Leukemia, a form of blood and bone marrow cancer, is caused by the production of abnormal blood cells, especially the white blood cells. Myeloid blast, monoblast and lymphoblast are the three deformed structure of white blood cells that cause different types of leukemia. Among the different types of leukemia cancers, acute lymphocytic leukemia (ALL) is the most common cancer in children, especially the children aged 2 to 4 as it accounts for 70% -75% of childhood leukemia cancer.[1c,4a] In leukemia patients, the abnormal lymphoblasts not only cannot develop into mature lymphocytes that fight infection in the body, but also disturb the function of bone marrow by preventing the production of red blood cells, white blood cells and platelets. Therefore, the leukemia patients will suffer from the anemia, easily bruising or bleeding, infection, tiredness, losing appetite, fever and night sweats. [4a]In the past, acute lymphocytic leukemia was a life-threatening disease as the cure rate was very low. However nowadays, the survival rate has been gradually increased due to the improvement and the advancement in the diagnosis and the treatments.

Figure 1a Normal blood development

http://www.cmlalliance.com/patient/what-is-cml-chronic-myeloid-leukemia.jsp

http://images.medicinenet.com/images/Government/leukemia.jpgFigure 1b Leukemia cells

http://www.medicinenet.com/leukemia/article.htm

Treatment

Chemotherapy

Chemotherapy is the main type and the most common way to treat the leukemia. It is a type of drug therapy and the ultimate goal of chemotherapy is to kill leukemia cells using anticancer drugs until there is no trace of any leukemia cells in the body. This stage is known as a complete remission. Chemotherapy treatment usually involves combinations of various anti-leukemic drugs rather than a single drug as the cancer cells can be attacked in several different ways and different drugs behave differently in controlling leukemia cells growth process. There are more than 50 chemotherapy drugs used in the chemotherapy treatment and they can be divided into several groups based on their chemical structure, the mechanism and interrelationship to another drug. The table below shows the percentage of number of drugs used in the treatment.

http://www.lakelandcancertreatment.com/Annual_Report_08/Graphs/Leukemia_Treatment.jpg www.lakelandcancertreatment.com/Annual_Report_08/Graphs/Leukemia_Treatment.jpg&imgrefurl=http://www.lakelandcancertreatment.com/Annual_Report_08/Acute_Leukemia.htm&usg=__p63UW_u0

Typically, chemotherapy treatment is given to the patient in cycles and in phases: induction, consolidation and maintenance therapy.

Induction therapy

Induction therapy is the initial treatment of the chemotherapy that aimed to destroy as many leukemia cells as possible, achieve normal level of blood counts and treat acute lymphocytic leukemia into remission. Induction therapy is usually very intense and lasts about one month. Drugs that commonly used in this stage are daunorubicin, vincristine, prednisolone and asparaginase.

About 98 to 99 percent of children with newly diagnosed acute lymphoblastic leukemia attain initial complete remissions(absence of detectable leukemic cells by microscopic examination) in four to six weeks. About 90 percent of children can be cured. Patients who remain leukemia-free for 10 years or more can be considered cured.

http://www.stjude.org/stjude/v/index.jsp?vgnextoid=4c5b061585f70110VgnVCM1000001e0215acRCRD&vgnextchannel=bc4fbfe82e118010VgnVCM1000000e2015acRCRD&SearchUrl=search_results.jsp&QueryText=

Consolidation therapy

The second phase of chemotherapy, consolidation therapy, is usually intense too and lasts about four to eight months. The goal of this phase is to reduce the number of leukemic cells left inside the body. A typical regime used includes doxorubicin, asparaginase, methotrexate and cytarabine.

Maintenance therapy

This stage whose aim is to destroy any disease cells that remain inside the body and leukemia is completely cured, is less intense than the other two phases and may last about two to three years.

These drugs can be administered through a vein, injected into a body cavity or delivered orally in the form of a pill.

Diagram showing the Huber needle being pushed through the skin and into the port. The Huber needle connects with the catheter allowing treatment to be given directly into the bloodstream. http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Lymphomanon-Hodgkin/TreatingNHL/Chemotherapy.aspx

Social and economic implications

In my point of view, chemotherapy is a long term suffers for the ALL children and also their family. Drugs received by the patients during the treatments would give side effects to themselves like vomiting, nausea, losing appetite and tiredness.[4c,4f] Besides, they must be careful or be protected all the times not to be injured in order to avoid the risk of the infection which may cause the spread of the cancer cells. As most of the ALL children suffer a lot either mentally or physically on facing the disease and even the treatments, some of them may refuse to take any medication as they think that the suffering will end. Therefore, the parents are having greater burden and stress in taking care of their children and they are mental support to their children.

In addition, the leukemia treatments are huge financial burden to the ALL children’s parents as most of the anticancer medicines used in chemotherapy treatment are costly. Even though there are some common and less expensive medicines, the duration of taking chemotherapy are quite long and maybe endless to get completely cure. The expenditure of the treatments normally cannot be afforded by low income family.

For example, a common and less expensive chemotherapy drug is called 5-FU.  This drug will run you about $100-$300 for an eight week supply.  However, if you need to add one of these new anticancer drugs like oxaliplatin or irinotecan, it will increase your cost of chemotherapy to $10,000, and sometimes even more. Not to mention the need for multiple anticancer medication.

http://www.chemotherapyfacts.com/cost-of-chemotherapy.htm

Benefits and risks

Chemotherapy treatment offers benefits to the ALL patients. Specifically, chemotherapy can lessen the cancer cells that spread to other parts of body, reducing the likelihood of the leukemia relapse and potentially prolonging life.[4g]

Progressive increase in long-term survival for children with acute lymphocytic leukemia

zie10509_fm-1

http://www.mja.com.au/public/issues/182_02_170105/zie10509_fm.html

From the graph, we can see that the survival rates for acute lymphocytic leukemia in children have improved significantly from 10% in 1970 to 90% in 2000 for children. This data can be supported by other source :

For children, the overall survival rate after chemotherapy is nearly 80%. This includes children with all levels of risk factors. Survival rates are much lower for children with high-risk disease, while children with low-risk disease have even higher rates of survival.

http://www.marrow.org/PATIENT/Undrstnd_Disease_Treat/Lrn_about_Disease/ALL/index.html#treatment_options_for_all

However, the chemotherapy drugs can cause side-effects to the patients during the treatment. The most common side effects of anticancer drugs that can be occurred are nausea, vomiting, hair fall, loss of appetite, fever, tiredness and others. Short-term side- effects can be relieved or treated but side-effect which are long- lasting can cause damage to other organs like lungs, kidneys and heart. This is because chemotherapy not only kills the leukemia cells, but also harms the normal cells.[4i] Therefore, the patients may get the infections easily as the level of healthy cells declines.

Toxicity caused by anticancer drugs to internal organs:

http://healthplansystems.com/wp-content/uploads/2010/07/side-effects-chemo.gifhttp://www.google.com.my/imgres?imgurl=http://healthplansystems.com/wp-content/uploads/2010/07/side-effects-chemo.gif&imgrefurl=http://healthplansystems.com/page/2/&usg=__U2AFwCBPuyvnuO4T

Furthermore, leukemia cells can be found in the central nervous system, which is brain and spinal cord, in some patients (about 2% to 3%). This area is hardly treated by chemotherapy because most of the drugs given orally or through the veins cannot pass from the bloodstream into the central nervous system.

Then, although most of the ALL children (more than 90%) achieve a remission after chemotherapy, there may be a relapse in two years, five years or ten years in some patients, which is about 3% to 8%. [4h]These relapsed leukemia cells can be found in or spread to the central nervous system and other organs like kidneys. In some cases which involve the patients of high-risk group, chemotherapy is less likely to be used in achieving long-term remission.

Alternative solutions

Biotherapy

Biotherapy or immunotherapy is an alternative way to treat ALL in children by utilizing the body’s immune system to fight the leukemia cells or to minimize the side effects caused by other leukemia treatments. As cancer has been developed due to inefficiency of immune system, biotherapy is designed to repair, stimulate and improve the immune system.

Biotherapy is aimed to stop the cancer growth, boost the efficiency of lymphocytes,

inhibit the transformation process of a normal cell or a pre-cancerous cell into a cancerous cell and stop leukemia cells from spreading to other parts of your body.

Table below shows the drugs that commonly used in this therapy.

http://journals.prous.com/journals/dof/20083305/html/df330411/images/tab03.gif

http://www.google.com.my/imgres?imgurl=http://journals.prous.com/journals/dof/20083305/html/df330411/images/tab03.gif&imgrefurl=http://journals.prous.com/journals/servlet/xmlxsl/pk_journals.xml_article_pr%3Fp

Immunotherapy also can cause some side effects like flu-like symptoms. In my opinion, however, unlike chemotherapy, these side effects are mild and short term compared to the chemotherapy. Immunotherapy also stimulates the body to overcome the side-effects that caused by other treatments like chemotherapy.www.cancerhelp.org.ukThen, it does not kill destroy the normal cells which important in maintaining the functions of the body. Therefore, chemotherapy along with immunotherapy is an effective way to treat chemotherapy.

http://64.202.120.86/upload/image/articles/2008/smart-bombing-cancer/graph-depicting-the-growth-.jpg

Graph depicting the growth of a tumor over time. Yellow line indicates growth of the tumor without therapy; the blue line, with chemotherapy; and the white line, with immunotherapy.

http://thefutureofthings.com/articles/1012/smart-bombing-cancer.html

Nutritional therapy

“Let food be your medicine and medicine be your food.”—-Hippocrates, Greek physician.

ALL children require more nutrients than normal children due to the symptoms of the disease and the unpleasant side effects after the treatments especially chemotherapy. According to Cancer Treatment Centers of America, nutrition plays a crucial role in fighting the cancer especially for the children because high nutrient demand but low nutrient intake may leave them in a vulnerable condition and affect their physical development.

Thus, a nutrient assessment and an individualized plan are particularly designed for each patient according to the gender, size and the treatments that received. The aim of this nutritional therapy is to prevent patients to be malnourished, to relieve the side effects of the leukemia treatments and also to boost up their well being.

There are four important eating habits in optimal nutritional diet:

1. Consume plenty of vegetables and fruits. Some cruciferous vegetables, like cabbage and broccoli, contain chemicals that can control the spread of cancer cells. Indeed, National Cancer Institute recommends the patients to consume five to ten servings a day. Besides, some brightly-coloured vegetables and fruits have some compounds that enhance the potency of chemotherapy while protect the normal healthy cells from the toxic effect.

2. Intake unsaturated fat sources. For instance, essential fatty acids that found in olive, canola, flaxseed oil, fish, soy and pumpkin not only keep one well-nourished, but also may enhance the efficiency of the cancer treatments.

3. Take sufficient lean proteins like eggs, yogurt, fish as well as lean meats to maintain immunity system and protect lean muscle mass.

4. Consume whole grains which good in regulating blood sugar, aiding elimination and stimulating immunity system.

Nutritional therapy is highly recommended by the physicians and I think it is an essential requirement for the ALL children because there are no any side effects and provide all nutrients which help in development and increasing the immune system of the patients’ body. From the graph below, we can see that rate of infection in patients without nutritional therapy is doubly higher than the well-nourished patients.

Gianotta Trial graph

http://www.impactinformation.com/products/index.htm

Evaluation

Non web-page

J.B.King, Roger. Cancer Biology. 1996. Reprint. England: Prentice Hall, 2000. Print.

This book is a very reliable source because it is the second edition written by Roger King, Visiting Professor in Cellular Oncology at Surrey University, UK. This new edition has been updated to provide new treatments on different cancers, data on each treatment’s risk and also survival rates. This sort of information is a useful and valid reference for me as the author has done many extensive researches with the help of scientists from Imperial Cancer Research Fund. Imperial Cancer Research Fund is the world’s leading charity that has saved millions of lives through their groundbreaking work into preventing, diagnosing and treating cancer. Furthermore, the information provided in this book can be supported by other book and internet sources. For instance,

Chemotherapy has improved survival of childhood acute leukemias.

Other account that support this source is

For children, the overall survival rate after chemotherapy is nearly 80%. This includes children with all levels of risk factors. Survival rates are much lower for children with high-risk disease, while children with low-risk disease have even higher rates of survival.

http://www.marrow.org/PATIENT/Undrstnd_Disease_Treat/Lrn_about_Disease/ALL/index.html#treatment_options_for_all

Retrieved on 4 April 2010

Web page

www.stjude.org

This webpage is organized by St. Jude Children’s Research, one of the world’s premier pediatric cancer research centre located in Memphis, Tennessee. This website is useful to me because the researches and discoveries done in this centre are closely related to treat cancers in children. The centre has proved that chemotherapy is effective to treat acute lymphocytic leukemia into remission as other sources did like:

Induction therapy achieves a remission in more than 95% of children and fewer than 3% of children with leukemia die of complications during this initial treatment.

http://www.marrow.org/PATIENT/Undrstnd_Disease_Treat/Lrn_about_Disease/ALL/index.html#treatment_options_for_all

www.marrow.org is the official website for The National Marrow Donor Program and it is a non-profitable organization that providing bone marrow transplant opportunity to those leukemia patients. This program has been operated for more than 20 years and it has provided sufficient knowledge and experiences about acute lymphocytic leukemia. Therefore, this source is also one of the reliable references that I used.