Leukemia

City of Hope, located in Southern California, has been named a best hospital for cancer by U.S. News & World Report for over a decade, and a National Cancer Institute comprehensive cancer center, the highest designation that recognizes our commitment to cancer treatment, research and education. As a founding member of the National Comprehensive Cancer Network, our doctors also help develop and improve evidence-based leukemia treatment guidelines for patients throughout the country.

Highlights of our leukemia program include:

• A multidisciplinary team of specialists – including hematologists, medical and radiation oncologists, scientists, supportive care experts and other professionals – who work together to provide coordinated, personalized care for you and your loved ones
• Comprehensive molecular profiling and risk assessment tests that can help identify treatments that will produce the best outcomes
• A world-class bone marrow and stem cell transplant program with better than expected survival outcomes for over 10 years
• Leading-edge clinical trials for leukemia not available elsewhere, including CAR T cell immunotherapy, mutation-specific drugs and novel stem cell transplant regimens
• Total marrow irradiation that targets radiation therapy to bone marrow while minimizing exposure to healthy tissues and organs
• Specialized observation programs for slow-growing leukemia subtypes, allowing our doctors to deliver timely therapies when they are the most effective
• Long-term, follow-up program to minimize risk of recurrence and improve quality of life for leukemia survivors

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What is leukemia?

Leukemia is a disorder involving blood cells. Healthy cells form in the bone marrow and mature into red blood cells (to deliver oxygen and nutrients to the body’s tissues), white blood cells (to fight infections) and platelets (to stop bleeding).

In patients with leukemia, these cells do not mature as they should or they transform into irregular blood cells that do not function normally. As abnormal cells build up in the bone marrow and bloodstream, the patient may experience anemia, susceptibility to infections and bleeding that does not clot due to the lack of functional red blood cells, white blood cells and/or platelets.

On a general scale, leukemia is classified by the types of cells affected (myeloid or lymphoid) and whether it is fast- or slow-growing (acute or chronic). As such, the four major subtypes of leukemia are:

• Acute myeloid leukemia (AML)
• Acute lymphocytic leukemia (ALL)
• Chronic myeloid leukemia (CML)
• Chronic lymphocytic leukemia (CLL)

What risk factors are linked to leukemia?

Factors that can elevate risk of leukemia include:

• A personal or family history of leukemia or blood disorders
• Prior treatment with radiation or chemotherapy
• Exposure to radiation or certain chemicals, including benzene, formaldehyde and Agent Orange
• Infections with specific viruses, such as the Epstein-Barr virus or human T cell lymphoma/leukemia virus (HTLV-1)
• Being male
• Smoking

What are the symptoms of leukemia?

Common symptoms associated with leukemia include:

• Unexpected loss of weight or appetite
• Fatigue
• Anemia
• Frequent or long-lasting infections
• Excessive bleeding and bruises, or bleeding that does not stop
• Enlarged spleen or lymph nodes
• Petechiae (flat, round and red pinpoint spots under the skin)
• Shortness of breath
• Fevers, chills and other flu-like symptoms
• Night sweats

Although these symptoms can be caused by other conditions, you should check with a doctor – preferably a hematologist – to get a definitive diagnosis.

Sources: National Cancer Institute and American Cancer Society

Diagnosing leukemia

An accurate diagnosis is crucial to optimal treatment planning and outcomes. This is especially important for leukemia because this disease has numerous subtypes and factors that can determine specific courses of treatment.

At City of Hope, our team of experts can precisely diagnose leukemia, classify its subtype, identify its severity and find the best treatments to fight the disease.

How is leukemia detected?

Once you notice symptoms, or as part of a routine examination, your doctor may use the following tests to look for leukemia:

• Physical exam
• Blood tests
  • Complete blood count: This test checks for the number of red blood cells, white blood cells and platelets in your blood sample.
  • Peripheral blood smear: Also known as a blood film, this test smears a thin layer of blood on a glass slide for examination under a microscope.
• Bone marrow aspiration and biopsy: A hollow needle is inserted into your hipbone or breastbone to extract a sample of bone marrow, blood and bone tissue. A pathologist then examines the tissue for signs of cancer.
• Imaging tests: Although medical imaging procedures – such as X-ray and magnetic resonance imaging scans – are not typically used to diagnose leukemia, they may be ordered if your doctor suspects that leukemia cells are growing in an organ, such as the spleen or liver.

If cancer is found, additional tests are performed to determine the type and stage of disease. These tests include:

• Cytogenetic analysis: A test that looks for genetic or chromosomal abnormalities in a blood or bone marrow sample
• Immunophenotyping: This test looks for specific markers on the surface of the leukemia cells, and is used to help identify the disease subtype.
• Reverse transcription-polymerase chain reaction (RT-PCR) test: This test uses chemicals to look at structure or function of genes, and can help identify leukemia subtypes.
• Lumbar puncture (spinal tap): If your doctor suspects that leukemia cells have spread to your brain and spinal cord, a small sample of your cerebrospinal fluid – or CSF – may be extracted from your spine for further evaluation.

What are the current screening guidelines for leukemia?

There are currently no screening guidelines for leukemia, since no screenings have been shown to lower risk of dying from leukemia for people of average risk. However, your physician may recommend more vigorous monitoring if you are at a high risk of developing this disease, due to:

• Personal/family history
• Specific inherited conditions
• Prior chemical or radiation exposure
• Chemotherapy and radiation therapy to treat another cancer

What Leukemia treatment options are being offered?

We offer not just the best known therapies, but also the best therapy for a particular person." Joseph Alvarnas, M.D., associate clinical professor, Department of Hematology & Hematopoietic Cell Transplantation

Your cancer is every bit as unique as you are, and that is why treatment at City of Hope is focused around you and your loved ones.

This means our physicians will personally consult with you about your disease, treatment options and desired outcomes. We will also analyze your specific cancer for genetic and molecular markers that can guide us to more effective therapies. Afterward, our multidisciplinary team will work together to discuss, design and deliver an individual treatment plan to best meet those goals.

The innovative treatments we use to treat leukemia include drug therapy, radiation therapy and bone marrow/stem cell transplantation.

What is Drug Therapy?

Drug therapy may be given to patients to fight leukemia cells throughout the body by killing them or stopping their growth and spread. These drugs include:

• Chemotherapy, which targets rapidly dividing cells, including leukemia cells
• Targeted therapy, which selectively identifies and attacks leukemia based on specific markers expressed by the cancerous cells
• Immunotherapy, which stimulates the patient’s own immune system to attack leukemia cells

Drugs may also be prescribed to treat conditions related to leukemia or its treatments such as low blood cell counts, nausea or pain.

The drug or drug combination used depends on the leukemia subtype, disease prognosis, previous treatments used, the patient’s health and overall treatment goals. This personalized medicine approach also evaluates the leukemia cells’ molecular and genetic makeup, which can help identify treatments that are more effective and with fewer side effects.

City of Hope has a wide portfolio of cancer-fighting drugs available in its on-site pharmacy, allowing our medical oncologists to plan and prescribe a drug regimen that can best fight leukemia while minimizing side effects.

In addition to standard drug treatments, patients may also be eligible for new, promising drugs through our clinical trials program.

Leukemia and Radiation Therapy

Radiation therapy uses focused, high-energy X-rays or other forms of radiation to kill cancer cells.

For leukemia, radiation is typically used in the following manner:

• To treat leukemia cells that have accumulated in specific areas of the body such as the brain or the spleen
• Before a stem cell transplant to help kill leukemia cells throughout the bone marrow and body
• To treat symptoms caused by leukemia such as bone pain

City of Hope is a leader in the use of radiation to treat cancers. Our advanced technologies and experienced staff can plan and deliver radiation precisely to the bone marrow, where leukemia originates, while sparing nearby organs and tissues. This results in fewer radiation-associated side effects while maintaining excellent clinical outcomes.

LEARN MORE

• Radiation therapy and hematologic cancers

What is Bone Marrow / Stem Cell Transplantation?

Stem cell transplantation allows doctors to deliver greater doses of radiation and drugs to fight leukemia. After the high-intensity treatments, patients are infused with blood stem cells that will grow and mature in the bone marrow, restoring their blood-forming functions.

Stem cell transplants may also fight cancer through its graft-versus-tumor effect, where the newly transplanted stem cells produce an immune reaction against remaining leukemia cells throughout the body.

The stem cells may come from another donor (allogeneic transplant) or the patient’s own cells (autologous transplant).

City of Hope is one of the country's largest and most successful bone marrow and stem cell transplant centers. Our Hematologic Malignancies and Stem Cell Transplantation Institute is a leader in setting standards for this lifesaving procedure, improving outcomes for leukemia patients of all ages.

Highlights of our transplant program include:

• Recognition as an “overperforming” transplant center for 11 consecutive years by The Center for International Blood and Marrow Transplant Research Center
• One of the first and most experienced centers to use nonmyeloablative (mini) transplants, which allow a greater range of patients (particularly those older or too weak to tolerate a standard transplant) to be treated with this lifesaving therapy
• Integration of transplant and nontransplant therapies, so there is a smoother transition of treatments for leukemia patients who will eventually need a stem cell transplant
• Experience in treating a wide range of leukemia cases, including advanced disease and higher risk patients
• A long-term, follow-up program that monitors for late effects and provide timely interventions

Active Surveillance

For slower-growing, less aggressive leukemias, active surveillance – also known as watchful waiting – is a viable treatment option. This method involves closely monitoring a patient with regular checkups and blood work, and beginning therapy when the disease begins to show signs of progression. Active surveillance allow doctors to deliver treatment when it is the most effective, sparing patients from unnecessary therapies and side effects.

Research and clinical trials for leukemia

At City of Hope, leukemia clinicians and researchers collaborate extensively to develop and evaluate new therapies for better survival and quality-of-life outcomes. Our patients have access to a wide variety of clinical trials including new chemotherapy and targeted therapies, hormone therapies with fewer side effects, novel surgical techniques, innovative radiation approaches and new prevention strategies.

These trials give current patients access to promising, leading-edge therapies and improve overall care for future patients worldwide. Visit our clinical trials page to learn more about current studies and their eligibility criteria.

Some of our current research projects include:

• CAR T cell therapy: Immune system cells called T cells guard against disease; they can detect invaders such as bacteria and viruses and destroy them. City of Hope scientists are currently investigating to see how these cells can be reprogrammed to recognize and attack leukemia, as well.
  
  City of Hope is certified to administer tisagenlecleucel (commercial name Kymriah) chimeric antigen receptor (CAR) T cell therapy – the first CAR T cell therapy approved by the U.S. Food and Drug Administration (FDA) – to patients up to 25 years of age with B cell precursor acute lymphoblastic leukemia (ALL) that is refractory or in second or later relapse.
  
  We are also the only institution in Southern California to currently offer both tisagenlecleucel and axicabtagene ciloleucel (commercial name Yescarta), the second CAR T cell therapy approved by the FDA, solidifying City of Hope’s position as a leader in this newest form of cancer immunotherapy.
  
  Tisagenlecleucel, a Novartis product, is a CAR T therapy and one-time treatment that uses a patient's own T cells to fight B cell precursor ALL that has resisted all treatment options or has relapsed a second or subsequent time. 
• Enhanced subtype profiling: While leukemia is typically classified as one of four major groups, it is actually a collection of over a hundred abnormalities that lead to uncontrolled cell growth. Our researchers are actively studying these subtypes and whether they have specific genetic or molecular targets to focus therapy on.
• New therapies for relapsed/refractory disease for patients who have undergone and failed standard treatments. These clinical trials may include novel agents developed at City of Hope, or new combinations or regimens of already-approved therapies that may be more effective.
• Developing more tolerable regimens for patients who cannot withstand standard treatments such as older patients and those with comorbid conditions.
• Investigating "leukemia stem cells" that allow the disease to relapse and grow following cancer treatment. By better understanding the biology and weaknesses of these cancer stem cells, scientists and clinicians can develop better treatments that produce lasting cures.
• Enhance bone marrow/stem cell transplants: While stem cell transplants can be a lifesaving procedure for leukemia patients, they also carry a risk of graft-versus-host disease (GvHD), in which the newly transplanted stem cells do not recognize the recipient’s body as their own and start producing an immune response against it, leading to chronic and potentially serious complications. To reduce the likelihood of GvHD and to improve transplant outcomes, City of Hope is researching new ways to classify and match stem cell donors and recipients.
• Improving survivorship: City of Hope runs an ongoing long-term, follow-up program for bone marrow transplant recipients, which monitors them for chronic side effects and educates them on improving their quality of life based on their disease and the treatments they have received.

GEHR FAMILY CENTER FOR LEUKEMIA RESEARCH

Living with leukemia

I am going to beat this. I’m going to come back and retrace these steps." Gus Perez, leukemia survivor

When you come to City of Hope, you automatically gain access to an unparalleled array of support services to help you and your loved ones take each step during and after your leukemia treatment.

We can help with all of the following concerns, and more:

• Managing symptoms and side effects, such as pain, nausea and fatigue
• Recovering after stem cell transplantation
• Handling emotional, social and spiritual issues in group or one-on-one settings
• Coping with the stress of diagnosis, treatment and recovery
• Addressing fertility and family planning issues
• Navigating the health care system, including related legal and financial issues
• Maintaining a healthy lifestyle with expert nutrition and physical activity guidance
• Building caregiver skills
• Improving communication with family, partners and loved ones
• Restoring normalcy in your family, job or school routine
• Restoring your body and mind through healing arts workshops
• Connecting with and learning from other patients and survivors
• Returning to wellness after active treatment

Learn more about these resources at our Living with Cancer or Supportive Care Medicine sites.

For more information about the supportive care programs we offer, please contact the Sheri & Les Biller Patient and Family Resource Center at 626-218-2273 (CARE).