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Video Transcript: Leukemia and Lymphoma

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt. When you hear the word "cancer," you may think of a tumor growing somewhere in the body. But in leukemia and lymphoma, the cancerous cells travel throughout the body in the blood, bone marrow or lymphatic system. There are some new treatment approaches, and we'll learn about them on the show today.

My guest is Dr. Maria Baer, head of the Hematologic Malignancies Program at the University of Maryland Marlene and Stewart Greenebaum Cancer Center. Dr. Baer is also a professor of medicine at the University Of Maryland School of Medicine.

Welcome to the show.

Maria Baer, M.D.: I am happy to be here.

Ellen Beth Levitt: Can you tell us how these types of cancer are different from solid tumors?

Maria Baer, M.D.: Sure. They arise in the bone marrow throughout the body, or the lymphatic system they tend to involve multiple areas of the body unlike solid tumors at presentation. They are also very treatable and often curable. And because the cells are so accessible, because they are often in the blood, they are readily able to be studied. A lot of what we've learned about cancer we've learned from studying, in particular, leukemia.

Ellen Beth Levitt: How common are these blood cancers?

Maria Baer, M.D.: They are rare compared to cancers such as breast cancer and colon cancer. There are 750,000 individuals in the United States with these disorders at this time. It is less common than the solid tumors. They are important cancers.

Ellen Beth Levitt: How would you describe what leukemia is to your patients?

Maria Baer, M.D.: There are multiple forms of leukemia. But, all of the forms of leukemia are cancers that arise in the bone marrow. And the bone marrow is the spongy substance inside the bones where the blood cells are produced. It has young cells that produce all the blood cells. And they suffer damage. They become cancerous if the damage is not repaired. And it produces leukemia of one sort or another.

Ellen Beth Levitt: What causes leukemia?

Maria Baer, M.D.: We wish we understood that better. We have an increasing understanding that there are certain chromosome changes, molecular changes that are associated with or directly caused by leukemia. Often, for a given individual with leukemia, we don't know why that person developed leukemia. There are a few risk factors. But, our knowledge of why certain people and not others develop leukemia is incomplete. We understand leukemia better and better.

Ellen Beth Levitt: You mentioned that the bone marrow and the blood cells arise from the bone marrow. What cells are affected by leukemia or does the leukemia spring out of, which type of blood cells?

Maria Baer, M.D.: Leukemias arise in progenitor cells that form all of the blood cells. The bone marrow then becomes abnormal, and you have impaired production of the normal blood cells. There are three main types of blood cells: red cells, white cells and platelets. In the acute leukemia all of those become decreased in number. That produces the symptoms of leukemia. So the red cells carry oxygen, and when there are a decreased number of red cells that's anemia. The white cells fight infection, so when those are impaired people have infections and fever. The platelets clot the blood. So when those are decreased in number you have increased bruising and bleeding. That is how it presents with low blood counts.

Ellen Beth Levitt: What actually happens in the blood when somebody has leukemia? Are there abnormal cells that crowd out the normal cells? I know I am describing it in a very sort of simplistic way.

Maria Baer, M.D.: It's different in the different types of leukemia. In acute leukemia, what happens is that the cells are abnormal. They suffer genetic damage, damage to the DNA. Due to the damage they don't mature. So you have an accumulation of immature cells in the bone marrow. And the immature cells suppress the mature cells. Ultimately in full-blown leukemia, then the bone marrow is full of these cells. It looks like crowding. It produces substances that suppress the production of normal blood cells. In the chronic leukemias often the blood cells are not impaired initially. But over time you have increasing impairment of production of these normal blood cells and increasing symptoms.

Ellen Beth Levitt: So people will either get acute or chronic. They are two separate types of the leukemia. When we think of other health problems sometimes we think someone has something acutely, or right away. And then it can become chronic and stays with them for a long period of time. I understand that these terms don't apply in the same way when you talk about leukemia.

Maria Baer, M.D.: That's right. So acute leukemia refers to where leukemia is the primary problem where the cells don't mature. It presents as acute leukemia.

Ellen Beth Levitt: On its own?

Maria Baer, M.D.: Yes, usually. In chronic, the cells mature normally. You have an expansion of their numbers. In chronic myelogenous leukemia, you have what looks like mature white cells. But, there are too many of them. And of course, there is an exception; chronic leukemia in its natural history becomes acute. That's called blast transformation. Chronic's natural history is to become acute.

Ellen Beth Levitt: I guess the goal is to prevent that.

Maria Baer, M.D.: Yes we have new treatments that have done that it's a drastic change.

Ellen Beth Levitt: How do you diagnose leukemia and a type that a person has?

Maria Baer, M.D.: Sure. Sometimes it's apparent from looking at the blood. We look at the counts and a smear and what it looks like. Sometimes it's quite apparent. One has a good idea of looking at the blood. But then the bone marrow needs to be tested. Often you can't tell from the blood or you need additional information that is obtained from the bone marrow.

Ellen Beth Levitt: You look at the DNA of the cells as well?

Maria Baer, M.D.: We look at the cells under the microscope. We look at their appearance. Usually that will tell you what kind, what disease entity you are looking at. But there is more knowledge to be gained from looking at, first of all, the proteins that are expressed on leukemia cells. And then we do a chromosome analysis to look at the chromosome changes and doing a DNA or an RNA analysis to look at the molecular changes, which helps to guide treatment. We know that they signify a better or worse outlook. So we would taper the treatment accordingly, and increasingly, and more exciting, there are specific treatments for specific...

Ellen Beth Levitt: Targeted treatments, I guess.

Maria Baer, M.D.: Yes, that targets the chromosome changes and/or DNA changes. It may occur as a molecule change without the chromosome change. When I say chromosome they develop abnormalities as part of becoming leukemic. It doesn't mean they are hereditary or inherited or passed along. It's always a question when you say chromosome.

Ellen Beth Levitt: That's interesting. Is it important to diagnose it early and if so why?

Maria Baer, M.D.: Yes, with any disease the less symptomatic and less ill a patient is the better shape that they are in the better.

Ellen Beth Levitt: Is their a better prognosis for treatment if you catch it earlier?

Maria Baer, M.D.: Yes, so you want to catch it before it's caused major symptoms or damage, so you don't want to catch it late I would say.

Ellen Beth Levitt: What are the symptoms of leukemia?

Maria Baer, M.D.: With acute leukemia, it's the symptoms of low blood count of the red cells and it causes fatigue and shortness of breath and loss of energy. The low numbers of mature white cells are predisposed to infection. And sometimes dentists diagnose patients with acute leukemia. They come in with recurrent mouth infections or gum swellings. We get referrals from dentists. The low platelets can cause bleeding, bruising and the classic would be nose bleeds. Another symptom is excessive bleeding when people brush their teeth.

Ellen Beth Levitt: That's interesting. A lot of the symptoms may be due to other health problems too.

Maria Baer, M.D.: If it happens once or if something won't go away, it's something to get checked out. It's a recurring problem.

Ellen Beth Levitt: Is leukemia in children different from the kind of leukemia that affects adults?

Maria Baer, M.D.: Yes, children have more acute than chronic leukemia. It's common about 80% of the time and whereas with the adults it's reversed in the disease.

Ellen Beth Levitt: I've heard that it's a lot better now in terms of treatment for children who get leukemia, that they can be treated effectively and that the prognosis for a cure is good?

Maria Baer, M.D.: It is. It's been a major success story in modern medicine from the 1950s when there was one drug that could potentially slow the progress of the disease and then after that, combinations of drugs that could produce a remission. About 80% of the children are cured. It's remarkable. And some of this is through progress in medicine. Some of this is through a lot of clinical trials. Childhood leukemia is rare. It's important that children and people enroll in clinical trials. ... You create a trial that is well-designed and to answer the questions investigators have.

Ellen Beth Levitt: Then you know how the progress is going?

Maria Baer, M.D.: Yes, we are grateful to the patients that go in clinical trials. Ultimately, that is what causes progress. It's important.

Ellen Beth Levitt: You mentioned Gleevec and other targeted drugs now so that the chemotherapy doesn't kill a lot of healthy cells. It's targeted at the cancer cells, right?

Maria Baer, M.D.: Targeted therapies, there are a variety of them that do different things. There are targeted therapies developed to give in conjunction with chemotherapy and specific subsets of the acute leukemia. The gold standard for these wonderful success stories is Gleevec. So in chronic myelogenous leukemia, there is a specific chromosome abnormality, which is an exchange of genetic information between chromosome 9 and chromosome 22. The derivative chromosome is called the Philadelphia chromosome.

Ellen Beth Levitt: Really?

Maria Baer, M.D.: Yes. But, this new segment of DNA that's formed partially from chromosome 9 and partially from chromosome 22 codes for a protein that is an enzyme called BCR able. That cause chronic myelogenous leukemia. There is a direct link between the abnormality and the disease.

Ellen Beth Levitt: It helps to develop a therapy that targets that.

Maria Baer, M.D.: It's extremely successful in treating chronic leukemia. As I said earlier, it has totally altered the outlook for patients in this disease. It's drastically different. It spawned an entire field; now there are newer inhibitors for the rare patients that are resistant to Gleevec. But it happens. Their new inhibiters are being developed. It's a huge field. It has altered the outlook for the disease. It's exciting.

Ellen Beth Levitt: That's great. We have to take a break in a moment. I want to ask you about bone marrow transplants because I understand that it's very difficult for someone whose life really depends on getting the bone marrow transplant if some of the other therapies have not worked. They look for a donor. If they don't have a suitable donor in their family they try to get a donor who is good match from the general public. It's no longer extracting bone marrow from the spine. It's like giving blood essentially?

Maria Baer, M.D.: We say bone marrow transplant. It's a stem cell transplant, which is a bone marrow stem cell. These can be obtained from the blood. Most commonly these days cells for transplants are obtained by the blood from the arm, which circulates through a machine and it circulates back into the body so it's easier than donating bone marrow.

Ellen Beth Levitt: Stay with us. When we come back we'll talk about detecting and treating lymphoma.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland health today. I'm Ellen Beth Levitt. On the show today, we are talking about cancers that affect the blood, bone marrow and the lymph system.

Before the break, we were talking about leukemia and I know that there is another type of blood cancer, called multiple myeloma. How is that different from leukemia?

Maria Baer, M.D.: Multiple myeloma, the cancerous cells are plasma cells which is a mature form the lymphocyte. In presents in older people, itn people with bone problems and often kidney problems. There are wonderful new treatments that are being developed. So the outlook is changing quite a bit also.

Ellen Beth Levitt: That's interesting the age is different. That affects people in older ages.

Maria Baer, M.D.: Typically.

Ellen Beth Levitt: And lymphoma is different? It's different from solid tumors. What is lymphoma? How would you describe that?

Maria Baer, M.D.: Lymphoma is a cancer that arises in the lymphatic system. The cells are lympocytes, and we talked about lymphocytes with acute lymphoblastic leukemia, so they are related. So it does arise more in lymph nodes.

Ellen Beth Levitt: Lymph nodes are in different parts of the body in the neck, under the arm and the groin.

Maria Baer, M.D.: Those are the ones that you can feel externally. There are internal lymph nodes too that one is not aware of but they are there.

Ellen Beth Levitt: What is the purpose of the lymph system?

Maria Baer, M.D.: It helps to form immunity in children. It filters the blood and helps to fight infection. It's a different infection fighting system than the white cells and the bone marrow. They work together and are all necessary.

Ellen Beth Levitt: There are different types as well as? So Hodgkin's and non-Hodgkin's is the major first subdivider. There are multiple subtypes of Hodgkin's and multiple subtypes of non-Hodgkin's? How do these develop, do we know? What causes these abnormal cells within the lymphatic system?

Maria Baer, M.D.: As with leukemia any person that develops one of these diseases often we don't know why they got it rather than someone else. There are some risk factors for non-Hodgkin's lymphoma. Some diseases that deregulate the immune system can predispose to lymphoma.

Ellen Beth Levitt: Such as?

Maria Baer, M.D.: Some of the rheumatologic diseases, such as HIV. There's HIV lymphoma.

Ellen Beth Levitt: And things like arthritis?

Maria Baer, M.D.: It's rare. It's an exception. It's quite rare, but yes, there is an association with inflammatory arthritis, not with osteoarthritis.

Ellen Beth Levitt: What about exposure to certain chemicals in the environment?

Maria Baer, M.D.: Yes, insecticides, pesticides. Paint is more a leukemia, associated with leukemia.

Ellen Beth Levitt: I guess some people are more sensitive to these chemicals because there are plenty of people that can work in industry that are exposed to chemicals and never have the health problem?

Maia Baer, M.D.: Definitely. We are learning about the problem call polymorphisms. It may make them react to them differently. It's a field growing in recent years.

Ellen Beth Levitt: How would you diagnose lymphoma? Is it similar to leukemia, when you look at the cells under the microscope?

Maria Baer, M.D.: Yes, you biopsy the lymph node. You need to look at the architecture not just of cells, but the relationship to each other; and that in combination with also looking at the proteins on antigens on the cells. Typically, it's on the lymph node rather than on the bone marrow.

Ellen Beth Levitt: How often would it be swollen before somebody should be concerned and see their doctor?

Maria Baer, M.D.: It varies. Sometimes a lymph node is swollen acutely in relation to an infection and it gets better. That is not particularly alarming. But, yeah, if it's persisting over time or not related to infections or how big it is how quickly, certainly if people are concerned they should seek medical attention. Unless it's a sore throat or swollen glands it shrinks.

Ellen Beth Levitt: What is the prognosis now for people with these blood and lymphocyte cancers? Is there a lot of hope and research going on?

Maia Baer, M.D.: There is an immense amount of research; laboratory research and clinical trials, as I talked about earlier. There is an amazing expansion of our understanding of biology and development of treatments. This is an incredibly exciting era in study and treatment of these diseases. And the outlook is better and better for targeted treatments, for understanding biology better, to better understand who benefits most from what treatment, including bone marrow transplants.

Ellen Beth Levitt: Many years they were considered experimental, but not today?

Maria Baer, M.D.: That's true. It's not experimental but building on the transplant experience for example, what is called mini transplants that are being developed that can be applied to people who are older. So, there too, there is a tremendous amount going on.

Ellen Beth Levitt: So those aren't as toxic on the body?

Maria Baer, M.D.: Right; you are relying on the immune system.

Ellen Beth Levitt: Triggering the person's immune system?

Maria Baer, M.D.: Actually, the donor immune system to fight the cancer. When you transplant bone marrow or blood cells as we said earlier, part of the effect is that the transplant itself sets up an immune reaction against any lingering cancer cells.

Ellen Beth Levitt: So you are using--

Maria Baer, M.D.: It's graph versus tumor.

Ellen Beth Levitt: That's interesting. Thank you for being our guest today.

Maria Baer, M.D.: Thank you for having me.

Ellen Beth Levitt: My guest has been Dr. Maria Baer, head of the Hematologic Malignancies Program at the University of Maryland Marlene and Stewart Greenebaum Cancer Center. Dr. Baer is also a professor of medicine at the University Of Maryland School Of Medicine.

If you have any comments or questions about this program, please contact me by email at eblevitt@umm.edu.

If you'd like to reach Dr. Baer or any other University of Maryland physician, call 1-800-492-5538 or visit the Web site, there you'll find a great amount of health information and be able to see other "maryland health today" programs. That address is www.umm.edu. Take good care of yourself, and we'll see you next time for "Maryland Health Today."

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This page was last updated on: December 22, 2008.

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