What is Consolidation in Leukaemia and Why it is Important?

I have described what remission induction in my previous posts. This remission induction is followed by consolidation. Simply, consolidation means giving further treatment, so the patient won’t have the disease again. Consolidation is achieved by giving further treatment when the patient remits. If not, the disease will reappear invariably. The following factors determine whether consolidation will be done or not.

·         Type of leukaemia

·         Patient risk factors

·         The patients tolerance of treatment

Why consolidation is important?

Even though remission induction means bringing the bone marrow and the blood in to normal state, there could be still some leukaemic cells remaining in the bone marrow, undetected. So, these cells can multiply and the disease can relapse. Therefore, there should be a way to prevent these cells from raising their heads. This is where consolidation comes into play. The continuation of the treatment prevent the disease from relapsing again.

References : Kumar P and Clark M, 2009. Clinical Medicine. 7th ed.

Treatment for acute Leukaemia

The following treatment options are available for the patient with acute leukaemia.

1.      Palliative Therapy

2.      Curative Therapy

3.      Active Therapy

Palliative Therapy

Palliative therapy involves both chemotherapy and radiotherapy. The patient is given the opportunity to stay at home as much as possible.

Curative Therapy

This is only done if the benefits outweigh the risks; since the treatment itself carries a considerable morbidity (also read Why Everybody with Acute Leukaemia is not Treated with Curative Intent). The cure can never be guaranteed or even expected in some of the cases. So, it is a controversial issue whether to start treatment of not. This is carefully discussed among the physician and the patient. 

 Curative therapy is given only in specialized centers which handles only about 10 such cases per year. Therefore the patient may have to be transferred to one of such centers. It also involves long term hospitalization. In the first instance the patient will have to be hospitalized for about a month and subsequent admission for several days to weeks. So the patient may have to discuss about their work pale/education, etc.

Even after the successful therapy life won’t be the same for some of the patients.

 Active Therapy

This involves supportive care and specific treatment. 

Supportive Care

Supportive care is targeted at providing comfort to the patient. It treats only for the symptoms. So the each symptom is treated separately.

·         For anaemia – most of the symptoms in leukaemia is due anaemia. So, it is corrected by repeated blood transfusion (packed red cells). Everybody with leukaemia is not transfused with blood. Only those who have severely reduced haemoglobin are transfused.

·         For thrombocytopenia – as mentioned in my previous posts, thrombocytopenia means reduced platelet counts. Their reduction in number results in bleeding tendencies. So the patients bleeding tendencies should be controlled. The exact platelet count is determined before the beginning of the treatment and the decision whether to transfuse or not is taken according to the platelet count. The platelet counts requiring transfusion in uninfected is <10×10⁹ /L and that in infected is <20×10⁹ /L.

·         For leucopenia – As I have mentioned in my previous posts the reduction of white blood cells leads to higher risk of infections. So these infections should be treated. Some of the patients may not have already developed any infections but still they should be treated prophylactically. Prophylaxis means treating in order to prevent a disease. Prevention does not only involve medication. It also contains education of patients, relatives and staff about hand washing and other hygienic activities. That’s why such patients are isolated in hospitals. Appropriate antifungals and antibiotics will be chosen by the physician and prescribed.

Infected patients are treated therapeutically with appropriate antifungals and antibiotics.

·         Another problem they might develop is hyperuricaemia. This condition is treated with hydration and prophylactic alopurinol and rasburicase. So, the patient will be asked to drink plenty of water.  

Specific treatment 

This is targeted in bringing the blood and bone marrow to their normal state. The therapy it self impairs bone marrow function. Therefore, it carries the risk of life threatening bone marrow function. Therefore, the treatment is carried out in a hospital where the patient has his/her separate room, lavatory facilities and lesser risk of infection.

A venous catheter is inserted in to the patient and Cytotoxic drugs are administered through this line. Remission induction and consolidation are achieved.

References : Kumar P and Clark M, 2009. Clinical Medicine. 7th ed.

Why Everybody with Acute Leukaemia is not treated with a Curative Intent

Since acute leukaemia is a rapidly developing disease, it is fatal unless treated as soon as possible. Untreated patient can die within month. Therefore, quick treatment is mandatory. It is very hard to predict the response to the treatment because different people respond differently. Some may get cured, and some may have recurrences. Some of they may even not respond at all. Unsuccessful therapy could be either because the patient cannot withstand the treatment or because the type of leukaemia he/she is having is incurable.

Treatment methods available to cure the disease also carry a very high morbidity rate. This is because the drugs given to the patient can themselves harm the patient’s normal body cells in the process of killing the malignant cells. Therefore curative treatment is given only for those who have low risk (possibly curable) leukaemia.

Childhood Acute lymphoblastic Leukaemia is considered as low risk leukaemia and they are treated with curative intent. Even for them the treatment brings considerable morbidity. The morbidity is even more if the same treatment is given for the high risk groups. So, the physician will weigh the risks against benefits and offer the most suitable treatment option. 

Following leukaemias are considered as probably incurable 

1.      Acute myeloid leukaemia with adverse cytogenetic features in elderly

2.      Secondary acute myeloid leukaemia

3.      Recurrent acute leukaemias

References : Kumar P and Clark M, 2009. Clinical Medicine. 7th ed.