Leukaemia

Chemotherapy and how it is given

Chemotherapy is the use of drugs, known as “cytotoxic”, which destroy rapidly dividing cells like cancer cells. Unfortunately, certain healthy cells in the body also divide rapidly, such as those of the skin and gut, and these can also be damaged by chemotherapy, causing unwanted side effects. (See ‘Unwanted effects of treatments’). The range of chemotherapy drugs and their combinations is huge, and complex protocols for treating different types of leukaemia have been developed in clinical trials. Development continues, so most people diagnosed with leukaemia are invited to join a trial. You can learn about people’s experiences of being invited to take part in a clinical trial in a dedicated section of healthtalk.org; see Clinical Trials.
 
Chemotherapy takes many forms. Stronger chemotherapies are given by injection or drip (often into a vein but sometimes into muscle, under the skin or into the spine) and are usually used in acute leukaemias to destroy the leukaemia cells and allow the bone marrow to work normally. Milder chemotherapies are often used to relieve the symptoms of chronic lymphocytic leukaemia and are given as tablets to take at home. Chemotherapy can be combined with other types of treatment, for example, radiotherapy.
 
Injection into a vein (intravenously)
People with acute leukaemia get most of their chemotherapy intravenously, meaning the drug is injected directly into a vein. Much of their leukaemia treatment will take place in hospital and will require periods when they are given chemotherapy daily, known as ‘intensive chemotherapy’ (see ‘Intensive chemotherapy’ and ‘Being in hospital’). To avoid repeated vein punctures in the arms for injections and taking blood samples, most inpatients have a central line installed in a vein in their chest, arm or groin (e.g. a Hickman line), which can stay there for the duration of treatment (see ‘Central lines’).
 
When intravenous chemotherapy is needed less often than in intensive treatment regimens, a central line is not used and people are treated as outpatients, with the drugs being given through a drip in the arm. Having received intensive chemotherapy in hospital for his acute lymphoblastic leukaemia (ALL), Jim now attends a day centre for occasional intravenous chemotherapy. On other days he takes chemotherapy tablets at home. He advises others to take something with them to pass the time in outpatient sessions.

Two men we spoke to had a rare type of leukaemia called 'hairy cell' leukaemia. Mike attended hospital on five days in a row, for an intravenous infusion of a chemotherapy drug called cladribine or Leustat. Luke attended hospital once a week for six weeks for an infusion of a drug called pentostatin or Nipent. In both cases the infusions took about 2 hours each and no further treatment was needed.

Into the spine (intrathecally)
Some people with acute leukaemia received chemotherapy intrathecally alongside other treatments. This is necessary when doctors think that leukaemia cells have entered the brain, as chemotherapy given by injection into a vein or via a central line does not reach the brain. After giving a local anaesthetic a hollow needle is inserted into the spinal canal (lumbar puncture) and the chemotherapy injected. It is important to stay as still as possible during the procedure and people must lie flat for one or more hours afterwards to avoid headaches. Several people had this type of chemotherapy and most found the procedure bearable but Frances found it the most distressing part of her treatment and developed a phobia about it. Some had problems with pain and headache afterwards.

Oral chemotherapy
Several people with acute leukaemia followed their intensive treatment with so-called ‘maintenance’ chemotherapy in tablet form (oral) and were grateful for the sense of freedom it gave them to be treated at home. Two people with chronic myeloid leukaemia (CML) had a mild oral chemotherapy drug called hydroxyurea immediately after diagnosis to tide them over until more aggressive treatment could be started. Elsa had this drug for her essential thrombocythaemia that preceded her myelodysplastic syndrome (MDS).

Oral chemotherapy is usually the first-line treatment for chronic lymphocytic leukaemia (CLL), typically after a period of watch and wait. At the time these interviews were done the oral chemotherapy drugs commonly used were chlorambucil, a combination of fludarabine and cyclophosphamide (known as FluCy). A typical course of chlorambucil involves several tablets a day taken for the first few days in each month with the rest of the month off to recover. The dose and the number of courses varied. Of those we interviewed most people started with one or more courses of chlorambucil, the mildest drug, and then if necessary moved on to fludarabine or cyclophosphamide or both together ('FluCy').


Nowadays the treatment of choice for CLL is fludarabine and cyclophosphamide combined with an intravenous infusion (through a drip) of the biological therapy, rituximab (see ‘Biological therapies’); this combination treatment is known as FCR. FCR may not be suitable for people with other health issues, who may be given chlorambucil instead.  We have not yet interviewed anyone who had FCR.
Newer drugs for the treatment of CLL are being developed which are proving to be very effective and safe.
 
These treatments aim to reduce the numbers of white blood cells (known as a “remission” in leukaemia) and hence cause a reduction in, or the complete elimination of, symptoms (see ‘Living with the symptoms of CLL’). Remissions vary in length from a few weeks to several years. When treatment is needed after a remission, often the same drug is used as before but after a while it may stop working, so people are switched to one of the others.

One woman had a problem getting her chemotherapy pills. Having seen her consultant late in the day, the pharmacy had closed so she had to return on another day to collect them, only to find that the consultant had not specified the dose or signed the prescription, causing further delays.

In addition to taking chemotherapy tablets, people may be given steroids, anti-sickness drugs, antibiotics and antivirals, all in tablet form. This meant having to take many pills on some days and different numbers of pills on different days at different times, which could be complicated to keep track of, especially for people already taking medicines for other conditions. For a long time after her treatment Deirdre had an aversion to drinking water because she associated it with taking tablets. Despite the large number of tablets they had to take, some felt it was preferable and much easier than attending hospital for intravenous chemotherapy.

Other
Thelma mentioned having intramuscular injections of a trial drug and also injected herself with a chemotherapy called cytarabine (Ara C). Kerry was given chemotherapy via an inhaler because her lungs were affected by her ALL.

Last reviewed: August 2015.

Last updated: August 2015.

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