Treatment types for Chronic T-cell Lymphocytic Leukemia

“Standard to care” refers to the best-known treatment. In cancer care, different doctors work together to bring out an overall treatment plan for the patient. This is called a multidisciplinary team. 

Treatments recommendations depend on many factors:

  • The size, grade and type of tumour
  • Whether the tumour is applying pressure on vital parts of the brain
  • If the tumour has increased to other parts of the body
  • Possible side effects
  • The patient’s preferences and overall health

Watch and wait for active surveillance.

People with leukaemia are monitored with blood and other tests at regularly scheduled checkups during active surveillance. These checkups are done to track blood cell counts and look for other signs of worsening disease. Studies have shown that active surveillance is not harmful to people with certain disease features other than starting treatment earlier.

Treatment begins when people develop signs of worsening disease, such as increasing fatigue, night sweats, enlarged lymph nodes, or decreasing blood cell counts. People with leukaemia are encouraged to talk with their doctors about whether their symptoms need treatment and consider the benefits of treatment compared with the side effects of treatment.

Chemotherapy

Chemotherapy uses medicine to kill or stop the growth of cancerous cells. Depending upon the stage, different chemotherapy is given. The point that makes a difference is how the chemotherapy enters the body and which cells it affects.

Systemic chemotherapy enters the bloodstream to reach cancerous cells all over the body.

A chemotherapy schedule usually consists of a certain number of cycles over a fixed period. A patient can be given one drug at a time or a combination of different drugs given simultaneously.

The side effects depend on the patient and the dose used. Still, they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhoea. These side effects usually go after treatment is completed.

Immunotherapy

Immunotherapy, a type of biological therapy, uses artificial or natural substances to harness our immune system to fight. 

It uses materials formed either by the body or in a laboratory to improve, target, or restore immune system function.

Interferon (Alferon, Infergen, Intron A, Roferon-A) treats ATLL. 

Different types of immunotherapy can cause various side effects. 

Targeted Therapy

Targeted therapy aims at any factor contributing to the growth and development of cancer cells. It can be a specific protein, gene or tissue environment. This treatment blocks the growth and spread of tumour cells while limiting damage to healthy cells.

A targeted therapy called a monoclonal antibody might be used for T-cell leukaemia. It recognizes and attaches to a specific protein on the surface of the leukaemia cells. It does not affect cells that do not have that protein, which can kill some of the leukaemia cells. 

Radiation Therapy

Radiation therapy uses high-energy X-rays or particles to destroy cancer cells. The most common radiation treatment type is external-beam radiation therapy, in which radiation is given from the machine outside the body. Internal radiation therapy or brachytherapy is when radiation treatment is given using implants. A radiation therapy schedule consists typically of a specific number of treatments offered over a set period.

Surgery

The spleen helps form the body’s white blood cells. Surgery to remove the spleen is known as splenectomy. This may be suggested for some patients. 

Before surgery, talk to the health care team about the possible side effects of the specific surgery.

Stem cell Transplantation/Bone marrow Transplantation

A stem cell transplant is a medical process in which bone marrow that contains the cancer is replaced by highly specialized cells. These cells, known as hematopoietic stem cells, develop into the healthy bone marrow. Hematopoietic stem cells are the blood-forming cells found in the bloodstream and the bone marrow. These stem cells form all of the healthy cells in the blood. Presently, this procedure is more commonly called a stem cell transplant than a bone marrow transplant because it is the stem cells in the blood typically being transplanted, not the actual bone marrow tissue.

Before suggesting transplantation, doctors talk to the patient and family members regarding the risks of this treatment. They will also consider several other factors, like age and general health, cancer type, and previous treatment results.

Stem cell transplantation is not a standard treatment option for people with T-cell leukaemia because it is not always an effective treatment for this disease. Many patients with this disease are older, and the procedure’s risks are higher. 

There are two types of stem cell transplantation depending on the source of the replacement blood stem cells – autologous (AUTO) and allogeneic (ALLO). AUTO uses the patient’s stem cells, while ALLO uses donated stem cells. In both types, the goal is to destroy all cancer cells in the blood, marrow, and other body parts using high doses of chemotherapy or radiation therapy and then allow replacement blood stem cells to create healthy bone marrow.

ALLO transplants are the more common type for patients with chronic T-cell leukaemia.

Side effects depend on the general health, the type of transplant, and other factors.

Palliative Care 

Cancer and its treatment have side effects that can be mental, physical or financial and managing the effects are palliative or supportive care.

Palliative care includes medication, nutritional changes, emotional and spiritual support and other relaxation therapies. 

Palliative care focuses on alleviating how you feel during treatment by managing symptoms and supporting patients and their families with other non-medical needs. Regardless of type and stage of Cancer age, any person may receive this type of care.

Treatments specific to T-cell leukaemia type

  • LGLL – For LGLL, active surveillance is sometimes suggested during its early stages, with treatment beginning once symptoms develop. When treatment for the disease is required, LGLL can be treated with drugs that lower the immune system-
    • Cyclosporine (Gengraf, Sandimmune, Neoral), which may also be used when low neutrophil and platelet levels cause problems
    • Low-dose methotrexate (multiple brand names)
    • Cyclophosphamide (Neosar)

Sometimes, low levels of neutrophils cause infections that need antibiotics. Treatment with growth factors, like filgrastim (Neupogen, Zarxio), which helps to stimulate the growth of neutrophils, is sometimes used when infections from low neutrophil counts become a problem. Treatment with a combination of drugs is sometimes used if the disease worsens quickly. The combination is similar to that used for aggressive lymphoma. 

  • T-PLL- T-PLL may be treated with the following drugs-
    • Chlorambucil (Leukeran)
    • Fludarabine (Fludara)
    • Doxorubicin (Adriamycin)
    • Cyclophosphamide
    • Prednisone (multiple brand names)
    • Vincristine (Vincasar)
    • Pentostatin (Nipent)
    • Alemtuzumab (Campath), a monoclonal antibody that has helped manage T-PLL for some patients
  • Adult T-cell leukaemia/lymphoma (ATLL)- ATLL may be treated with zidovudine (Retrovir) and recombinant interferon-alpha in the chronic or acute phase. Treatment aims to strengthen the immune system and treat the human T-cell leukaemia virus (HTLV). The lymphoma phase is usually treated with combination chemotherapy.
  • Sezary syndrome – Treatments for Sezary syndrome may focus on the skin or include systemic whole-body treatments. Skin treatments include the following-
    • The use of light to kill cancer cells is called phototherapy.
    • Skin creams
    • Radiation therapy, including total skin electron-beam radiation therapy, can treat the skin’s entire surface.

Systemic treatments for Sezary syndrome include the following. The treatment choice depends on the extent of the disease and other factors.

  • Chemotherapy
  • Oral bexarotene (Targretin), a drug that resembles vitamin A
  • Denileukin diftitox (Ontak) is an antibody that helps deliver a drug directly to the leukaemia cells.
  • Alpha interferon
  • Alemtuzumab may also be effective.
  • Vorinostat (Zolinza) and romidepsin (Istodax) for cutaneous T-cell lymphoma if other treatments do not work.
  • Sometimes, ALLO stem cell transplantation.

Refractory T-cell Leukemia

If leukaemia continues to worsen despite treatment, it is called refractory leukaemia. If this happens, it is good to talk to doctors who have experience treating it. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials can be an option. 

The treatment plan may include a combination of chemotherapy, immunotherapy, and targeted therapy. Palliative care will also be essential to help relieve symptoms and side effects.

Remission and chance of recurrence

When cancer can’t be detected in the body, and there are no symptoms, this is known as remission. This may be called having ‘no evidence of disease’.

A remission can be temporary or permanent. Many people worry about the recurrence of cancer.

The doctor performs another round of tests to know the extent of the recurrence.

Mainly the treatment plan includes the treatments explained above, like surgery, chemotherapy, radiation therapy, and targeted therapy.

If treatment doesn’t work

If cancer can’t be treated or controlled, it leads to advanced or terminal cancer. It is vital to have straightforward conversations with your health care team to express your feelings, preferences, and concerns. The health care team has unique skills, knowledge, and experience to assist patients and their families. Ensuring that a person is physically comfortable, free from pain, and emotionally supported is extremely important.