Consultant Paediatric Haematologist and Oncologist Dr Anselm Lee was in Sri lanka recently to attend sessions of the College of Physicians . Attached to the, East Shore Medical Centre, Singapore of Parkway hospital Dr Anselm Lee spoke on Leukemia and stem cell transplantation to a group of journalists. Here is an excerps from the interview

Dr Anselm Lee helped established the paediatric bone marrow transplantation (BMT) programme in the Queen Mary Hospital, Hong Kong. He performed the first BMT for thalassaemia. In 1994, Dr Lee performed the first case of umbilical cord blood transplantation in Hong Kong. In 1995, Dr Lee moved to Tuen Mun Hospital and successfully restructured its paediatric haemotology and oncology service.

A graduate of the University of Hong Kong, Dr Anselm Lee received his postgraduate training in the Department of Paediatrics in Queen Mary Hospital, His subspecialisation in paediatric haemotology and oncology started in 1990. As a Croucher Foundation Fellow, Dr Lee trained in paediatric oncology and bone marrow transplantation (BMT) in the institute of Child Health, Department of Haematology and Oncology, the Great Ormond Street Children’s Hospital London.

Leukeamia is a type of cancer that affects the bone marrow and lymphatic tissues. All cancers begin in cells, which make up blood and other tissues. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. This is known as leukeamia where the bone marrow produces abnormal white blood cells that eventually crowd out other cells.

When asked what causes it doctor Amselm Lee said that the doctors cannot always explain why one person develops leukeamia and another does not. However, we do know that a person with certain risk factors may be more likely than others to develop leukeamia.

He said studies have found that individuals who are exposed to very high levels of radiation and industrial chemicals (such as benzene and formaldehyde) are at increased risk of leukeamia.

Also, patients who are treated with anti-cancer drugs (such as alkylating agents) sometimes develop leukeamia many years later. Additionally, patients who are affected by Human T-cell leukeamia virus-I (HTLV-I) are also susceptible. Other risk factors for leukeamia include individuals with certain genetic (such as Down’s syndrome) or blood (such as myelodysplastic syndrome) disorders.

The symtoms he pointed out like all blood cells, leukeamia cells travel through the body. Depending on the number of abnormal cells and where these cells collect, patients with leukeamia have a number of common symptoms which may include:

= Fevers or night sweats

= Frequent infections

= Feeling weak or tired

= Headache

Bleeding and bruising easily (bleeding gums, purplish patches in the skin, or tiny red spots under the skin)

= Pain in the bones or joints

= Swelling or discomfort in the abdomen (from an enlarged spleen)

= Swollen, especially in the neck or armpit

= Weight loss

Speaking about the diagnosis he said If you have a symptom or screening result that suggests leukeamia, your doctor must find out whether it originates from the cancer or other health conditions. You may be required to do some blood tests and diagnostic procedures:

= Physical Examination - The doctor checks for any swelling of the lymph nodes, spleen, and liver.

= Blood Tests - The laboratory checks the level of blood cells. Leukeamia causes a very high level of white blood cells and low levels of platelets and hemoglobin, which is found inside red blood cells. The lab also may check the blood for signs of any arising liver and/or kidney problems.

= Biopsy - The doctor removes some bone marrow from the hipbone or another large bone. A pathologist examines the sample under a microscope to look for cancer cells. This is called a biopsy and it is the definitive way to know whether leukeamia cells are in the bone marrow.

= Cytogenetics - The laboratory examines the chromosomes of cells from samples of peripheral blood, bone marrow, or lymph nodes.

= Spinal tap - Using, a long thin needle, the doctor carefully removes some of the cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). The procedure takes about 30 minutes and is performed under local anesthesia. The patient must lie flat for several hours afterward to keep from getting a headache. The laboratory checks the fluid for leukeamia cells or other signs of problems.

= Chest x-ray - The x-ray can reveal signs of disease in the chest.

Speaking about the treatments offered he said that most patients with leukeamia receive chemotherapy. This type of cancer treatment uses drugs to kill leukeamia cells. Depending on the type of leukeamia, the patient may receive a single drug or a combination of two or more drugs.

People with leukeamia may receive chemotherapy in several different ways: said the doctor. It can be by mouth or by injection directly into a vein (or intravenous)

It can be Through a catheter (a thin, flexible tube) placed in a large vein, often in the upper chest-The nurse injects medicine into the catheter, to minimize the need for multiple injections. This reduces discomfort and/or injury to vein/skin. By injection directly into the cerebrospinal fluid - If the pathologist finds leukeamia cells in the fluid that fills the spaces in and around the brain and spinal cord, the doctor may order intrathecal chemotherapy said Dr Amslem. The doctor injects drugs directly into the cerebrospinal fluid. This method is used because drugs given by IV injection or taken by mouth often do not reach cells in the brain and spinal cord pointed out the doctor.

People with certain types of leukeamia receive biological therapy to improve the body’s natural defenses against cancer. The therapy is given by an injection via a vein.

For some patients with chronic lymphocytic leukeamia, the type of biological therapy used is a monoclonal antibody that binds to the leukeamia cells. This therapy enables the immune system to kill leukeamia cells in the blood and bone marrow. For others with chronic myeloid leukeamia, the biological therapy used is a natural substance called interferon to slow the growth of leukeamia cells.

Radiation therapy (also called radiotherapy) uses high-energy rays to kill leukeamia cells. For most patients, a large machine directs radiation at the spleen, the brain, or other parts of the body where leukeamia cells may have collected. Some patients receive radiation that is directed to the whole body. (Total-body irradiation usually is given before a bone marrow transplant).

Some patients with leukeamia have stem cell transplantation. A stem cell transplant allows a patient to be treated with high doses of drugs, radiation, or both. The high doses destroy both leukeamia cells and normal blood cells in the bone marrow. Later, the patient receives healthy stem cells through a flexible tube that is placed in a large vein in the neck or chest area. New blood cells develop from the transplanted stem cells.

After a stem cell transplant, patients usually stay in the hospital for several weeks. The health care team protects patients from infection until the transplanted stem cells begin to produce enough white blood cells. What type of support is available for leukemia. In Singapore the CanHOPE, a ParkwayHealth initiative together with the multi-disciplinary team of doctors tries to bring about a holistic approach to cancer care at no extra cost. Counsellors manned its cancer counselling service through a hotline and email to provide emotional and psychosocial support to all patients and caregivers to assist them to cope effectively with cancer. A ‘meet and greet` service with face-to-face counselling can also be arranged.

Patients, health care professionals and the general public can also receive up-to-date cancer information, its related screening tests, treatment and referral to appropriate cancer services, resources for further rehabilitation and support services, advice on side-effects of cancer treatment, coping strategies, diet and nutrition.