Stages & Prevention of Leukemia Cancer | Dr Meenu Walia | DNB Medical Oncologist

Stages of Leukemia Cancer

A staging system is a standardized way for the cancer care team to summarize information about how far a cancer has spread. There are 2 different systems for staging leukemia:

• Rai system: This is used more often in the United States.
• Binet system: This is used more widely in Europe.
• Rai staging system
• The Rai system was originally devised in 1968. At that time, all that was needed to diagnose CLL was lymphocytosis – a high number of lymphocytes in the blood and bone marrow that didn’t have any other cause (like infection). This was originally defined as over 15,000 lymphocytes/mm3 of blood and at least 40% of the bone marrow being made up of lymphocytes.

There are 5 Stages:

• Rai stage 0: Lymphocytosis and no enlargement of the lymph nodes, spleen, or liver, and with near normal red blood cell and platelet counts.
• Rai stage I: Lymphocytosis plus enlarged lymph nodes. The spleen and liver are not enlarged and the red blood cell and platelet counts are near normal.
• Rai stage II: Lymphocytosis plus an enlarged spleen (and possibly an enlarged liver), with or without enlarged lymph nodes. The red blood cell and platelet counts are near normal.
• Rai stage III: Lymphocytosis plus anemia (too few red blood cells), with or without enlarged lymph nodes, spleen, or liver. Platelet counts are near normal.
• Rai stage IV: Lymphocytosis plus thrombocytopenia (too few blood platelets), with or without anemia, enlarged lymph nodes, spleen, or liver.

Doctors separate the Rai stages into low-, intermediate-, and high-risk groups when determining treatment options.

Stage 0 is considered low risk.
Stages I and II are considered intermediate risk.
Stages III and IV are considered high risk.

Binet staging system

In the Binet staging system, CLL is classified by the number of affected lymphoid tissue groups (neck lymph nodes, groin lymph nodes, underarm lymph nodes, spleen, and liver) and by whether or not the patient has anemia (too few red blood cells) or thrombocytopenia (too few blood platelets).

Binet stage A: Fewer than 3 areas of lymphoid tissue are enlarged, with no anemia or thrombocytopenia.

Binet stage B: 3 or more areas of lymphoid tissue are enlarged, with no anemia or thrombocytopenia.

Binet stage C: Anemia and/or thrombocytopenia are present.

Both of these staging systems are helpful and have been in use for many years.

Prevention of Leukemia Cancer

Acute lymphoblastic

In general, ALL treatment is divided into several phases

1. Induction chemotherapy to bring about bone marrow remission. For adults, standard induction plans include prednisone, vincristine, and an anthracycline drug; other drug plans may include L-asparaginase or cyclophosphamide. For children with low-risk ALL, standard therapy usually consists of three drugs (prednisone, L-asparaginase, and vincristine) for the first month of treatment.
2. Consolidation therapy or intensification therapy to eliminate any remaining leukemia cells. There are many different approaches to consolidation, but it is typically a high-dose, multi-drug treatment that is undertaken for a few months. ALL receive therapy with antimetabolite drugs such as methotrexate and 6-mercaptopurine (6-MP). High-risk patients receive higher drug doses of these drugs, plus additional drugs.
3. CNS prophylaxis (preventive therapy) to stop the cancer from spreading to the brain and nervous system in high-risk patients.
4. Maintenance treatments with chemotherapeutic drugs to prevent disease recurrence once remission has been achieved. Maintenance therapy usually involves lower drug doses, and may continue for up to three years.

Alternatively, allogeneic bone marrow transplantation may be appropriate for high-risk or relapsed patients.

Chronic lymphocytic

• CLL treatment focuses on controlling the disease and its symptoms rather than on an outright cure. CLL is treated by chemotherapy, radiation therapy, biological therapy, or bone marrow transplantation. Symptoms are sometimes treated surgically (splenectomy removal of enlarged spleen) or by radiation therapy (“de-bulking” swollen lymph nodes). While generally considered incurable, CLL progresses slowly in most cases. Many people with CLL lead normal and active lives for many years-in some cases for decades. Because of its slow onset, early-stage CLL is, in general, not treated since it is believed that early CLL intervention does not improve survival time or quality of life. Instead, the condition is monitored over time to detect any change in the disease pattern.
• The decision to start CLL treatment is taken when the patient’s clinical symptoms or blood counts indicate that the disease has progressed to a point where it may affect the patient’s quality of life. Combination chemotherapy regimens are effective in both newly-diagnosed and relapsed CLL. Combinations of fludarabine with alkylating agents (cyclophosphamide) produce higher response rates and a longer progression-free survival than single agents: FC (fludarabine with cyclophosphamide); FR (fludarabine with rituximab); FCR (fludarabine, cyclophosphamide, and rituximab); CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone).
• Monoclonal antibodies, such as alemtuzumab (directed against CD52), rituximab (directed against CD20), and ofatumumab (Arzerra ) (directed against CD20) are also used.

Stem cell transplantation

Younger patients that are at high risk for dying from CLL might consider hematopoietic stem cell transplantation (HSCT). Autologous stem cell transplantation, a lower-risk form of treatment using the patient’s own blood cells, is not curative. Myeloablative (bone marrow killing) forms of allogeneic stem cell transplantation, a high-risk treatment using blood cells from a healthy donor, may be curative for some patients, but most patients cannot tolerate the treatment. An intermediate level, called reduced-intensity conditioning allogeneic stem cell transplantation, may be better tolerated by older or frail patients.

Acute myelogenous:

Many different anti-cancer drugs are effective for the treatment of AML. Overall, the strategy is to control bone marrow and systemic (whole-body) disease, while offering specific treatment for the central nervous system (CNS), if involved. In general, most oncologists rely on combinations of drugs for the initial, induction phase of chemotherapy. Such combination chemotherapy usually offers the benefits of early remission and a lower risk of disease resistance. Consolidation and maintenance treatments are intended to prevent disease recurrence. Consolidation treatment often entails a repetition of induction chemotherapy or the intensification chemotherapy with additional drugs. By contrast, maintenance treatment involves drug doses that are lower than those administered during the induction phase.

Chronic myelogenous:

There are many possible treatments for CML, but the standard of care for newly diagnosed patients is imatinib therapy. In a more advanced, uncontrolled state, when the patient cannot tolerate imatinib, or if the patient wishes to attempt a permanent cure, then an allogeneic bone marrow transplantation may be performed. This procedure involves high-dose chemotherapy and radiation followed by infusion of bone marrow from a compatible donor.