for this time. The social worker or nurses can assist you with this.
When you are having radiotherapy you usually lie on a table underneath the radiotherapy machine, which delivers the planned dose of radiation. If necessary, important structures like your heart and lungs are shielded as much as possible to ensure that they are not affected by the treatment given. Radiotherapy is painless. In fact you do not see or feel anything during the actual treatment. You will however need to stay perfectly still for a few minutes while the treatment is taking place. You might like to bring along some music to help you relax.
Stem cell transplant
For some people very high doses of chemotherapy or radiotherapy are needed to effectively treat their cancer. A transplant will only be offered if your doctor feels that it will be of benefit to you. You will be able to discuss with your doctor if a transplant is a suitable treatment option in your case. Whether you will be offered a transplant will depend on a number of factors, predominantly the risk of relapse you are estimated to have if treated with chemotherapy alone together with your tolerability of the chemotherapy you will receive. This risk will vary between different patients so the advice from your doctor will be very specific to your circumstances.
There are two main types of transplant, allogeneic and autologous. These are discussed below:
Autologous transplant involves collecting your own stem cells, usually from your blood stream (via peripheral apheresis) and storing them, then giving them back after you have received high doses of chemotherapy. This type of treatment is commonly used for myeloma and relapsed lymphoma. Your bone marrow has to be clear of cancer to be eligible for this type of transplant.
For more information on Autologous transplants download our booklet.
Allogeneic transplant involves the use of very high doses of chemotherapy, with or without radiotherapy, which kills the normal marrow cells (as well as, hopefully, any cancerous cells that have survived thus far). The term used for this intense treatment is ‘myeloablative’. This is then followed by infusion of blood stem cells or bone marrow, which have been donated by another person; a suitably matched donor, usually a sibling or sometimes an unrelated donor from worldwide donor registries.
Due to the potential toxicities of this type of allogeneic transplant it is not generally suitable for older patients (e.g. over 50 – 60 years).
An alternative approach involves using lower and therefore less toxic doses of chemotherapy and radiotherapy. This is called a reduced intensity, nonmyeloablative, or miniallogeneic (mini-allo) transplant.
This may be suitable for selected older patients and those with certain health problems who would benefit from, but might not be able to tolerate a conventional donor transplant. Using this approach less intensive doses of chemotherapy are used to treat disease in the bone marrow and suppress the patient’s immune system sufficiently for it to accept the new, donated healthy stem cells. Meanwhile it is hoped that the donor’s immune system will attack and destroy any leftover disease.
For more information on Autolgous Transplants download our booklet.
Targeted therapies include monoclonal antibodies and inhibitors.
Monoclonal Antibodies – refers to medications which work with your immune system to target specific cells, such as rituximab (MabThera). Monoclonal antibodies are specifically engineered to lock on to specific proteins found on the surface of abnormal cells like cancer cells.
Rituximab works by binding to a specific B-cell antigen, named CD20, found on the surface of some types of the lymphoma cells. This helps the patient’s own immune system to recognise these cells as foreign and kill them. Because this type of therapy specifically targets one type of cell, they tend not to affect other healthy cells, which is why they are usually well tolerated with few side effects.
Further monoclonal antibodies continue to be developed and trialled which target specific antigens found in other types of lymphomas and also in different types of cancers. Monoclonal antibodies are given as intravenous infusions, usually in the outpatient department of the hospital. They are usually used in combination with chemotherapy, but can be given alone or continued after the chemotherapy has been completed (called maintenance therapy). Side effects are generally mild and can generally be easily managed. They may include fever, chills and mild skin reactions.
Inhibitors work by inhibiting the action of specific cells, such as imatinib mesylate (Glivec) which belongs to a class of drugs known as tyrosine kinase inhibitors. When an inhibitor blocks or stops specific cells, such as cancer cells, growth and development of the cell is prevented.
Imatinib works by binding to a specific tyrosine kinase, called bcr-ABL, found on the surface of cells which are Philadelphia chromosome positive (Ph+). These cells are found in people with Chronic Myeloid Leukaemia (CML), and in some forms of Acute Lymphoblastic Leukaemia (ALL). This treatment can be taken in tablet or capsule form at home and is well tolerated by the majority of patients.
Newer inhibitors are being developed, not only in the treatment of CML, but across a range of cancers. Often they are given as a sole treatment agent (in the case of CML), but may be given as maintenance (in the case of ALL). Side-effects are generally mild and reduce over time. They may include fatigue, skin reactions, mild gastric upsets and fluid retention.
Palliative care is aimed at relieving any symptoms or pain you might be experiencing as a result of your disease or its treatment, rather than trying to cure or control it. Palliative care is not purely aimed at end of life cares and they may be involved in your care throughout treatment to help with any symptoms you may experience that are problematic.
If a decision is made to discontinue curative treatment for your blood condition, there are still many things that can be done to help you to stay as healthy and comfortable as possible for as long as possible. This may involve receiving palliative chemotherapy or radiotherapy to control symptoms, but at much lower doses to reduce side effects.