Leukemia: blood cancer treatment in Germany

The results of blood cancer treatment in Germany are considered one of the best in Europe, which attracts hundreds of foreign patients with leukemia each year.

The term "leukemia" refers to a group of hematopoietic cancers, which vary widely in frequency, causes, treatment options and prognosis.

Leukemia in some patients is characterized by a large increase in the number of leukocytes (white blood cells).

The term "leukemia" literally means "white blood."

However, the number of leukocytes in the blood can also be normal or even low at the time of diagnosis.

All blood cells (leukocytes, red blood cells and platelets) come from a common “mother cell” in the bone marrow, which is called a hematopoietic stem cell. At each stage of development, cells can mutate, becoming malignant.

Leukemias develop when the normal process of leukocyte maturation in the bone marrow is disturbed by an error in certain control genes. Instead of mature, fully developed and functional leukocytes, a huge number of immature cells appear in the blood.

These cells are usually non-functional. They also have the ability to multiply quickly and uncontrollably. Normal blood formation is gradually being replaced. Healthy white blood cells as well as red blood cells and platelets are no longer formed in the required amount.

Anemia, infections and bleeding can be the result and the first sign of leukemia.

Classification of leukemia

Depending on the type of leukemia cells, a distinction is made between myeloid and lymphocytic leukemia. Myeloid leukemias are caused by granulocyte progenitor cells, and lymphocytic leukemias are caused by lymphocyte progenitor cells.

Each of these diseases can be acute or chronic. Acute leukemia develops very quickly. They are usually associated with severe symptoms, such as fever.

In contrast, chronic leukemias often go unnoticed for a long time and progress relatively slowly.

There are four types of leukemia:

• Acute myeloid leukemia (AML)
• Acute lymphocytic leukemia (ALL)
• Chronic myeloid leukemia (CML)
• Chronic lymphocytic leukemia (CLL)

In addition to these four main types, there are precursors of leukemia, the so-called myelodysplastic syndromes (MDS). Myelodysplastic syndromes can develop into acute leukemia. However, since these syndromes are rare, we will discuss only four main types of leukemia.

Blood cancer incidence in Germany

Leukemias are relatively rare compared to other cancers, such as breast cancer, colorectal cancer, or lung cancer. In Germany, this blood cancer accounts for 2.7% of tumor diseases in women and 3.1% of tumor diseases in men.

Every year about 13,700 people in Germany develop leukemia, including 10% of CML, 50% of CLL, and about 40% of ALL and AML. People aged 60 to 70 years are more likely to suffer from blood cancer. Men suffer from leukemia more often than women. 4% of patients are children under 15 years old.

Certain types of leukemia can occur at any age, but they are especially common in certain groups:

• Acute lymphocytic leukemia (ALL) is most common in children and young people. It is the most common type of leukemia and the most common type of cancer in children. The disease especially often develops between the ages of three and seven years.

• Acute and chronic myeloid leukemia are common among middle-aged and older people.

• Chronic lymphocytic leukemia (CLL) mainly affects elderly patients. The disease is relatively rare in the age group up to 50 years.

Possible symptoms of leukemia

German oncologists do not mention any symptoms that are typical only for leukemia. However, there are a number of symptoms that may indicate this disease and require a visit to a doctor. They may vary depending on the type of leukemia or severity.

As a rule, acute leukemia is associated with severe symptoms and fever.

Chronic leukemias always start slowly. The patient does not notice anything for a long time and does not feel limited in his daily life. Chronic forms of leukemia are sometimes detected only by chance during a routine examination.

The following symptoms may be signs of leukemia:

• Weakness and fatigue
• Dyspnea even with moderate exertion
• Unusual pallor of skin and mucous membranes
• Malaise and fever, often associated with persistent infection
• Frequent bleeding and bruising
• Dizziness, night sweats
• Loss of appetite, weight loss
• Bleeding that can be difficult to stop
• Point petechial hemorrhages
• Increased susceptibility to infection
• Enlarged lymph nodes
• Hematomegaly
• Splenomegaly
• Bone pain
• Skin rash

If you observe one or several of the symptoms described above, this does not mean that you have blood cancer!

These symptoms also occur in "harmless" diseases. However, you should definitely consult a doctor to find out the reason for these changes.

Turning to the leading oncology clinics in Germany, foreign patients can get a comprehensive consultation of experienced hematologists.

A consultation with a doctor in Germany costs about $ 300-500, but the cost of expert opinion from leading hematologists can exceed $ 1000.

Diagnosis of blood cancer in Germany: methods and prices

Important stages of the examination for the detection of leukemia are:

• physical examination
• laboratory blood tests
• bone marrow biopsy

The study of blood and bone marrow allows doctor to determine the type of leukemia. In some cases, especially if acute lymphoblastic leukemia (ALL) is suspected, additional spinal fluid examination may be required.

If chronic lymphocytic leukemia (CLL) is suspected, a histological examination of a removed lymph node may provide important clues. If the diagnosis is confirmed, further studies are performed in the context of the upcoming treatment.

Other methods for diagnosing blood cancer include ultrasound (sonography), computed tomography (CT) and magnetic resonance imaging (MRI).

Decisive for the choice of treatment methods are the results of blood / bone marrow examination. Modern laboratory test used in German hospitals identify all subtypes of leukemia, some of which differ in terms of aggressiveness and the possibility of recovery.

Accurate determination of the type of leukemia helps to predict the further course of the disease and prognosis. Thanks to them, the doctor can predict how the disease will respond to a particular treatment and how high the risk of cancer recurrence after therapy.

Determining the type of leukemia is an important prerequisite for targeted therapy.

When all examinations are completed, the doctor together with the patient will decide which treatment methods are most acceptable. This takes into account clinical, financial and other aspects.

Blood tests ($ 500-1550)

Complete blood count is the first important step in the diagnosis of leukemia. The doctor determines whether the patient's leukocytes have changed, and if so, which subgroups of leukocytes have been affected.

The percentage distribution and appearance of various white blood cells (granulocytes, lymphocytes and monocytes) are also checked – the so-called differential blood count.

New German technologies allow detecting more and more subtle changes in cells both in appearance (cytological) and in genetic characteristics (cytogenetically). This information helps the doctor to choose the right treatment for leukemia and, thus, significantly improve the prognosis.

Bone marrow examination (starring $ 1000)

Since leukemia originates from the bone marrow (the place of blood formation) patient’s bone marrow must also be examined. Under local anesthesia, a small amount of bone marrow is removed from the pelvic bone or from the sternum. This tissue is sent for laboratory testing.

The purpose of modern methods of examination is the differentiation between different types of leukemia and, thus, obtaining important information about the malignancy, prognosis and treatment options of a particular disease. The classification of leukemia is based on criteria established by the World Health Organization (WHO).

Spinal Fluid Analysis (starting $ 800)

Lumbar puncture is usually performed when there is a suspicion of acute lymphoblastic leukemia (ALL) or certain subgroups of acute myeloid leukemia (AML). In these forms of the disease, the meninges are often affected. Therefore, in addition to the examination of the blood and bone marrow, it is necessary to take a spinal fluid.

Ultrasound examination (starting $ 500)

Using ultrasound, the doctor can determine whether the internal organs (liver, kidneys, spleen or intestines) are affected. Lymph nodes enlarged due to leukemic cells or due to inflammation can be easily visualized with sonography.

Ultrasound examination is painless and 100% safe for patients. Sonography can be repeated as often as the diagnostic process requires.

Computed tomography (up to $ 1500)

Computed tomography is a special X-ray method in which the patient's body is scanned layer by layer. Although CT is commonly used to diagnose solid tumors, in patients with leukemia, this method may be useful for assessing the spread of cancer. For example, enlarged lymph nodes and signs of infection in the liver can be visualized using CT.

Magnetic resonance imaging (up to $ 2000 per area)

Unlike X-ray methods, this method uses magnetic fields that are harmless to the body. MRI is increasingly used to examine the brain and spinal cord in patients with leukemia.

Principles of blood cancer treatment in Germany

The basis of the treatment of acute leukemia is chemotherapy. Chemotherapy drugs (cytostatics) inhibit cell growth throughout the body. So, the goal of blood cancer treatment is the complete destruction of leukemia cells or their suppression.

In chronic leukemia, chemotherapy can be supplemented with the targeted therapy (including antibodies and small molecules that affect the metabolism of the tumor cell), radiation therapy, and stem cell transplantation. Acute and chronic leukemias are treated differently.



It can be a long and expensive treatment that requires frequent laboratory tests.

Treatment of chronic leukemia

Cytostatics are prescribed for the treatment of chronic leukemia (CML and CLL). In contrast to acute forms, the treatment of chronic forms of the disease is usually based on less aggressive, but long courses. Drugs are given in pills. Monitoring is provided by a family physician.

Chemotherapy is supplemented with other medicines that can alternate. A complete cure with the elimination of all leukemic cells is not yet possible with such treatment, but the symptoms of the disease can be alleviated.

Treatment methods for chronic myeloid leukemia (CML)

The final treatment of chronic myeloid leukemia is possible only by stem cell transplantation. However, this is a risky procedure that is possible only in young and healthy patients.

In Germany, the standard method for CML is treatment with tyrosine kinase inhibitors.

At the first stage of the disease, three drugs are available:

• Imatinib
• Nilotinib
• Dasatinib

The cost of targeted therapy for leukemia in Germany reaches $ 10,000.

These targeted agents inhibit tyrosine kinase, which is formed only by leukemia cells.

Imatinib, nilotinib and dasatinib can delay the disease in many patients for years.

Because these drugs target cancer cells, they cause relatively few side effects compared with chemotherapy.

However, due to the specific side effects and the need for careful monitoring, patients need regular blood tests and bone marrow examination.

Treatment with tyrosine kinase inhibitors is usually expensive and lifelong.

Scientific studies have not yet confirmed whether it is possible to stop taking the drug in some patients after several years without recurrence of the disease. Under no circumstances should the patient stop treatment without prior consultation with the doctor.

Other treatments for CML include chemotherapy and interferon therapy.

Interferons are mediating substances that help the body's immune cells communicate with each other. Interferons can inhibit the growth of malignant cells.

Neither chemotherapy nor interferon therapy gives the same results as therapy with tyrosine kinase inhibitors.

Treatment of chronic lymphocytic leukemia (CLL)

Patients suffering from CLL may feel good for long periods of time, without signs of disease. Because of the slow progression of this disease, an active surveillance strategy makes sense.

Treatment is necessary only if the laboratory indicators deteriorate rapidly or symptoms associated with the disease appear.

Patient health, previous diseases and kidney function determine the choice of therapy.

Young patients without severe comorbidities will receive standard chemoimmunotherapy consisting of rituximab (an antibody against CD20), fludarabine and cyclophosphamide (FCR). However, this therapy is very stressful for the kidneys and, therefore, FCR is only suitable for patients with good kidney function.

For patients with impaired renal function, a combination of active substances bendamustine and rituximab may be considered. Antibodies obinutuzumab and ofatumumab are less toxic, so they are prescribed for elderly and weakened patients.

Some patients show certain genetic changes in the blood cells. Such changes affect the mechanism of action of standard chemo-immunotherapy (FCR). Therefore, these patients receive therapy with a tyrosine kinase inhibitor ibrutinib.

CLL treatment is carried out for many years on an outpatient basis with regular visits to the doctor. However, a complete cure is impossible with this treatment.

In young and healthy patients, high doses of chemotherapy followed by transplants of bone marrow or blood stem cells can lead to a cure.

Patients with CLL are at high risk of infection due to a weakened immune system. They often have to take antibiotics. Additional treatment with immunoglobulins (antibodies) may also be required.

Treatment of acute leukemia

Chemotherapy

Both acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) require intensive treatment, mainly chemotherapy. In order to get the best possible treatment and be able to participate in clinical trials using the latest active substances, patients with leukemia should be referred to a certified hematology center.

Treatment of acute leukemia in Germany is carried out in several stages. Initially, induction therapy is prescribed to maximize the destruction of abnormal blood cells. Then consolidation therapy follows. In the case of ALL, supportive therapy is prescribed, which serves to maintain remission and prevents the development of altered blood cells in the bone marrow.

Induction therapy

Chemotherapy at this stage is usually very aggressive and consists of several cycles that last several weeks. The goal of induction therapy is complete remission, that is, complete regression of abnormal blood cells.



Standard induction therapy for AML in German clinics includes a 3 + 7 regimen.

The patient will receive anthracyclines (for example, daunrobitsin, idarubitsin or mitoxantrone) for three days, followed by a 7-day course of cytarabine therapy.

Patients with ALL also receive aggressive chemotherapy, but with other combinations of drugs. The most common combination is vincristine and dexamethasone + anthracycline and asparaginase.

The duration of this phase depends on the particular case and the response to therapy.

Consolidation and maintenance therapy

In acute leukemia, intensive induction therapy in a hospital is usually followed by a one-year treatment phase, which can be carried out on an outpatient basis (consolidation therapy). For the optimal results of treatment, especially for ALL, it is very important to start consolidation therapy as soon as possible after induction therapy.

The choice of an appropriate consolidation therapy depends on the patient’s condition and the risk of recurrence. In general, there are three options:

• Further intensive chemotherapy
• Transplantation of the patient’s autologous stem cells
• Transplantation using donor stem cells (allogeneic transplantation).

Stem cell transplantation is an important alternative to chemotherapy, especially for patients with proven genetic changes that increase the risk of recurrence.

In acute lymphoblastic leukemia, radiotherapy is often used in addition to chemotherapy to destroy any leukemic cells present in the meninges (head irradiation) or to treat lymph nodes (for example, in the chest area).

All patients who are not candidates for stem cell transplantation receive mercaptopurine and metorexate for a long time.

The total duration of treatment for acute myeloid leukemia (AML) is about half a year, for acute lymphoblastic leukemia (ALL) is about 2,5 years due to the maintenance therapy. During maintenance therapy, patients usually feel well and can enjoy their usual professional and everyday life. If there is no recurrence a total of five years, the patient is considered cured.

Physical fitness is crucial to the choice of therapy

In elderly patients over 60, it is important to assess individual risks when making treatment decisions. What is the physical condition of the patient? Does he or she already have existing diseases that make aggressive chemotherapy even more stressful?

Elderly patients without pre-existing conditions can follow the same treatment regimen as younger patients. But elderly patients with multiple pre-existing conditions may be given better quality of life by a less intensive therapy, and unnecessary drugs may be excluded.

What happens during cancer recurrence?

If cancer recurs, an attempt is made to completely destroy the bone marrow as the site of the disease, followed by very intensive chemotherapy (high-dose chemotherapy). Whole body irradiation may be required to destroy abnormal cells. The patient then receives donor bone marrow to restore normal blood formation. This treatment is very difficult, risky and expensive.

The cost of bone marrow transplantation in Germany reaches $ 200,000.

Maintenance therapy for acute leukemia

In recent decades, the prognosis of patients with leukemia is constantly improving.

To a large extent, this success was facilitated by modern supportive therapy. Its key element is the prevention of infections in patients with stem cell transplantation and immunocompromised patients. Effective symptomatic therapy helps patients successfully continue chemotherapy, avoiding the side effects associated with cytostatics.

Therefore, it is important that patients do not hide the side effects from their physician.

Innovative blood cancer treatment options in Germany

Chemotherapy is central to the treatment of leukemia. In addition, in recent years, numerous targeted drugs have been developed that inhibit specific molecules of abnormal blood cells. These targeted drugs have a more favorable side effect profile than chemotherapy.

German researchers have also made significant progress in immunotherapy. They succeeded in stimulating T-cells, allowing the immune system to completely clear the blood of abnormal cells.

Hope is placed on CAR-T cell therapy, which is being developed by the largest German academic centers. CAR-T cells are currently used mainly in acute and chronic B-cell leukemia. These cells are obtained by modifying the patient's own T-lymphocytes with a chimeric antigen receptor (CAR), which “reboots” the immune system. CAR-T cells can eventually solve the main problem of leukemia treatment, and the results of clinical trials look promising.

This is an extremely expensive therapy, which costs hundreds of thousands of dollars.

© Analytical reviews and oncology news by K. Mokanov: clinical pharmacist and professional medical translator