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Blood Cancers: When Helpful Turns Harmful
pathology perspectives

By Ruth Werner

Originally published in Massage Bodywork magazine, July/August 2011. Copyright 2011. Associated Bodywork and Massage Professionals. All rights reserved.

When we think of cancer, most of the time we think of piles of mutated cells accumulating into tumors that crowd out healthy tissue cells, get first dibs on our nutrients to grow even bigger, and threaten to use our lymphatic system to travel to other places, wreaking havoc as they go.

The structures most often associated with this activity are epithelial cells: they are designed to replicate quickly, so they are vulnerable to subtle mutations that change their characteristics from friendly to unfriendly. This description is relatively accurate for some epithelial cancers, including colorectal, for example.

But among the most common cancers in our country, and definitely the most common cancers in children, we see an entirely different type of tissue involved and an entirely different growth pattern. These cancers do not affect the epithelial cells of the lungs, colon, breast ducts, or prostate gland. These cancers affect our bodies' other fast-growing cells: the blood cells that are manufactured in bone marrow.

Here we will take a short look at each of the three most common hematological cancers: leukemia, lymphoma, and myeloma. First, let's do a quick review of white blood cells and their functions.

- Myeloid cells--Myeloid cells, also called granulocytes, are manufactured in bone marrow. They can be delineated into neutrophils, basophils, and eosinophils and monocytes. Each of these has a role to play in nonspecific immune defense. The life span of a myeloid cell varies from a few hours to many days or weeks, depending on circumstances.

- Lymphocytes--These white blood cells may be manufactured either in bone marrow or in lymphoid tissue (including lymph nodes, the spleen, and other locations). They include T cells, which direct specific immune responses against identified invaders, and B cells, which manufacture antibodies to disable identified invaders. Natural killer cells are also lymphocytes; they are associated with the ability to identify and attack cancer cells.

Hematologic cancers involve the production of white blood cells--either in bone marrow or in lymph tissue--that have changed their properties from helpful to harmful. How each disease affects function depends on the growth pattern of the particular cancer involved.

Leukemia
Leukemia, or "white blood," is a group of cancers that affect several types of white blood cells. It used to be thought that leukemia was completely distinct from lymphoma, but research methods that allow scientists to track cell lineage more precisely have revealed that some types of leukemia affect the same cells as some types of lymphoma, so the delineation between these diseases is now largely tied to location: leukemia begins in bone marrow and releases mutated cells into the bloodstream, while lymphoma begins in lymph tissue and cells usually accumulate rather than travel.

How Common Is It?
Leukemia is diagnosed in about 36,000 Americans every year, and it is responsible for about 22,000 deaths. Although this disease is the leading cause of death from cancer in children, it is much more common in adults. More than 200,000 leukemia patients and survivors are living in the United States today.

How Does It Affect The Body?
Two types of stem cells--myeloid cells and lymphoid cells--manufacture most of our white blood cells in bone marrow. Leukemia occurs when a mutation in the DNA of one or more stem cells in the bone marrow causes the production of multitudes of nonfunctioning leukocytes. Leukemia can be aggressive and quickly progressive, releasing immature cells into the bloodstream (acute), or it can be slowly progressive, leading to the release of mature but nonfunctioning cells (chronic). In either case, the mutated cells do not function as part of the immune system, and they live far longer than normal cells, leading to dangerous accumulations of nonfunctioning cells.

Untreated leukemia results in death from excessive bleeding or infection. The uncontrolled bleeding is tied to the suppression of thrombocyte production; the infection risk occurs because, while many white blood cells are present, they are completely nonfunctioning and offer no protection from pathogenic invasion. Many types of leukemia have been identified, but the most common forms are classified into four types:

- Acute myelogenous leukemia (AML)-- This is an aggressive cancer of the myeloid cells that mainly affects people over 60 years old. The genetic damage that causes AML has been linked to high doses of radiation, chemotherapy for other types of cancer, and exposure to benzene. AML cells can congregate to form a tumor outside the bone marrow.

- Chronic myelogenous leukemia (CML)--This is a slowly progressive cancer of the myeloid cells. Unlike other forms of leukemia, CML has been traced to a specific dysfunctional chromosome called the Philadelphia chromosome. Faulty cells can interfere with and slow down normal immune system activity, but they do not usually bring it to a halt. CML occasionally changes its pattern and becomes more aggressive, in which case it is approached as AML.

- Acute lymphocytic leukemia (ALL)-- This is an aggressive cancer of the lymphocytes. ALL is the type of leukemia found most often among children. The proliferation of cells in a person with ALL is so overwhelming that all other bone marrow activity is suppressed, and immune system function is effectively crippled. Cancerous lymphocytes are released into the blood before they are fully mature. These lymphocytes may gather in lymph nodes, or they may cross into the central nervous system.

- Chronic lymphocytic leukemia (CLL)--This is a slowly progressive cancer of the lymphocytes. Although it can involve T cells or natural killer cells, most cases involve B-cell malignancies. CLL is especially common among veterans of the Vietnam War who were exposed to Agent Orange. In some cases, CLL transforms into an aggressive form of lymphoma.

Lymphoma
Lymphoma is a collective name for cancers that start in the lymph nodes. Some types of lymphoma affect the same cells as some types of lymphocytic leukemia, so the delineations between these cancer labels are no longer entirely clear-cut.

How Common Is It?
About 58,000 people will be diagnosed with non-Hodgkin lymphoma this year, and about 20,000 deaths will occur due to this disease. Hodgkin lymphoma is more rare, with about 8,200 diagnoses and 1,300 deaths.

How Does It Affect The Body?
Lymphoma begins with a mutation of the DNA of the affected cells, usually some type of B cell (these account for about 80 percent of cases), T cells, or natural killer cells. The mutated cell begins to replicate, producing massive numbers of nonfunctioning lymphocytes. This causes the lymph tissues to enlarge, and it initiates the other symptoms associated with lymphoma, namely, anemia, night sweats, itchy skin, and fatigue, among others.

Mutated cells may travel through the lymphatic system to begin tumors elsewhere: this can occur in other lymph node regions, or in organs like bones, the spleen, or the liver. In some cases, cells can gain access to the central nervous system and begin growing tumors there.

A statistical relationship exists between lymphoma and exposure to insecticides, herbicides, fertilizers, and black hair dye, but the direct cause-and-effect sequences have not been established. Lymphoma risk is increased with some infections, including HIV, hepatitis B and C, Epstein-Barr virus, human T-cell lymphotropic virus (HTLV), and helicobactor pylori. Other risk factors for lymphoma include the presence of autoimmune disease, using immune-suppressant drugs, and genetic predisposition.

The two major classes of this cancer are Hodgkin lymphoma and non-Hodgkin lymphoma. Hodgkin lymphoma has several subtypes, but they all involve B cells. Overall, this is a predictable and highly treatable form of cancer. Non-Hodgkin lymphoma is much more common, has many subtypes, and is notorious for being unpredictable and resistant to treatment. It can affect any type of lymphocyte, including B cells, T cells, or natural killer cells.

In addition to being identified as Hodgkin or non-Hodgkin lymphoma, this disease is sometimes described by its behavior:

- Low-grade, or indolent, lymphoma grows slowly. It is often nonresponsive to treatment and may change to a more aggressive form later.

- Intermediate-grade lymphoma is aggressive, but responsive to treatment.

- High-grade lymphoma is aggressive and grows rapidly, but it may be resistant to treatment.

Myeloma
Myeloma (literally, "marrow tumor") is a blood cancer involving maturing B cells that are found in bone marrow.

How Common Is It?
Myeloma is almost exclusive to people over 50 years old. It is twice as common among African-Americans as it is among the general population, and Asian Americans have the lowest rate of myeloma in the United States. Myeloma is diagnosed about 177,000 times each year, and it causes about 11,000 deaths.

How Does Myeloma Affect The Body?
Most B cells are produced in bone marrow. Sometimes as they mature, they begin to differentiate into nonfunctional cells. This condition is called monoclonal gammopathy of undetermined significance (MGUS): it points to the presence of some dysfunctional B cells and the production of abnormal antibodies, but it does not always develop into myeloma.

If myeloma does develop, it means cells have undergone a mutation that causes them to do three bad things: they proliferate into tumors; they secrete cytokines that dissolve bone (usually in the spine, pelvis, or skull); and they produce faulty antibodies, called monoclonal immunoglobulins, or M-proteins. Fragments of M-proteins can pass through the kidneys into the urine. This is good news because myeloma can be detected and, to a certain extent, tracked through urinalysis. It is also bad news, because if the disease is rapidly progressive, the kidneys can sustain extensive damage and even fail altogether.

Tumors inside bone marrow can interfere with normal blood cell production, leading to the signs and symptoms of other blood cancers: anemia, poor clotting, and reduced resistance to infection. But because myeloma cells also secrete cytokines that signal osteoclasts to dismantle bone tissue, this disease leads to pathologic thinning or spontaneous fractures in bone tissue. When this occurs at the spine or pelvis, the result can be devastating.

A single tumor is called solitary myeloma; more than one tumor is called multiple myeloma. Occasionally tumors form outside the bones: these are called extramedullary plastocytomas.

Treatment Options For Hematologic Cancers
Chemotherapy
Chemotherapy is the use of medications that kill any fast-growing cells. The idea is that this suppresses the growth of new tumors, but the side effects of chemotherapy involve other fast-growing cells as well. In the case of hematologic cancers, the side effects of chemotherapy essentially exacerbate the symptoms of the cancer: bone marrow function is suppressed, with the result that the patient experiences anemia (shortage of red blood cells), neutropenia (shortage of the most common and fastest-moving white blood cells), and thrombocytopenia (shortage of platelets). The net results: poor stamina, poor resistance to infection, and poor blood clotting.

In addition to limiting bone marrow function, chemotherapy affects other cells, notably the follicle cells of the skin (leading to hair loss), and the epithelial lining of the GI tract, leading to painful ulcers, nausea, and vomiting.

Radiation
Radiation is the use of high-energy waves to "burn" or kill cancer cells in specific targets. It is a frequently used strategy in many cancers, but tends to have a fallback position in the treatment of refractory, or treatment-resistant, blood cancers.

Stem Cell Or Bone Marrow Transplant
Harvested stem cells, healthy marrow cells from the patient, or cells from a matching donor can sometimes be transplanted into blood cancer patients, but this requires that virtually all functioning bone marrow be killed off first. These procedures are highly risky, and the incidence of life-threatening complications is high.

Biologic Therapies
Biologic therapies are in use for some forms of blood cancers. These include using interferon to enlist the immune system in more aggressive cancer fighting; specially sensitized antibodies may be targeted against cancer cells, or "cancer vaccines" can alter the way the immune system behaves in this context. These therapies are relatively new among the cancer-treating arsenal, but they hold great promise for fighting cancer without accumulating the immense amount of collateral damage that occurs with the more traditional chemotherapy, radiation, and surgical options.

Implications For Massage
Blood cancers, by definition, spread through the lymphatic and circulatory systems. They involve seriously impaired immunity and create a tendency to bleed easily. Myeloma adds the complication of delicate, unstable bones, especially in the pelvis and spine. All of them involve treatment options that make some of their worst complications even worse for a period of time. Obviously, bodywork that requires a strong adaptive response is not appropriate in this context.

But far from the "cancer and massage don't go in the same sentence" paradigm that many of us grew up in, the research on the benefits of massage for cancer patients is strong and compelling. Types of bodywork that enlist the healing energies of the client (as opposed to imposing outside forces on blood flow or tissue manipulation) are helpful and supportive for a person going through a difficult, stressful, and often painful process. Through bodywork, we can offer pain relief, anxiety reduction, the mitigation of some of the side effects of chemotherapy, improved appetite, and sleep. Perhaps, more than anything, we can offer touch that is not task-oriented at a time when our clients feel like patients more than like people. It is important in this situation to work as part of a well-informed health-care team, so that the possibility of secondary infection or other complications can be carefully avoided. What a wonderful gift you can offer your clients!

Ruth Werner is the president of the Massage Therapy Foundation, and a writer and educator. She wrote A Massage Therapist's Guide to Pathology (Lippincott Williams Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.comor wernerworkshops@ruthwerner.com.




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