Dr Oladapo Aworanti is a consultant haematologist and the acting Zonal Director of National Blood Service Commission, South-West Zonal Centre. In this interview by SADE OGUNTOLA, he speaks about leukaemia, a blood and bone marrow cancer, challenges of its management in Nigeria, and what Nigerians need to know about it. Excerpts:
W hat is leukaemia and how common is it?
Leukaemia is a cancer of the white blood cells (cells that fight infection) which originates from the bone marrow. The bone marrow is the site of blood cell formation, and these cells migrate into the peripheral circulation thereafter. There are three main types of cells in the blood: red blood cells, white blood cells and then platelets (cells that help the blood clot). These cells have different functions and specific quantities. When there is cancer of the white blood cells, it is referred to as leukaemia. At this point, there is an increase in the number of types of white cells involved (most of the time) and a loss of functions. There are different types of leukaemia based on the type of white blood cells involved and the onset of the disease.
So generally, there are four major types of leukaemia: acute (growing quickly) myeloid leukaemia; acute (grows quickly) Lymphoblastic leukaemia; chronic (growing slowly) myeloid leukaemia and chronic (growing slowly) lympocytic leukaemia
Leukaemia is relatively uncommon in our environment; it is one of the top five most frequent cancers in males, after prostate, colorectal, non-Hodgkin lymphoma and liver cancers, but not one of the top five most frequent cancers in females. Leukaemia constitutes about 10 percent of all haematological malignancies (cancers that affect the blood, bone marrow and lymph nodes).
According to the latest WHO data published in 2020, leukaemia deaths in Nigeria reached 2,257, or 0.15 percent of total deaths. The age-adjusted death rate of 2.06 per 100,000 of the population ranks Nigeria 151st in the world.
How does leukaemia affect a person?
The white blood cells have the major function of fighting infections in the body and thereby protecting mankind. When there is leukaemia, there is a loss of function, and this ability to fight infection is hereby lost. The individual is then prone to all forms of infection. In most cases, when there is leukaemia, there is an increase in number of white cells involved, which will affect the production of other blood cells in the marrow. These patients will now have a reduced number of red blood cells, functional white blood cells and platelets; this is termed bone marrow failure. The patients will have features suggestive of infections, anaemia, and thrombocytopenia (a deficiency of platelets in the blood that results in bleeding problems). White blood cells are crucial for countering infection. If white blood cells do not work correctly, a person may develop frequent infections. The immune system may attack the body’s own cells.
Some of these cells can also infiltrate into organs like the spleen, liver and lymph nodes, so there could be enlarged lymph nodes, an enlarged spleen and an enlarged liver.
Also, because of the anaemia, there may be other symptoms such as faintness and dizziness, weakness, tiredness, shortness of breath, body aches and a rapid heartbeat.
What is the main cause of leukaemia?
The cause of leukaemia is not known most of the time, although genetic disorders such as Down’s syndrome and Fanconi anaemia are risk factors for acute leukaemia. Other risk factors are exposure to radiation, contact with chemicals like benzene, which is found in gasoline and is used by the chemical industry, pesticides, chemotherapy and some viruses.
Scientists have found links between leukaemia and various factors, although more research is needed to confirm most of them. They include a history of certain infections, such as the Epstein-Barr virus, having a high or low birth weight, having parents who smoke tobacco, having a caesarean delivery before labour started, a previous history of chemotherapy and having already had one type of blood cancer.
However, most people with known risk factors don’t get leukaemia. And many people with leukaemia have none of these risk factors.
What are the early warning signs of leukaemia?
Leukaemia can only be picked early if a routine checkup is done; by the time the signs are picked, they are not early signs again. Recurrent infections, generalised body weakness, tachycardia, fever, bleeding gums, or bleeding from any part of the body are signs of leukaemia. These are features of bone marrow failure, as the bone marrow cannot produce other blood cells — red blood cells, platelets and functional white cells. Individuals with leukaemia can also present with swelling in the neck, armpits, groin, and abdomen.
Diagnosis is usually based on repeated complete blood counts and a bone marrow examination following observations of the symptoms. Sometimes, blood tests may not show that a person has leukaemia, especially in the early stages of the disease or during remission.
Following diagnosis, blood chemistry tests can be used to determine the degree of liver and kidney damage or the effects of chemotherapy on the person. When concerns arise about other damages due to leukaemia, doctors may use an X-ray, MRI, or Ultrasound. These can potentially show leukaemia’s effects on such body parts as bones (X-ray), the brain (MRI), or the kidneys, spleen and liver (ultrasound).
Despite the use of these methods to diagnose whether or not a person has leukaemia, many people have not been diagnosed because many of the symptoms are vague, nonspecific, and can refer to other diseases.
Who is most at risk of leukaemia?
Everybody is at risk of leukaemia. Acute lymphoblastic leukaemia is common in children; however, it can also affect adults, typically over the age of 50. Around 60 percent of cases involve children. Acute myeloid leukaemia is more common in adults than children and is more likely to affect males than females. Overall, however, it is rare. Likewise, chronic leukaemia affects more adults. So, everybody is at risk and should watch our backs by doing routine checks.
Can leukaemia cause other cancers or lead to other cancers?
Well, chronic leukaemia can transform into acute leukaemia. For example, a patient with chronic myeloid leukaemia can develop blastic transformation; at this stage, the patient is managed as an acute leukaemia patient. Chronic lymphocytic leukaemia can also transform (Richter’s transformation) into a more serious disease. However, a patient with leukaemia can also have other forms of disease, including cancers. For example, a patient with a form of cancer on a specific chemotherapy regimen can develop secondary leukaemia as a result of the chemotherapy. They also stand a higher risk of developing skin cancer, melanoma of the skin, and cancer of the larynx.
How can an individual reduce his risk of leukaemia?
Ways to reduce the risk of chemotherapy include avoiding all the risk factors that could cause leukaemia. Avoid radiation as much as possible. Every request for radiological investigations should be made by a doctor. Limit the number of X-rays and CT scans so that radiation can be avoided. Also, avoid pesticides as much as possible. The use of a face mask while using these pesticides is advised. For everyone in contact with one form of chemical or another, there is a need to limit the number of hours one get in contact with these chemicals and always use protective coverings. It has been found out that alcohol and cigarettes increase the risk of cancer, not leukaemia alone, so as much as possible, avoid them.
All these risk factors alter the genetic configuration of individuals and predispose them to leukaemia. Some studies have shown that being overweight or obese may increase your risk of leukaemia. You may lower the risk by having a healthy body weight. Eating well and being physically active can help a person have a healthy body weight.
What are the available treatment options for leukaemia in Nigeria?
Basically, treatment options will depend on the type of leukaemia, the person’s age, and their overall health. However, treatment options for leukaemia include chemotherapy and stem cell transplantation. In Nigeria, we have access to conventional chemotherapy for the treatment of leukaemia, except for chronic myeloid leukaemia, for which we have targeted chemotherapy. For proper management of leukaemias with improved outcomes, there is a need for proper diagnosis, which is still difficult or currently not available.
Immunophenotyping and immunohistochemistry to determine the clusters of differentiation (CD) to target in the treatment of haematological malignancies are not readily available in Nigeria. Other molecular tests are also not available in Nigeria. This makes it difficult for us in Nigeria to use targeted drugs for our patients. These drugs that we use in treating leukaemias are not produced in Nigeria, so they are expensive for most patients. There is a need to start producing these drugs in the country. The other treatment option, stem cell transplantation, is not currently available. There are two centres where stem cell transplantation is being done currently in Nigeria, but none is doing it for leukaemia, so we cannot include that as a treatment option in the country.
Can it be cured?
Yes, with stem cell transplantation, leukaemia can be cured, but this is more important for acute leukaemia. For chronic leukaemia, chemotherapy can be used to manage the diseases, and the patients will live a relatively normal life like other individuals without leukaemia. Stem cell transplantation will then be done when there is a form of transformation.
What are challenges with the management of leukaemia?
There are a lot of challenges with the management of leukaemias, from late presentation to the hospital by the patients to a lack of funds to do the needed investigations, wrong or delayed diagnosis due to poor diagnostic facilities, non-availability of the equipment to do the molecular diagnosis, and high cost of medications. There were poor outcomes, such as signing or withdrawing from medical advice due to financial constraints to continue with treatment, which increased morbidity and mortality.
All these are some of the challenges we face when taking care of patients with leukemia. But awareness creation and education on the importance of early presentation to health facilities should be encouraged. The health system should be strengthened by including haematological malignancies in national health insurance and providing well-equipped health facilities for the proper diagnosis and management of haematological malignancies. The government should also subsidise the cost of diagnosis and management of haematological cancers.
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