This form of leukemia is found most frequently in adults. It is a separate disease entity and does not constitute the progressive stage of acute leukemia. It is more common in men and boys than in women. The diagnosis depends upon the microscopic examination of the blood and bone marrow.

The symptoms of chronic leukemia do not usually occur until the disease is well advanced. At best they may be vague-fatigue, loss of strength, loss of weight, fever, occurrence of petechiae and marked pallor. The spleen is sometimes enlarged. Lymphadeno-pathy may or may not occur.

Treatment

The treatment of chronic leukemia is somewhat different than for acute leukemia. In general, chronic leukemia responds more favorably to X-ray than to chemotherapy, although the lives of many patients with chronic leukemia can be prolonged by means of selected chemotherapeutic agents. With current treatment it is no longer necessary for patients with chronic leukemia to become helpless invalids for long periods of time.

1. X-ray is frequently employed and, in addition, drug therapy with nitrogen mustard, Fowler's solution, myeleran, 6-MP, cortisone, ACTH, and TEM (see glossary). Urethane is also used in some instances.

2. Antibiotics, usually the oral type, are given to combat infection.

3. Blood transfusions may be frequently ordered to relieve anemia and raise the platelet count.

Complications of chronic leukemia and its therapy include stomatitis, ulcerations in the mouth, hemorrhage, and susceptibility to infection. The treatment regimen varies for each patient and will be changed by the physician as resistance to each particular form of treatment occurs.

Nursing Care

The nursing care does not differ very much whether the patient has acute or chronic leukemia. Attention must be given to essentially the same factors.

In almost every instance a patient who is receiving intensive therapy for leukemia is hospitalized during the period of therapy. Occasionally patients with chronic types of leukemia are treated on an outpatient basis. The public health nurse will therefore have most of her contacts with children or adults who are in a remissive stage of acute leukemia or adults with chronic leukemia.

It is important for the nurse to know that during the stage of remission signs and symptoms of the disease should be absent. This means that if hemorrhage or signs of infection should occur during the remissive stage the patient should be advised to report to his physician as soon as possible, regardless of the date of his next appointment.

Since these patients are very prone to infection they should avoid becoming chilled. Exposure to others with upper respiratory or gastrointestinal disorders should be avoided as much as possible. All cuts and abrasions should be treated promptly to minimize the danger of infection. Septicemia is all too common.

Sleep and rest are important and planned rest periods and early bedtime are important. Fatigue occurs easily, especially during periods when the red cell count may be low. During periods when the patient may be on bed rest good skin care is essential. Injury to the back occurs readily and a decubitus is extremely difficult to heal. However, bruising of body tissues must be avoided and rubbing should be omitted because of danger of hemorrhage; the back may be lightly powdered after bathing.

Good oral hygiene should be promoted, but not too vigorously, since injury to the gums will occur. Soft tooth brushes may be used until sore or bleeding gums make the use of a soft swab necessary to gently cleanse the mouth.

The leukemia patient has a poor appetite and the tender mucous membranes of the mouth make eating difficult. Maintaining adequate nutrition may perhaps be achieved by appealing to the patient's wishes. Attractive food of high nutritive value, well prepared and served in small amounts may encourage a flagging appetite. Foods should be soft so they can be easily chewed. Tart fruit juices and highly seasoned foods are sometimes irritating, as are very hot beverages. Food should not be offered when the patient is very tired or when he has just returned from a painful treatment.

As the disease progresses increased irritability of the patient is typical. He will dislike being handled because of weakness and joint pain. An enlarging spleen may result in a heavy, protruding abdomen, and the patient's most comfortable position may be on his side supported by blankets. Pressure bandages may be needed to prevent bleeding from the entry point of the needle after blood tests and bone marrow examinations.

Drugs must be given on schedule and appointments for blood tests and bone marrow examinations must be faithfully kept.

The nurse must understand that with today's therapy the patient with leukemia will probably experience more than one remission of his disease. During the period of remission he looks well and gains weight. In the case of a child he is able to play and attend school. The tendency of the parents is to be overprotective and they must be encouraged to let the child lead as normal a life as possible during these periods. Even though parents and families are made fully aware of the eventual outcome of the disease-it is these periods which may lead the family, and even the nurse, to believe that a cure has been effected. This is not the case however; sooner or later the symptoms will reappear and the patient will again be very sick. This repeated building up and dashing of the family's hopes is a harrowing experience and they need a great deal of support. The encouragement and understanding of the nurse may be most helpful. The knowledge that the patient is receiving all of the treatment that medical science now has to offer is also of help and there is always the hope that research will produce a cure. It is this thought that gives the family and the patient courage to continue treatments that are often unpleasant and painful.