Haemato-Oncology Nursing

This course is aimed at new starters in Haemato-oncology learning and those who want to refresh their knowledge. We will cover the basic knowledge and skills you need to be confident in your role.

Module 1: Understanding Blood Cancers

Contents

Leukaemia

  • Acute Leukaemia
  • Acute Leukaemia Symptoms and Treatment
  • Chronic Leukaemia
  • Chronic Leukaemia Symptoms and Treatment

Lymphoma

  • Hodgkin Lymphoma
  • Hodgkin Lymphoma Treatment
  • Non-Hodgkin Lymphoma
  • Non-Hodgkin Lymphoma Treatment

Myeloma

  • Symptoms
  • Treatment

Other Blood Disorders

Leukaemia

Leukaemia is a type of blood cancer that affects blood cells, usually white blood cells, and bone marrow. White blood cells are an important part of your immune system that fight infection, and bone marrow is where blood cells like these are made.

People with leukaemia have large numbers of abnormal blood cells, usually types of white blood cell, which take over the bone marrow and spill out into the bloodstream. Other areas that might be affected are lymph nodes (glands), spleen, liver, testes, the membranes surrounding the brain and spinal cord, gums and skin.

Leukaemia is divided into many different types – some which develop faster (acute leukaemias) and others which develop more slowly (chronic leukaemias). Each type of leukaemia acts differently, and will need to be treated differently. When you’re looking for information about leukaemia, it really helps to know the proper medical diagnosis so that you can find the right information.

Acute Leukaemia

ALL affects cells called lymphoblasts (or blast cells, for short). They’re a type of white blood cell, which are a vital part of your immune system. Lymphoblasts are the immature cells that should develop into lymphocytes, in your bone marrow.

Your body needs new lymphocytes all the time, and it usually makes the right amount. When people have ALL this process goes wrong. The blast cells reproduce too quickly, and they don’t mature properly. We’ll refer to these immature blast cells as leukaemia cells.

The leukaemia cells build up in your bone marrow and eventually there’s no room for normal blood cells to be made there. So your body doesn’t have enough white blood cells, red blood cells, or platelets to work properly.

ALL develops more quickly than some other blood cancers, so quick diagnosis and treatment are really important.

Acute myeloid leukaemia (AML) is a type of blood cancer. In AML, the cells in the bone marrow that produce myeloid cells become cancerous.

AML is a form of cancer which affects a type of blood cell called myeloid cells, which include red blood cells, platelets and certain types of white blood cells. When you have AML, it stops you making enough of these blood cells, which makes you unwell. The symptoms you get will depend on the type of blood cell your body isn’t making enough of.

As blood cells are made in the bone marrow, the cancer will be present in the bone marrow and in the blood.

Acute Leukaemia: Symptoms and Treatment

The main signs and symptoms you get with ALL and AML are due to you not having enough normal blood cells, because there are too many blast cells in your bone marrow. This can cause a number of symptoms, which may make you feel run down, or like you’ve got the flu. The four most common signs and symptoms are:

  • Fatigue
  • Bruising and bleeding
  • Infections
  • Weight loss

Phases of treatment for ALL

Chemotherapy is the main active treatment for ALL. You’ll be offered a combination of chemotherapy drugs in line with your treatment plan (your healthcare team may call this a protocol or regimen)

Phase 1: remission induction

The aim of this first phase of treatment is to get you into remission. This involves using several chemotherapy drugs in combination. The goal is to clear the cancer cells completely from your bone marrow and blood.

Phase 2: consolidation

 

This phase is also sometimes called post-induction or post-remission therapy.

It’s possible that some leukaemia cells could still remain after your initial chemotherapy, even if doctors can’t see any under the microscope. So when the induction phase is finished, you’ll have further chemotherapy to clear any leukaemia cells that might remain in your blood and bone marrow.

Some people may be offered a stem cell transplant (also called a bone marrow transplant) during this phase.

Phase 3: maintenance

Maintenance therapy aims to prevent relapse and usually involves low doses of chemotherapy and steroids. 

Treatment for AML

Intensive Treatment

Although each patient is treated on an individual basis, intensive chemotherapy treatment is normally appropriate if you’re under 70–75 years of age and you have good medical fitness.

You’ll have intensive treatment in two phases called remission induction therapy and consolidation therapy. This treatment involves strong chemotherapy which often successfully kills the leukaemia cells, but it’s associated with more severe side effects. 

Non-Intensive Treatment

Non-intensive treatment involves low doses of chemotherapy. Non-intensive treatment can be less effective in guaranteeing long term remission but it’s much less toxic. This may be a better option if you’re older or have other medical problems.

Chronic Leukaemia

What is Chronic Lymphocytic Leukaemia?

If you’ve got CLL, your body produces too many of a certain type of white blood cell called lymphocytes which don’t work properly. They then build up in the bone marrow, which means there isn’t room for enough normal blood cells to be made. This is what causes most of the symptoms that people with CLL get. 

What is Chronic Myeloid Leukaemia?

Chronic myeloid leukaemia (CML) is a cancer of the blood. There are three stages of CML and most patients are diagnosed in the early or chronic phase. In this phase your body makes too many mature white blood cells called granulocytes.

If the disease is left untreated it progresses through a period of instability known as the accelerated phase, to the blast phase. In this phase there are too many immature cells (blast cells). You have very few blast cells in your blood or bone marrow if you’re in the chronic phase. The granulocytes can collect in the spleen, making it swell. The spleen is part of your lymphatic system. It’s an organ on your left side, under your ribs.

The blasts can overcrowd the bone marrow, meaning there isn’t enough room for other important blood cells to be made. This can cause many of the signs and symptoms of CML.

Chronic Leukaemia: Symptoms and Treatment

CLL: Symptoms

It’s likely that you won’t have any symptoms at all before or when you’re diagnosed. That’s why so many patients with CLL are diagnosed after routine blood tests or when a doctor finds swollen lymph glands at a check-up.

Some patients may notice early symptoms and signs such as:

  • tiredness
  • swollen lymph nodes
  • frequent infections.

Other people may notice the symptoms below, which might mean you need to have treatment soon after you’re diagnosed. Some patients have one or two of the symptoms; others may have all of them:

  • weakness
  • fatigue
  • night sweats
  • weight loss
  • repeated infections.

CLL: Treatment

The first treatment you have after being diagnosed is called initial or first-line treatment. The aim of initial treatment is to reduce the number of CLL cells, to get control of the disease. Other treatments include:

 

 

 

  • Clinical trials

  • Chemo-immunotherapy

  • FCR

  • Alemtuzumab

  • Bendamustine and chlorambucil

  • Ofatumumab

  • Radiotherapy

  • Stem cell transplant

 

CML: Symptoms in the chronic phase

Symptoms in this phase are usually quite vague, and appear and develop very slowly. Remember that many of these symptoms are very common, and are often caused by other things. They include:

  • fatigue, or tiredness – this is sometimes caused by anaemia
  • loss of appetite
  • unexplained weight loss
  • increased sweating, particularly at night
  • abdominal bloating, swelling and occasionally pain (if your spleen is enlarged)
  • blurred vision
  • unusual or excessive bleeding – for example from your gums or nose.

Most patients with chronic phase CML will have an enlarged spleen, which may cause abdominal discomfort (tenderness around the stomach) and a feeling of fullness when you eat. Rarely, the liver might be enlarged at the time of diagnosis.

Symptoms in the accelerated phase

If you’re in the accelerated stage, your symptoms don’t normally change much from the chronic stage. Progression to this stage is measured by looking at changes in your blood, bone marrow and blast count. This stage may sometimes indicate a progression to the more aggressive blast stage. The change in symptoms you might notice from chronic stage is an increase in bone pain, which may be caused by leukaemia cells building up in your bone marrow.

Symptoms in the blast stage

It’s rare for people to be diagnosed at the blast phase, sometimes known as ‘blast crisis’. It’s also rare, with current treatments, for people to progress from the chronic to blast phase, but both of these things can happen. People in the blast phase often have noticeable extra symptoms. These may include:

  • weight loss
  • fever
  • bone pain
  • tiredness or fatigue
  • bruising more easily than normal
  • unusual bleeding, for example from your gums or nose
  • repeated infections
  • painful haemorrhages
  • swollen lymph nodes
  • blast cells may be present in the fluid which surrounds the brain and spinal cord, and this can cause severe headaches.

CML: Treatment

The most common treatment for CML are drugs called tyrosine kinase inhibitors (TKI). The very first TKI to be made, which is still the most commonly used, is called imatinib. Once the diagnosis is confirmed, your doctors will prescribe a TKI. The aim of treatment is to get you into remission.

The usual drugs you’ll have for your first treatment, if you’re diagnosed in the chronic phase, are standard doses of one of the TKI licensed for first-line use, such as imatinib, dasatinib or nilotinib. These drugs allow most people with CML to return to a virtually normal lifestyle, including continuing to work and study.

Test: Leukaemia

  • True
  • False
Leukaemia is divided into different types - some of which are acute (develop faster) and some are chronic (develop over a longer period of time).

Complete this statement

, unexplained bruising and  are possible symptoms of leukaemia.

Lymphoma

Lymphoma is a type of blood cancer that affects blood cells called lymphocytes and the lymphocyte-producing cells in your body.

Lymphocytes are one type of white blood cell and are part of the immune system, which defends the body against infection. When you have lymphoma some of your lymphocytes don’t work properly. Sometimes they aren’t developed fully (they’re immature), they divide in an abnormal way, or they don’t die when they should. These abnormal lymphocytes can build up in your lymph nodes (also known as glands – bean-shaped organs that act as a filter to catch viruses, bacteria and other foreign material), causing them to swell and form a lump.

This image shows the location of lymph nodes in the body.

Types of lymphoma

There are two main kinds of lymphoma – Hodgkin lymphoma and non-Hodgkin lymphoma.

Hodgkin lymphoma (HL)

In Hodgkin lymphoma, the abnormal cells are called Reed–Sternberg cells; these are always present if you have Hodgkin lymphoma. Reed–Sternberg cells are a type of white blood cell called a B lymphocyte that has become cancerous.

Non-Hodgkin lymphoma (NHL)

Any other lymphoma without these cells is called a non-Hodgkin lymphoma (NHL). There are lots of different types of NHL. To make things clearer, doctors put non-Hodgkin lymphomas into two groups depending on how fast they grow and spread.

  • Low-grade NHL: this usually develops slowly and is said to be a more ‘chronic’ disease. This means that people may not need treatment for many years.
  • High-grade NHL: this refers to lymphoma that usually develops quickly and needs treatment.

Hodgkin Lymphoma

 In Hodgkin lymphoma, the abnormal cells are called Reed–Sternberg cells; these are always present if you have Hodgkin lymphoma. Any other lymphoma without these cells is called a non-Hodgkin lymphoma. Reed–Sternberg cells are a type of white blood cell called a B lymphocyte that has become cancerous.

The most common place where patients find a lump caused by Hodgkin lymphoma is the neck or chest but they can occur anywhere in the body where there are lymph nodes and also in some organs. There are two main types of Hodgkin lymphoma:

  • classical Hodgkin lymphoma
  • nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL).

Common symptoms

The most common symptom of Hodgkin lymphoma is one or more swellings in the neck or above the collar-bone – these are swollen lymph nodes. Usually the enlarged nodes are painless, but in about 1 in 10 cases they become painful after drinking alcohol.

You might also get swollen lymph nodes in your armpit or groin. However, if you have Hodgkin lymphoma you can get swelling in any of your lymph nodes.

If the affected node is deeper in your body, rather than just beneath the surface of your skin, then the swelling may not be visible. However, you may experience other symptoms, caused by the pressing of this lump against another organ. For example, if you develop Hodgkin lymphoma in your chest you may feel chest pain, a cough or breathlessness. This can sometimes be found during a routine chest x-ray, at a time when you have no other symptoms.

B Symptoms

There are three specific symptoms of Hodgkin lymphoma known as B symptoms. Having or not having these can affect which treatment is right for you, because they can show how far the lymphoma has spread. These symptoms are:

  • fever
  • weight loss
  • night sweats.

Hodgkin Lymphoma: Treatment

Chemotherapy

Most patients with Hodgkin lymphoma will have chemotherapy. This is usually a combination of drugs known as ABVD, This stands for:

  • A Adriamycin™, also known as doxorubicin or hydroxydaunorubicin.
  • B bleomycin
  • V vinblastine
  • D dacarbazine

Steroids

You may take steroids as well as chemotherapy drugs. Steroids can make some chemotherapy treatments more effective and reduce sickness you may get. The steroid normally given to reduce sickness is called dexamethasone, which is given as an injection or as a tablet.

If you’re taking steroids, you should carry a card around with you which makes this clear, so doctors will know in case of an emergency. Your healthcare team should give you one of these cards.

Radiotherapy

Radiotherapy uses high energy rays to kill cancer cells in a specific area. It can be an effective treatment for diseases which affect a particular part of the body, such as lymphoma.

Non-Hodgkin Lymphoma

NHL is divided into two main groups:

  • Low-grade lymphoma: this usually develops slowly and sometimes doesn’t require treatment at the time of diagnosis.
  • High-grade lymphoma: this usually develops more quickly and usually requires more urgent treatment.

Watch this video for more information: 

Main symptoms

The main symptom of  NHL is having swollen lymph nodes. You might have heard this being called ‘swollen glands’. Your glands will get bigger quite quickly but won’t usually be painful.

The most common place for you to notice these would be in your neck, armpit or groin. In these areas the lymph nodes lie just under the skin, so you’re more likely to notice if they are swollen.

Sometimes, the affected lymph nodes can be deeper in your body. You may not be able to see the swelling, but you might have other symptoms caused by this. The symptoms you get will depend on where the swollen lymph nodes are in your body, and which organs they’re pressing against.

These symptoms might include:

  • chest or abdominal (stomach area) pain
  • bone pain
  • skin lumps
  • coughing or breathlessness.

B symptoms

You might also have some of the following symptoms. Together these are known as ‘B symptoms’:

  • fever (greater than 38°C)
  • drenching night sweats which soak your nightclothes and bedding
  • unexplained weight loss in the last six months (10% or more of your previous weight).

Non-Hodgkin Lymphoma: Treatment

Low-Grade NHL: Treatment

Early stage: stages 1A and 2A without symptoms

NHL at this stage is classified as early stage – this means that the lymphoma hasn’t spread and you’ll have no symptoms aside from a lump at the time of your diagnosis. It’s also called localised lymphoma, which means that the glands affected by the cancer are close together. Only a small number of patients will fit this description when they’re diagnosed.

Your healthcare team will normally recommend having only localised radiotherapy (radiotherapy that’s only given directly to the area where the lump is). This is usually given over about 12–17 days.

If after you have radiotherapy your healthcare team is confident that all the lymphoma cells have been killed, you might not need any more treatment. You’ll be monitored carefully. If the radiotherapy hasn’t killed all the lymphoma cells, you and your healthcare team will discuss an alternative treatment plan with you.

Advanced stage with no symptoms

If the lymphoma has spread but you don’t have symptoms when you’re diagnosed, your consultant might recommend that you don’t start treatment immediately – this is called ‘watch and wait’. Instead, you’ll have regular appointments with your healthcare team and you’ll be carefully monitored.

In the first year after your diagnosis you’ll usually have appointments every three months. In the second year after your diagnosis, you’ll have appointments every three to four months. After two years, there’ll then be bigger intervals between your appointments depending on if the disease is progressing. You’ll have more scans that will look at glands inside your body, to find out if this is the case.

It can be hard to find out that you have cancer but that it won’t be treated immediately. If you have any questions or worries, do discuss them with your healthcare team. Our online community is also a good place to hear from other people going through the same thing.

High-Grade NHL: Treatment

Treatment regimens

There are many different treatment regimens used to treat high-grade NHL. Your healthcare team will talk you through the different options and explain why they’re recommending a certain treatment plan.

Which drugs you take will depend on where the lymphoma is in your body and on other factors like the stage of the cancer.

R-CHOP

The most common combination of drugs is called R-CHOP, which includes the following drugs:

  • rituximab
  • cyclophosphamide
  • hydroxydaunorubicin
  • Oncovin™, which is the trade name for a drug called vincristine
  • prednisone, a steroid tablet.

If you’re not fit enough to have R-CHOP, you might be given a modified version of these drugs. You’ll be given this as an outpatient as an infusion (through a drip).

Test: Lymphoma

Select the location of the lymph nodes on this body diagram.

Test: Lymphoma Symptoms

  • Drenching night sweats are
    a B symptom of lymphoma.
  • Englarged lymph nodes are
    a symptom of lymphoma.

Test: Lymphoma

What are the two main types of lymphoma called?

Myeloma

Myeloma is a type of cancer which affects plasma cells. A plasma cell is a type of white blood cell which produces antibodies to fight infection.

When you have myeloma, too many abnormal plasma cells are made in your bone marrow (the spongy tissue inside your bone where your blood cells are made). This also means there isn’t enough room for normal red and white blood cells, which both play an important role in keeping you well.

Usually the bone marrow is affected in a number of places around your body, which is why myeloma is sometimes known as ‘multiple myeloma’.

Myeloma is divided into two main groups:

Smouldering or asymptomatic myeloma

This is where there are no symptoms or tissue damage.

Symptomatic myeloma

This is where there are symptoms and/or tissue damage.

Types of myeloma

A large majority of myeloma patients will have a type of disease called IgG or IgA myeloma. If you’re healthy your body will produce a similar number of each of the heavy chain antibodies. In myeloma, too many of one type of antibody is produced, meaning that the healthy ones can’t effectively fight infection. IgG is the most common type of myeloma – 66% of cases are this type. 20% of patients will have type IgA, whilst the other types are very rare. However, all of these five types of myeloma are treated in the same way.

Free light chain myeloma (formerly known as Bence Jones myeloma)

One in five people get this type. This is where the body produces antibodies that are incomplete, so they may not have a Y shaped heavy chain, only the light chain (either kappa or lambda).

If you have this type of myeloma a special test known as the serum free light chain assay, or Freelite assay, will be done to detect the abnormal light chains.

Patients with this type of myeloma should receive guidance from their healthcare team about taking extra care of their kidneys, because these free light chains can damage them. These antibodies are referred to as ‘free light chains’ because they are unattached to the heavy chains.

Non-secretory myeloma and oligosecretory myeloma

Fewer than one in 100 people get true non-secretory myeloma. This is where the cancerous plasma cells do not produce any paraprotein at all. Oligosecretory myeloma is when the plasma cells only produce very small amounts of paraprotein.

Myeloma: Symptoms

About three out of 10 patients with myeloma are diagnosed at a time when they have no symptoms. The most common symptom, if you do have any, is back pain which is more severe and lasts longer than normal back pain.

Myeloma can damage muscle, bone, and the kidneys. The symptoms linked to this are often described as ‘CRAB’ because they are due to too much calcium in the blood, renal (kidney) damage, anaemia or bone damage.

Too much calcium in the blood might lead to:

  • nausea (feeling sick)
  • low appetite
  • constipation
  • needing to pass urine more often
  • feeling thirsty or being dehydrated
  • not having as much energy as usual
  • feeling confused or dazed.

Renal (kidney) damage can lead to:

  • itchy skin
  • nausea (feeling sick)
  • impotence in men
  • fluid retention that can make you short of breath or cause your ankles to swell.

Anaemia can lead to:

  • tiredness
  • breathlessness
  • paleness.

Some patients also have symptoms linked to their bones, such as:

  • bone pain
  • bone damage shown on X-rays – this may be thinning or fracturing of your bone in a few or many areas.

Myeloma: Treatment

The stages of myeloma treatment

Myeloma is not usually considered a curable disease. Instead, it is a disease which shifts between phases of remission and relapse. These phases of remission, sometimes called ‘plateau phases’ can vary in length of time considerably between patients.

First-line therapy: remission induction

There are two stages involved in first-line therapy. The aim of the first phase of treatment is to remove as many of the myeloma cells as possible from your bone marrow. This first stage is known as remission induction or just induction therapy, which involves a combination of chemotherapy, steroids and biological therapies.

Chemotherapy, steroids and biological therapies

Chemotherapy is directly toxic to cancer cells. Steroids are toxic to these cells too, but steroids can also increase the cancer-killing effects of other chemotherapies. Biological therapies work to discourage the future growth of other cancer cells. The exact drug, dose and combination you’ll be offered will depend upon your general health, age, and whether you’ll have a stem cell transplant at a later date.

 

The most common drugs prescribed are listed below. All are taken orally, unless otherwise noted.

Chemotherapy

  • cyclophosphamide
  • melphalan (Alkeran™)
  • bortezomib (Velcade™) (given subcutaneously-injected under the skin).

Biological therapies

  • thalidomide
  • lenalidomide (Revlimid™)
  • pomalidomide (Imnovid™).

Steroids

  • dexamethasone
  • prednisolone.

First-line therapy: consolidation therapy

 

If after your initial treatment all the myeloma cells have gone, it’s called a complete response. If you have a complete response you’ll still need further treatment or consolidation therapy. This is because without the consolidation, the myeloma would quickly come back.

Consolidation therapy tends to involve either a stem cell transplant or a further combination of drugs. These consolidation treatment options are explained below:

Stem cell transplant

A stem cell transplant (sometimes called a bone marrow transplant) aims to give patients healthy stem cells, which then produce normal blood cells.

Drugs to treat the symptoms of myeloma

You may also experience symptoms which are related to the disease, instead of the treatment. The following drugs may be used in this situation:

  • Bisphosphonates to reduce any pain resulting from bone damage.
  • Erythropoietin (EPO) injections to treat anaemia – this will increase your red blood count and stop you feeling tired and breathless.
  • Granulocyte-colony stimulating factor (G-CSF) to trigger the production of white blood cells to protect against infection.
  • Antibiotics to help prevent or treat infections.
  • Painkillers to help relieve bone pain.

Test: Myeloma

  • White blood cell
  • Plasma cell
  • Red blood cell
  • Platelets
Myeloma affects which type of cell?

What is the most common symptom of myeloma?

  • The most common symptom of myeloma, if there are any, is severe back pain which lasts longer than normal.
  • The most common symptom of myeloma is enlarged lymph nodes.

Other Blood Disorders

Myeloproliferative neoplasms (MPN) are a group of rare conditions related to leukaemia. In these blood disorders, your body produces too much of a particular type of blood cell.

There are three main types of MPN:

 

  • polycythaemia vera (PV)
  • essential thrombocythaemia (ET)
  • myelofibrosis (MF).

The myelodysplastic syndromes, or MDS for short, are a group of diseases in which the production of blood cells by the bone marrow is faulty. It is a type of cancer and sometimes may be referred to as bone marrow failure. The bone marrow is the factory where blood cells are made and it is here where the problem lies.

Monoclonal Gammopathy of Unknown Significance (MGUS) is a condition related to myeloma. 

Solitary plasmacytoma is usually considered to be the diagnosis in cases where only one plasma cell tumour is found. If more than one tumour is found this would be multiple myeloma.

Test: Other Blood Disorders

  • Myeloma
  • Leukaemia
MGUS is a precursor to what other condition?

Module 2: Haemapoisis and Blood Counts

Module Contents

Haemapoisis Overview

Basic Blood Counts

Electrolyte Imbalances

Module 3: Basic Haematology Skills

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Module 4: Haematological Emergencies

Module Contents

Spinal Chord Compression

Neutropenic Sepsis

Perforation in Lymphoma Patients

Tumour Lysis

Module 5: Chemotherapy Management

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Module 6: Other Treatment Modalities

Module Contents

Radiotherapy

Targetted Therapy

Bone Marrow and Stem Cell Transplant

Module 7: Supportive Care

Module Contents

Mucositus Management

Anti-emetics

Supportive medicines

CVC Care

Discharge Information

Module 8: Advanced Skills

Module Contents

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Module 9: Clinical Trials

Module Contents

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Untitled multiple choice question

  • Put your answer option here
  • Put your answer option here

Module 10: Emotional Support and Signposting

Module Contents

Providing Emotional and Psychological Support

Make some notes as you watch this video and think about the importance of providing emotional support and how you can apply this to your role.

Test: Emotional Support

Signposting for Information

List of reliable information sources

Signposting for Support

Finding emotional support

Perhaps link to connect