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Chronic myeloid leukemia

About Chronic myeloid leukemia
Chronic myeloid leukemia is one of the types of blood cancer (leukemia) that develop from cells that would normally develop to form white blood cells other than lymphocytes. Chronic myeloid leukemia is sometimes called chronic myelogenous leukemia or chronic non-lymphocytic leukemia. The term “chronic’’ simply means leukemia progress slowly over time and normally people with this type of leukemia don’t show any symptoms for at least a few years. By that time, cancer cells can spread to other parts of the body, including the liver, spleen and lymph nodes. To understand well about leukemia, it is important for one to have knowledge on blood first.

Blood
Bloodis a fluid flowing in our bodies and it is the one that usually conveys nutrients and oxygen. In the body blood is carried in specified tubes known as vessels (veins and arteries). Blood is pumped around the body by a muscular organ called heart. Blood is made up of cells carried in a clear fluid called plasma. Blood cells are mainly of three types, red blood cells, white blood cells and platelets.
• Red blood cells. These carry oxygen around the body
• White blood cells. These are responsible for fighting infections
• Platelets. These help in blood clotting.
All these blood cell types have a limited life span, hence they are continuously replaced. Most are made in the bone marrow, which is the spongy part in the center of the bones such as the skull, ribs, hip bones, shoulder blades and backbones (vertebrae). Since leukemia is a blood cancer that mainly involves white blood cells, it is important to have a bit more knowledge on white blood cells.

Types of white blood cells
• Lymphocytes. These are the cells responsible for fighting infections and they develop from stem cells known as lymphoblast. Lymphocytes are the cells that mainly make up lymphoid tissue, which are major part of the immune system. The two main types of lymphocytes are;
• B- Cell lymphocytes. These cells make antibodies that fight germs and other infections. These are also called B-Cells.
• T-Cell lymphocytes. These are responsible for destroying germs and they also trigger B-cell lymphocytes to produce antibodies
• Granulocytes. These are mature cells that are responsible for fighting infections. These cells develop from myeloblasts. They are known as granulocytes because they have granules that show up as spots under the microscope. Types of white blood cells known as granulocytes include; neutrophils, eosinophils and basophils. These three differ in color and size of granule.
• Monocytes. These develop from blood-forming monoblasts in the bone marrow. After sometime in the blood stream, monocytes will enter body tissues to become macrophages. Macrophages destroy germs as well as help lymphocytes recognize germs.

About leukemia
Leukemia is a term used to describe blood cancer. Leukemia originates from the term leucocytes which means white blood cells. Leukemia begins in the bone marrow, the spongy part in the center of the bone where blood cells are produced.
The bone marrow contains stem cells. These are unspecialized blood cells that first develop into immature cells known as blast cells. Normally, the blast cells then become mature red or white blood cells or platelets and carry out their set functions but if the blasts fail to mature properly or if they are too many in the blood, it can result into leukemia. There are two types of stem cells;
• Myeloid stem cells. This develop into myeloblast cells that further develop into red blood cells, most types of white blood cells and platelets.
• Lymphoid stem cells. This develop into lymphoblast cells which then becomes lymphocytes which are type of white blood cells.
Following failure to mature properly into normal blood cells, myeloblast cells will result into development of type of leukemia known as myeloid leukemia while lymphoblast cells will result into lymphoblastic leukemia.
In leukemia, abnormal white blood cells grow out of control and multiply in such a way that they crowd the bone marrow. This affects bone marrow’s ability to produce normal levels of other blood cells, hence affecting the way the rest of the body work.
As leukemia progresses, more abnormal blood cells and fewer normal blood cells are produced in the marrow. Those abnormal cells in the marrow will spill out into the blood stream and build up in the blood, which may spread to other parts of the body such as lymph nodes, lungs, liver, spleen and kidneys

Risk factors of chronic myeloid leukemia
When dealing with cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factors only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. The risk factors for chronic myeloid leukemia (CML) include the following;
• Age. Chronic myeloid leukemia is much more common in older adults and not common among teens and children.
• Exposure to radiations. Exposure to high dose of radiations increase chances of developing CML at one point in life. These include atomic bomb survivors and radiation accident victims such as those in nuclear reactors.
• Exposure to chemicals. Some studies link exposure to chemicals like benzene to development of CML. Benzene is normally used for various purpose such as in oil refining and rubber industries.
• Gender. Statistics indicate that, number of men who develop CML is slightly high compared to that of women. The reason for this is still unknown.
• Cigarette smoking. In cigarette smokes there are chemicals such as benzene that increase the risk of CML.

Prevention of chronic myeloid leukemia
To prevent something, you first need to know what causes it. But since the specific cause of chronic myeloid leukemia is still unknown, there is no way of completely preventing development of this cancer.
In addition to that, the risk of developing many other types of cancer can be reduced through various factors including changing lifestyle and vaccinations, but because there are few known risk factors for this type of cancer and most of them cannot be changed so preventing this disease becomes even more difficult.

Early detection and screening
Early detection and screening
When it comes to cancer, early detection normally provide better treatment outcome. When chronic myeloid leukemia (CML) is found early, chances for better treatment outcome are very high. For most cancers, early detection has been greatly contributed by the presence of screening processes.
Screening is the process of running some tests to someone with no symptoms of the disease with the intention of determining presence or absence of the disease. Unfortunately, currently there are no widely recommended screening tests for chronic myeloid leukemia. In order to detect this type of leukemia at an early stage, it is recommended to see the doctor immediately upon experiencing any possible signs or symptoms of leukemia.

Signs and symptoms of chronic myeloid leukemia
Many people with chronic myeloid leukemia have no symptoms. Often the disease is discovered during a routine blood test when the test results shows some abnormalities. At this stage, the abnormal cells may not be causing any harm but as time goes the symptoms tend to get worse slowly. The signs and symptoms of this disease include the following;
• Feeling tired
• Easily bruising and bleeding
• Fever
• Persistent infections
• Shortness of breath
• Frequent or severe nosebleed
• Enlarged liver and spleen
• Unexpected weight loss
• Enlarged lymph nodes
• Headaches
• Nausea and vomiting

Diagnosis of chronic myeloid leukemia
Following suspicion of chronic myeloid leukemia, various tests are used to verify the suspicion, learn if the disease has spread to other parts of the body and some tests will help to determine prognosis of the disease. When running those diagnostic tests, the doctor will consider some of the factors including;
• Results of previous tests
• General health condition
• Type of cancer suspected
The following are some of the diagnostic tests for chronic myeloid leukemia (CML) although not everyone will need to go through all those tests during diagnosis.
• Medical history and physical examination. The doctor will review patient`s history for risk factors but also do some physical examinations to check if there is any enlarged lymph nodes (lymphadenopathy) and abdominal swelling which can be a result of enlarged liver (hepatomegaly) and spleen (spleenomegaly).
• Blood tests. Blood samples will be taken and checked in the laboratory for full blood count (FBC). The results will reveal whether the levels of blood cells are normal or not. Blood sample may also be used to find if the blood cells are normal or abnormal (leukemia cells).
• Bone marrow tests. If the blood test shows abnormalities in the number or appearance of the white blood cells, the doctor may take some bone marrow sample to check for signs of leukemia. There are two main procedures used in taking bone marrow samples for testing;
• Bone marrow aspiration. This involves the removal of a fluid sample by using a needle (fluid part of bone marrow).
• Bone marrow biopsy. This involves the removal of a small amount of solid tissue using a needle.
If the results from blood tests suggest presence of leukemia, bone marrow tests are advised to be done at the hospital where treatment will be given so as not to do these tests twice.
• Genetic tests. When dealing with CML, genetic tests are normally used as confirmatory tests. They involve studying genetic makeup of cancer cells. The main purpose for these tests is to see if there is Philadelphia chromosome and/or BCR-ABL gene in cancer cells. These genetic tests can be carried out in several ways including the following.
• Cytogenetics. Cytogenetics involves examining sample (bone marrow) to see if there is Philadelphia chromosomes in the sample. Philadelphia chromosome normally appear like a shortened version of chromosome 22, hence the pathologist will be able to tell the difference between chromosome 22 and Philadelphia chromosome.
• Polymerase chain reaction (PCR). PCR is the test which involve checking for presence of BCR-ABL gene in the cells. It can be done on blood or bone marrow samples and can detect verysmall amounts of BCR-ABL, even when Philadelphia chromosome can`t be found in bone marrow cells with cytogenetic testing. In addition to its use in diagnosis, PCR is also used to assess disease response by checking if copies of the BCR-ABL gene are still there after treatment. If copies of this gene are still present it means leukemia is still there, even when cells aren’t detectable with a microscope.
• Imaging tests. Imaging tests like CT scan, MRI scan, chest X-ray and PET scan are used to determine if the disease has spread to other parts of the body such as lymph nodes, liver and spleen.

Treatment of chronic myeloid leukemia
After being diagnosed with CML, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps.
After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option.
Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored.
In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials.
If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time

Treatment options
Treatment of CML requires a team of doctors and other health care professionals. This team work together and it is called multidisciplinary team. Team may vary depending on the treatment option for a particular case. But generally multidisciplinary team for treatment of CML includes hematologist, medical oncologist and other health care professionals like oncology nurses and palliative care team. Treatment options include the following;

Targeted therapy
Targeted therapy is one of the treatment options that involve using drugs that target specific molecules in the cancer cells. The drug will stop the growth and spread of cancer cells while reducing possible harm to normal cells. Targeted therapy is normally the main treatment option when dealing with CML. Drugs used when dealing with CML are called tyrosine kinase inhibitors (TKIs). These drugs work by blocking a chemical called tyrosine kinase, which tells the leukemia cells to divide and grow. Without this signal, the cells die.
Drugs for this kind of treatment work differently to that of normal chemotherapy drugs. Drugs for this treatment option can sometimes help even when chemo isn’t, but they can also be used along with normal chemotherapy to help it work better

Side effects of targeted therapy
Some of the possible side effects of targeted therapy include the following;
• Nausea and/or vomiting
• Mouth sores
• Muscle or bone pain
• Increased risk of infection
• Upper respiratory infection
• High blood sugar level
• Increased level of bilirubin
• Loss of appetite
• Diarrhea
• Bruising

Chemotherapy
Chemotherapy is a treatment option that involve the use of drugs to destroy cancer cells or slow its growth. It is given by a specialized doctor known as medical oncologist or hematologist. Chemotherapy is normally given through injection into veins (intravenously) and rarely swallowed as pill or capsule.Most people will be prescribed TKIs as their first treatmentfor CML. However, some may be given a short course of chemotherapy tablets to get the disease under control before TKI treatment begins
Normally chemotherapy schedule consists of a certain number of cycles given over a set period of time. Patients with CML receive several different drugs throughout their treatment.

Side effects of chemotherapy
Side effects of chemotherapy depend on type of drug used, dose given and periodic time by which the drug has been used. Some of the possible side effects of chemotherapy include the following;
• Loss of hair
• Fatigue
• Mouth sores
• Nausea and/or vomiting
• Diarrhea
• Risk of infections
• Easily bruised and bleeding

Stem cell transplantation
Stem cell transplantation is a treatment option that involve replacing a patient`s bone marrow by highly specialized cells called hematopoietic stem cells. Bone marrow that contain cancer cells is destroyed first by using high dose of chemotherapy or radiation therapy, then replaced by healthy stem cells.
This treatment option is sometimes known as bone marrow transplantation. These cells will mature into heathy bone marrow. Hematopoietic stem cells are blood forming cells found in the bone marrow.
A transplant is normally done in several stages and the entire procedure, including recovery, can take months. There are two types of stem cell transplantation;
• Autologous stem cell transplantation. This type uses stem cells that were previously removed from your blood stream and later are transplanted (reinfused) back into your body.
• Allogeneic transplantation. This involve the use of stem cells taken from another person (donor). The donor may be a family member or from a donor registry.
When dealing with CML, allogenic stem cell transplantation is normally used. Sometimes this treatment option is used to younger patients when the standard treatment options have failed or when there is high possibility for CML to return in a short period of time.

Side effects of stem cell transplantation
Most of the side effects of this treatment option resemble to those of chemotherapy but with this treatment options the side effects may be a little bit severe. Those possible side effects of stem cell transplantation include the following;
• Nausea and vomiting
• Hair loss
• Risk of infection
• Easily bruising and bleeding
• Fatigue

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