Vacant chairs always leave us wondering who had sat there in the past.
It could be your mum, dad, sister, brother, aunty, daughter, son, friend or colleague diagnosed with cancer. Today, more than ever before in history, cancer is closer to us affecting a person we know. As we accept the reality of cancer and embrace the actuality of more cancer cases today, we need to understand the prevention, causes, treatment and management of cancer. This week, we pull a seat and learn more about Acute Myeloid Leukemia. The first step in defining cancer is to understand that it starts when cells in a part of the body begin to grow out of control.
Prof Jessie Githanga is a haematologist at the University of Nairobi, a specialist who deals with the cause, prognosis, treatment, and prevention of diseases related to blood. This week, she takes us through better understanding of Acute Myeloid Leukemia. We will later audit where Kenya falls in the diagnosis, treatment and management of this type of cancer.
What is Acute Myeloid Leukemia?
The word ‘acute’ denotes the disease’s rapid progression whereas ‘myeloid’ refers to the affected group of white blood cells called the myeloid cells, which normally develop into the various types of mature blood cells.
This type of cancer is caused by damage to the DNA of developing cells in the bone marrow hence blood cell production goes wrong. AML starts in the bone marrow which is the soft inner part of certain bones, where new blood cells are made. Once the cancer starts here, in most cases, it moves into the blood and sometimes can spread to other parts of the body including the lymph nodes, liver, spleen, the brain and spinal cord.
Prof Githanga explains how these changes take place that later leads to cancer.
“When the White Blood Cells transform, they become malignant (cancerous), they rapidly multiply and build up in the bone marrow and blood hence interfering with the normal blood cells,” Prof Githanga said. The normal myeloid cells fight infections. However, when they become cancerous they are unable to function normally hence the individuals with AML are prone to frequent infections, she added.
Prof Jessie Githanga is a haematologist and believes we need more facilities to diagnose and manage AML.
A quick memory trail to our form 2 biology in secondary school, there are three main types of blood cells;
- Red blood cells (RBCs)- carry oxygen from the lungs to all other tissues in the body, and take carbon dioxide back to the lungs to be removed.
- Platelets they are important in stopping bleeding.
- White blood cells (WBCs) help the body fight infections.
The signs and symptoms of AML include;
- Bone pain
- Lethargy and fatigue
- Shortness of breath
- Pale skin
- Frequent infections
- Easy bruising
- Unusual bleeding, such as frequent nosebleeds and bleeding from the gums
So, how is AML diagnosed?
According to Prof Githanga, the diagnosis of AML requires a high index of suspicion from the medical team especially stemming from a person’s initial complaints that can be a great pointer to an AML diagnosis.
“The early features like anaemia (lack of blood), tiredness, weakness, headaches, lethargy and lack of energy among others should be investigated more keenly. Others include signs of bleeding such as nose bleeds, gum bleeding and easy bruising. Prof Githanga also observed that very often the patient will also have frequent infections such as colds, pneumonia, and thrush in the mouth which is a sign of a fungal infection.
It all begins with an accurate diagnosis. Photo by Paweł Czerwiński on Unsplash
The diagnostic tests include;
- A blood test to look at Haemoglobin level, red blood cell levels, white cell counts and platelet count
- Bone marrow examination – the bone marrow is removed from specific areas on the hip (pelvic) bone or sometimes the chest bone
- Other specialised tests determine the exact type of AML n sets off the treatment plan
- Tests to determine infection if present, liver function, kidney function
What risk factors lead to this type of cancer?
A risk factor is something that affects your chance of getting a disease, such as cancer. However, Prof Githanga clarifies that not all persons with a risk factor get a disease.
Whereas the causes of most cases of AML are not known, Prof Githanga notes that the risk for getting this type of cancer increases with age, as it does for many other cancers. “Males are also seen to be slightly more affected than females,’ Prof Githanga said adding that a higher incidence has been noted in person who have previously been exposed to ionizing radiation. Long-term exposure to certain chemicals like benzene has also been found to increase the risk of this type of cancer. Benzene is a solvent used in the rubber industry, oil refineries, gasoline industry, chemical plants, shoe manufacturing. It is also found in cigarette smoke, gasoline, motor vehicle exhaust, some glues, cleaning products, detergents, art supplies, and paints. Smoking has also been linked to AML due to the cigarette smoke, which contains benzene and other known cancer-causing chemicals.
Smoking has also been linked to Acute Myeloid Leukemia. Photo by Patrick Brinksma
Prof Githanga was also keen to add more triggers of AML. “Patients who have been treated for cancer previously with anti-cancer drugs (chemotherapy) are more likely to develop AML in the years following treatment. Certain blood disorders and genetic diseases like Down’s syndrome may predispose one to AML,” she said.
What treatment is available?
Prof Githanga observes that treatment for AML aims at completely getting rid of all the cancerous cells. This can be done through chemotherapy where the anti-cancer medicines are given and their role is to kill all the cancerous cells. However, Prof warns that the chemotherapy can be quite toxic to the patient since the normal cells in the body are also affected. In some types of AML, targeted therapy is an option where a drug only (or majorly) affects the abnormal cell and not the normal cells. Whereas this would be the ideal therapy, this kind of treatment is only available for few cancers.
So which way? Prof Githanga shares her thoughts on the most preferred treatment mode; “Most cases of AML then would undergo a bone marrow transplant (also known as stem cell transplant) depending on the availability of a well-matched donor, the age and general condition of the patient, the type of AML ,’ she says.However in reality, given that the bone marrow transplant is not available in Kenya, the cost of testing potential donors and eventually getting the treatment, becomes prohibitive in most cases.
Kenya faces a great challenge in the diagnosis, treatment and management of AML.
“The diagnosis requires tests that are not widely available in many hospitals locally. Some of the tests to determine the exact type of AML such as molecular genetic tests are not available in-country and specimens would need to be exported to other centres mainly in India, South Africa, or Europe,” Prof Githanga said. She also re-emphasized the inclusion of diagnostic tests noting that many times this is usually delayed due to lack of funds.
On the treatment front, it’s a gloomy side of life;
“There are very few treatment centres for AML in Kenya with most centres in Nairobi and Eldoret. This is because chemotherapy needs to be given in controlled environment where the patient is well monitored. The patient needs to be nursed in a special room with limited/no contact with others especially when very prone to infection (immunosuppressed). Bone marrow transplant (BMT) is also not available in Kenya,” Prof Githanga noted. If the patient opts for the bone marrow transplant abroad, it is important to note that this involves travel with a matched donor who in most cases is a sibling or a parent. Thereafter, follow-up is highly advised because the disease can and often recurs.
Prof Githanga notes that the financial burden of AML treatment weighs heavily on families that do not have any form of health insurance. Prof Githanga cited the need for more research in this area. “We need to undertake clinical trials in Kenya to determine the best type of treatments for our population,” she said. However before the policymakers and scientists chart this part of medical research, what can be done right from our desks and into our homes and the health institutions too?
“There should be an awareness amongst healthcare providers to be keener on the presenting signs and symptom of AML that can be rather non-specific. Patients found with the symptoms should be subjected to careful evaluation that should include the diagnostic/laboratory testing mentioned above to catch the disease early,” Prof Githanga said. She also re-emphasized the need for better insurance coverage for AML, and indeed all cancers, too specifically to include the diagnostic tests as many times noting that this is usually delayed due to lack of funds.
The next steps would be calling for the building centres of excellence in the management of blood cancers. “These centres of excellence need to be in well- equipped facilities with qualified personnel, not only to give chemotherapy but also manage the complications arising from the same,” she added.
Finally, Prof Githanga throws a challenge aimed at preventing the prohibitive treatment abroad in search of treatment.
“Kenya ultimately needs to move towards bone marrow transplant, efforts to start a bone marrow donor registry (a listing of potential marrow donors) should be encouraged. This would make it quicker to identify a potential donor especially if relatives are not a good match,” Prof Githanga concluded.