Leukaemia

Leukaemia is a term used to describe a number of cancers of the blood cells. It affects the growth of white blood cells in the body, which are part of the body's defence mechanism against infection. Depending on the type of white cell affected and the rate of cell growth, the condition can be subdivided into either acute or chronic types.

Acute leukaemia can show very rapid progression and involves an overgrowth of immature white blood cells. This can disrupt the function of many tissues and organs and is life threatening because there are too few mature blood cells to prevent anaemia, infection and bleeding.

Chronic leukaemia involves the overgrowth of mature blood cells. The cell growth is less rapid than with the acute type and progression of the disease is slower.

Acute lymphoblastic leukaemia (ALL) is an overproduction of immature lymphocytes, called lymphoblasts (sometimes referred to as blast cells). Normally, white blood cells grow and divide in an orderly and controlled manner, but in leukaemia, the process gets out of control and the cells divide too quickly, but do not mature.

These immature cells fill up the bone marrow and prevent it from properly making blood cells. As the leukaemia cells do not mature, they cannot do the work of normal white blood cells, which leads to an increased risk of infection. Because the bone marrow is overcrowded with immature white cells it cannot make the right number and quality of red cells and platelets.

Approximately 600 adults are diagnosed with ALL in the UK each year. It occurs more frequently in children - under 15 years of age - than adults. When it occurs in teenagers or adults, ALL is most common between the ages of 15-25 and in people over 75 years of age. It is slightly more common in males than in females.

Acute myeloid leukaemia (AML) is an overproduction of immature myeloid white blood cells. The immature cells are also sometimes referred to as blast cells. Normally, white blood cells repair and reproduce themselves in an orderly and controlled way. In leukaemia however, the process gets out of control and the cells continue to divide, but do not mature.

These immature dividing cells fill up the bone marrow and prevent it from making healthy blood cells. As the leukaemia cells do not mature, they cannot work properly, which leads to an increased risk of infection. As the bone marrow cannot make enough healthy red blood cells and platelets, symptoms such as anaemia and bruising also occur.

AML can affect adults of all ages, but it is more common in older age groups. It is rare in people under 20.

Chronic lymphocytic leukaemia (CLL) and hairy cell leukaemia (HCL) is a cancer of the lymphocytes. It is the most common type of leukaemia. CLL mainly affects people over 60. It is rare in people under the age of 40.

Abnormal blood cells

Blood cells are normally produced in a controlled way, but in leukaemia the process gets out of control. The lymphocytes multiply too quickly and live too long, resulting in too many of them circulating in the blood. These leukaemic lymphocytes look normal, but they are not fully developed and do not work properly. Over a period of time the abnormal cells replace the normal white cells, red cells and platelets in the bone marrow.

The condition usually develops very slowly and many people with CLL do not need treatment for months or years, however, some need to have treatment straight away.

Chronic myeloid leukaemia (CML) is a rare type of cancer affecting approximately 500 people, mostly adults, in the UK each year. It is a cancer of granulocytes, one of the main types of white blood cells. In CML, too many granulocytes are produced and they are released into the blood when they are immature and unable to work properly. The immature white blood cells are known as blasts. The production of other types of blood cells is also disrupted.

Normally, white blood cells repair and reproduce themselves in an orderly and controlled manner, but in CML the process gets out of control and the cells continue to divide and mature abnormally. The disease usually develops very slowly, which is why it is called 'chronic' myeloid leukaemia. CML can occur at any age, but it more commonly affects middle-aged and older people. It is rare in children.

There are often no obvious symptoms of leukaemia and a diagnosis is only made after routine blood testing. Symptoms, when they do manifest, can be vague and non-specific and may appear flu-like. Commonly, symptoms include:

• Fever

• Weight loss

• Excessive bruising

• Frequent infections

• Breathlessness

• Anaemia

• Joint and bone pain

• Swollen lymph glands

• Abdominal discomfort

• Blood in urine and stools

Initially, blood tests will highlight an abnormally high level of blood cells. Referral to a haematologist should follow, where they will check for any enlargement of the lymph nodes, liver or spleen. If more detailed blood work indicates the presence of leukaemia cells a bone marrow biopsy will usually be required.

Poorer prognosis

The haematologist will then be able to determine which type of leukaemia is present by identifying which white cell type is showing abnormality. Occasionally, if doubt over the diagnosis persists, a lymph gland biopsy may be required. Other tests can include a chest X-ray, MRI scan, ultrasound scan and CT scan.

Treatment for leukaemia can take a number of forms such as chemotherapy, steroids, biological therapy, radiation therapy and bone marrow transplantation. Often a combination of therapies may be used.

Children with ALL tend to do much better than adults. What was once regarded as a fatal condition in children is now curable with many living on into healthy adulthood. Unfortunately, in adults the condition has a poorer prognosis. There is an increased risk of subsequent cancers due to the intensive use of cancer treatments in tackling ALL. Approximately 50% of adults diagnosed with ALL will be alive after five years.

The long-term prognosis for AML is poorer than for ALL. Again there is an increased risk of secondary cancers due to the high dose treatment therapies required. Average survival is two to three years.

Most patients live with CLL and HCL for many years and the disease may not shorten life expectancy at all.

The prognosis for CML is dependent on the stage of the disease at diagnosis. Patients in the chronic phase of the disease can expect to live for about two to three years after diagnosis. More than half of patients who have bone marrow transplantation therapy during this stage are cured. Later stages of this disease have a much poorer prognosis.

Kevin Edwards is a life and disability underwriter at Scottish Equitable Protect

Underwriting implications

A general practitioner's report (GPR), and full hospital reports, will be required to fully underwrite this condition.

For life cover, terms for the acute forms of the disease (ALL/AML) would not be available until approximately four years after completion of the client's primary treatment (i.e. chemotherapy, radiotherapy or surgery) together with confirmation that there has been no recurrence of the disease during that time.

Terms after this period will attract a temporary per mille loading for up to 10 years. Underwriting of the chronic forms of the disease differ quite markedly. Terms for CLL/HCL will not often be available for younger lives. Terms, when available, will be dependent on the progression of the disease and length of term being requested.

Unfortunately, the poor prognosis of CML means the disease is largely uninsurable. However, terms may be considered some time after successful bone marrow transplantation.

For critical illness cover, only ALL would be considered in the long term. For older lives, 10 years after completion of primary treatment, a permanent extra may be considered. Terms would not be available for AML,CLL, HCL and CML.

Terms for the various leukaemia types can be rated heavily and are very dependant on the client's age and the time elapsed since primary treatment.

An IFA may find it helpful to discuss their client's case with an insurer's underwriters before submitting an application.

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