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Pregnancy and Leukaemia

A Guide for Patients Introduction

Leukaemia in is rare, and is estimated to occur in only 1 in 75,000 to 100,000 , although its incidence is poorly documented. Controlled studies of leukaemia in pregnancy are very limited given its nature, and most of the data comes from analysis of previous case reports. If you have any questions about pregnancy and leukaemia - the types of leukaemia, diagnosis and treatment - this booklet covers the basics for you.

The booklet was compiled by For more tailored information, talk our Patient Information Writer to your haematologist, clinical Isabelle Leach and peer reviewed nurse specialist or hospital by CLL CNS Helen Knight, CML pharmacist. specialist Dragana Milojkovic and Consultant Haematologist Manos Nikolousis. We are also grateful to Vickie Webster for her valuable comments as a patient reviewer.

If you would like any information on the sources used for this booklet, please email [email protected] for a list of references.

Version 1 Printed: 11/2019 2 www.leukaemiacare.org.uk Review date: 11/2021 In this booklet

Introduction 2 In this booklet 3 About Leukaemia Care 4 Types of leukaemia in pregnancy 6 A diagnosis of leukaemia in pregnancy 8 Treatment 10 Glossary 18 Useful contacts and further support 23

Helpline freephone 08088 010 444 3 About Leukaemia Care

Leukaemia Care is a national charity dedicated to ensuring that people affected by cancer have access to the right information, advice and support.

Our services has been affected by a blood cancer. A full list of titles – both Helpline disease specific and general Our helpline is available 8:30am information titles – can be – 5:00pm Monday - Friday and found on our website at www. 7:00pm – 10:00pm on Thursdays leukaemiacare.org.uk/support- and Fridays. If you need someone and-information/help-and- to talk to, call 08088 010 444. resources/information-booklets/

Alternatively, you can send Support Groups a message via WhatsApp on Our nationwide support groups 07500068065 on weekdays are a chance to meet and talk 9:00am – 5:00pm. to other people who are going Nurse service through a similar experience. For more information about a We have two trained nurses on local to your area, hand to answer your questions go to www.leukaemiacare.org. and offer advice and support, uk/support-and-information/ whether it be through emailing support-for-you/find-a-support- [email protected] or group/ over the phone on 08088 010 444. Buddy Support Patient Information Booklets We offer one-to-one phone We have a number of patient support with volunteers who have information booklets like had blood cancer themselves this available to anyone who or been affected by it in some

4 www.leukaemiacare.org.uk way. You can speak to someone Website who knows what you are going You can access up-to-date through. For more information information on our website, on how to get a buddy call www.leukaemiacare.org.uk. 08088 010 444 or email [email protected] Campaigning and Advocacy Online Forum Leukaemia Care is involved in campaigning for patient well- Our online forum, being, NHS funding and drug www.healthunlocked.com/ and treatment availability. If you leukaemia-care, is a place would like an update on any of for people to ask questions the work we are currently doing or anonymously or to join in the want to know how to get involved, discussion with other people in a email advocacy@leukaemiacare. similar situation. org.uk Patient and carer conferences Patient magazine Our nationwide conferences Our quarterly magazine includes provide an opportunity to inspirational patient and carer ask questions and listen to stories as well as informative patient speakers and medical articles by medical professionals: professionals who can provide www.leukaemiacare.org.uk/ valuable information and support. communication-preferences/

Helpline freephone 08088 010 444 5 Types of leukaemia in pregnancy

Leukaemia CLL is 72 years, with only about 10% of patients under the age of complicating 55 years old. pregnancy and pregnancy in a patient These patients tend to have existing chronic leukaemias and with leukaemia become pregnant subsequently. Approximately 90% of leukaemias which occur during pregnancy Acute and chronic are acute leukaemias. Acute Out of the acute leukaemias that leukaemias are more commonly are diagnosed during pregnancy, diagnosed in teenagers and young 66% are acute myeloid leukaemia adults, which coincides with the (AML), and 28% are acute age of . These leukaemias lymphoblastic leukaemia (ALL). are often diagnosed during the course of the pregnancy, usually The remainder of the cases of in the second and third trimester. leukaemia in pregnancy include CML, CLL and myelodysplastic Chronic leukaemias during syndromes. pregnancy occur in a smaller proportion of patients as the Myelodysplastic syndromes median age at diagnosis is much is the collective name for a higher. group of cancers where bone marrow cells of varying types The median age of patients with reproduce uncontrollably CML is 50 years, ranging from and have dysplastic changes. 18 to 87 years. CML can occur at Myelodysplastic means abnormal any age, but is more common in growth in the bone marrow. middle aged and older people. Myelodysplastic syndromes are characterised by a poorly The median age of patients with functioning bone marrow and a

6 www.leukaemiacare.org.uk likelihood for developing into AML. Myeloid and lymphoid In pregnancy, the majority of leukaemia cells are myeloid in origin (relating to bone marrow cells) in 68% of cases: 61% being AML and 7% being CML.

The remaining 31% of cases are lymphoid in origin (relating to lymphocyte white blood cells): 28% being ALL and 3% being CLL.

Helpline freephone 08088 010 444 7 A diagnosis of leukaemia in pregnancy

Acute leukaemia in pregnant coagulation screening, renal women requires a rapid diagnosis and liver function tests are also because it can be life-threatening advised. for both the mother and baby. Peripheral blood smear: A However, the similarity of some of •• sample of blood is smeared and the symptoms in pregnancy and viewed under a microscope to leukaemia, such as weakness, count different circulating blood fatigue, shortness of breath and cells and to see whether the anaemia may make diagnosis cells look normal. difficult. Bone marrow aspiration As with most types of leukaemia, •• and biopsy: The bone marrow diagnosis can usually be made aspiration procedure removes with a bone marrow biopsy, which a liquid marrow sample and can help analyse the number the biopsy removes a small and types of the leukaemic cells amount of bone filled with in the bone marrow. Guidelines marrow. Examination of the by the British Committee for bone marrow liquid sample Standards in Haematology (BCSH) and biopsy can determine the for the diagnosis of leukaemia percentage of leukaemia cells in pregnancy recommend the in the bone marrow and any following investigations: abnormalities. ••Full blood count: This shows Immunophenotyping: This the number of red blood cells, •• process uses antibodies to white blood cells and platelets identify cells based on the types in the blood. Inclusion of a of antigens or markers on the differential count, which will surface of the leukaemia cells, provide additional details of the and can diagnose specific types different types of white blood of leukaemia by comparing the cells, is useful. Additionally, cancer cells to normal. vitamin B9, vitamin B12 and ferritin measurements, blood ••Chromosomal analysis: This

8 www.leukaemiacare.org.uk involves analysing the bone marrow or blood cells to identify any changes in the number and size of chromosomes within cells that might have led to the development of the leukaemia cells. ••Cerebrospinal fluid examination: If a spread of leukaemia cells to the central (brain and spinal cord) is suspected, a sample of cerebrospinal fluid, obtained from a lumbar puncture, is examined using flow cytometry. This process can rapidly measure the size and structures of thousands of cells in the sample.

Helpline freephone 08088 010 444 9 Treatment

Leukaemia occurring during the first trimester needs to be pregnancy is challenging and balanced against consequence treatment should be tailored to of delay to the mother and baby, the need of each patient. Both the particularly for acute types of immediate health of mother and leukaemia such as AML and ALL. baby, and the long term health of Treatments for leukaemia during the , need to be considered. pregnancy may differ from the During the first trimester, standard of care. It will depend treatment is best avoided if on how far along the pregnancy is possible, while it is safer to when the leukaemia is diagnosed, administer treatments during the the characteristics of the second and third trimesters. leukaemia, and potential toxic effects of treatment on mother General considerations and baby.

Pregnant women with leukaemia Supportive therapies in pregnant need to be managed by a patients are similar to those in multidisciplinary team that non-pregnant patients with a few includes haematologists, changes: obstetricians, neonatologists, anaesthetists and pharmacists Antibiotics in order to manage all the ••Penicillins, cephalosporins and treatments required. erythromycin have been shown Treatment during the first to be safe in pregnancy. trimester can be associated ••Aminoglycosides, despite only with congenital anomalies and limited data, seem to be safe in miscarriage. Treatment after the the first trimester of pregnancy. first trimester, when the baby’s organs have been developed, is ••Trimethoprim-sulfamethazine safer, although rare complications has been associated with can’t be excluded. cardiovascular malformations, even in the second and third Delay in treatment until after trimesters of pregnancy, and is

10 www.leukaemiacare.org.uk to be avoided. the and is safe to use in pregnancy. ••Quinolones and tetracyclines are known to affect joints, ••Granulocyte colony-stimulating bone and teeth, and should be factor has not revealed avoided during pregnancy. an increase in congenital abnormalities or death of the Sulphonamides have been •• baby when used in pregnant associated with brain and women, although the data is spinal cord defects and cardiac limited. malformations, and should also be avoided. Pain control Antifungal drugs ••Paracetamol can be administered safely throughout The best intravenous antifungal •• pregnancy. drug during pregnancy is liposomal amphotericin B. ••Nonsteroidal anti-infective drugs such as should Anti-emetics not be given during pregnancy ••, because of potential side effects antihistamines or ondansetron- for the baby. based anti-emetics have not been associated with foetal Breast feeding malformations. ••This is invariably contraindicated for Corticosteroids which is excreted in breast milk. ••Methylprednisolone and hydrocortisone are broken down Leukapheresis for very high by the placenta and therefore white blood cell blast levels are safe for the baby. ••This process involves collecting blood from a vein in one arm, Growth factors passing it through a machine ••Erythropoietin does not cross which removes the excess of

Helpline freephone 08088 010 444 11 Treatment (cont.)

white blood cells (including If the diagnosis of AML is made the leukaemia blast cells), and during the first trimester, it is then re-inserting the blood back unlikely that the pregnancy will through a vein in the other arm. be successful, and the risks for This process is thought to have the mother remain significant. minimal risk to the baby and Although a sensitive topic, is safe to be performed during planned termination may need pregnancy. to be discussed, as it is easier to manage than a miscarriage. Acute leukaemias When the pregnancy is between Acute leukaemias are usually 24 and 32 weeks at the time of reported in 37% of pregnancies diagnosis, the risks to the baby during the second trimester and from the must be 40% of pregnancies during third weighed up against the risks of trimester. Acute leukaemias in the prematurity if it is delivered early. first trimester of pregnancy are thought to occur in approximately If delivery is planned between 24 23% of pregnancies (including and 35 weeks, corticosteroids miscarriages). given for 48 hours in the week before the delivery can help the AML baby’s lungs to function better. If pregnant women with AML If delivery is planned before 30 are left without treatment, both weeks, magnesium sulphate can the mother and baby could die be given in the 24 hours before as the chance of remission delivery to protect the baby’s is seriously compromised. developing brain and help reduce Immediate treatment is therefore disability. recommended. This is generally a standard daunorubicin and When the diagnosis of AML is cytarabine regimen and must be after 32 weeks, it may be practical dosed according to the woman’s to deliver the baby before starting body weight as it changes during chemotherapy. pregnancy.

12 www.leukaemiacare.org.uk Blood products that may include High doses of cytomegalovirus will need to be are a main component of these screened to make sure they are ALL intensive regimens, but negative for the virus. An epidural unfortunately, methotrexate anaesthetic in women who have a is associated with severe very low platelet count (80 x 109/L) foetal malformations. When and/or white blood cell count methotrexate is given during (<1 x 109/L) should be avoided. the first trimester of pregnancy, it results in a high risk of ALL miscarriage or development It is important to give the of methotrexate syndrome, appropriate chemotherapy characterised by defects in the as soon as possible after the bones of the skull, abnormal diagnosis in order to control the structure of the face, delayed ALL. Treatment regimens for ALL development, and limb defects. are continually changing and If ALL is diagnosed before 20 differ between countries and weeks of pregnancy, termination hospitals. This makes developing of pregnancy is strongly specific recommendations or recommended in order to guidelines for the management of commence chemotherapy. ALL problematic. Nevertheless, the regimens contain similar drugs, After 20 weeks of pregnancy, but just with different doses and modified ALL regimens of schedules. chemotherapy can be given until the third trimester, although A practice followed by many patients must be advised that haematology teams is giving damage to the baby is still young adults and adults up to the possible. Prednisolone alone for age of 50 years the intensive ALL one to two weeks can enable the chemotherapy regimens normally patient to reach a stage where given to children because these they can receive more intensive regimens have been getting better chemotherapy thereafter. results in terms of survival in the older patients. In the third trimester of

Helpline freephone 08088 010 444 13 Treatment (cont.)

pregnancy, patients may be given the ability of viruses to multiply. the same chemotherapy regimens In patients with cancer, interferon as non-pregnant women with ALL. alfa stimulates the T lymphocyte Planned delivery after 32 weeks white blood cells and other should be the goal, but delivery is immune system cells to attack not advisable if the patient has the cancer. pancytopenia (deficiency of all All patients should be managed in three types of blood cells). a specialised haematology centre Chronic leukaemias used to dealing with CML and pregnancy. CML In the chronic phase of CML, Tyrosine kinase inhibitors patients can have little or no (TKIs) symptoms, and can remain in The use of tyrosine kinase this phase for years. If patients inhibitors has markedly improved proceed to the accelerated phase, the survival of all CML patients. symptoms become more obvious Patients can expect a relatively such as tiredness, weight loss normal lifestyle, even if the and a swollen abdomen due to majority of patients will have enlargement of the spleen. The lifelong treatment. Therefore, accelerated phase normally lasts patients with CML may not only between three to nine months be diagnosed while pregnant, but if untreated. In the final phase, some may also wish to become known as the blast phase, the pregnant while on treatment. disease is similar to AML and Promisingly, the course of CML unless it is treated, death can does not appear to be adversely occur within three to six months. affected by pregnancy.

Treatment of CML in pregnancy It is important to advise young includes leukapheresis, and female patients with CML of the interferon alfa. Interferons are a effect of tyrosine kinase inhibitors naturally occurring body protein on the baby’s development. Due to that send signals to interfere with the potential risks of miscarriage

14 www.leukaemiacare.org.uk or foetal malformations, TKIs If the RT-PCR remains low, are not to be used during then no intervention is usually pregnancy. Both men and women necessary after conception and are advised to use effective during pregnancy. If the blood contraception during treatment. count rises, then your doctor It is also important to be aware may consider IFN to ensure the that vomiting or diarrhoea may blood counts do not increase reduce the effectiveness of oral significantly. contraceptives. After conception, you are likely Pregnancy should only be to be referred for a considered when the patient (used to detect chromosomal has achieved at least a major abnormalities in the baby), and molecular response (<0.1%) for the pregnancy to be managed in at least two years, and been on hospital. Ideally, the pregnancy therapy for at least three years as care will be supervised by an a minimum requirement. There obstetrician and a haematologist are recommendations for patients with a special interest in who respond very well and may pregnancy. be able to discontinue therapy At present, there is no evidence to in general. Tyrosine kinase suggest that TKIs impair female inhibitors should be discontinued fertility. on the first day of the , and a RT-PCR (reverse transcriptase polymerase chain For more information on reaction, a test to analyse a short TKIs and TFR, you can read sequence of DNA) for BCR-ABL will our booklet Chronic Myeloid be done to closely monitor after Leukaemia (CML) – TKIs and that, usually on a four-weekly TFR. You can order one by basis to begin with. calling 08088 010 444 or If it takes some time to become by going online to www. pregnant your doctor may refer leukaemiacare.org.uk you for assisted conception.

Helpline freephone 08088 010 444 15 Treatment (cont.)

CLL also recommended to avoid fludarabine in pregnancy. For CLL, a ‘Watch and Wait’ approach may be possible, which Because CLL is a less aggressive means there is the option for disease, these treatments may be haematologists to keep a close delayed until after delivery. watch on the disease without starting any treatment. During the second and third trimester of pregnancy, In pregnant patients with rituximab, chlorambucil and untreated CLL, there may be a cyclophosphamide may be risk of a blast crisis. This is where given, if required. Rituximab is a the levels of immature white monoclonal antibody drug whose blood cells become so high as to effect during pregnancy has cause a malfunction in organs by been difficult to assess because affecting the small blood vessels. it is usually given with other This condition may also cause . Monoclonal damage to the placenta, low birth antibody drugs are antibodies weight, premature births and, created in the laboratory from sadly, the death of the baby. the same original cell and which target specific proteins on the Other complications for pregnant cancerous cells. women with CLL include anaemia, which requires blood Despite the reporting of only a transfusions, and few foetal malformations with autoimmune conditions, in which treatments including rituximab, the immune system mistakenly it is recommended that women attacks healthy cells in the body. wait a minimum of 12 months after rituximab exposure before During the first trimester of becoming pregnant until more pregnancy, chlorambucil cannot definitive data is available. be given to treat CLL because of its harmful effect on the development of the baby. It is

16 www.leukaemiacare.org.uk Helpline freephone 08088 010 444 17 Glossary

Acute lymphoblastic leukaemia which induces an immune (ALL) response in the body, especially the production of antibodies. A leukaemia in which lymphocytes start multiplying Blast cells (blasts) uncontrollably in the bone marrow Immature, abnormal cells resulting in high numbers of found in high numbers in the abnormal, immature lymphocytes bone marrow of patients with called blasts. Lymphocytes are a leukaemia. Normally, only a type of white blood cell involved in maximum of 5% of blast cells are the immune response. found in the bone marrow. Acute myeloid leukaemia (AML) Blast crisis A rapid and aggressive cancer A situation where the levels of the myeloid cells in the bone of immature white blood cells marrow. become so high as to cause Anaemia malfunction of the body organs by affecting their small blood A condition where the number of vessels. red blood cells are reduced. Red blood cells contain haemoglobin Bone marrow and transport oxygen to body The soft blood-forming tissue cells. This may be due to a lack that fills the cavities of bones of iron, leukaemia, or sickle cell and contains fat, immature and disease. mature blood cells, including Antibody white blood cells, red blood cells and platelets. A large Y-shaped protein produced by B-cell lymphocytes in response Bone marrow aspirate to a specific antigen, such as The process of taking a sample of a bacteria, virus, or a foreign the liquid part of the soft tissue substance in the blood. The bone marrow inside the bones antibodies neutralise the bacteria using a syringe. It is crucial and viruses. in establishing a diagnosis of Antigen leukaemia and may be performed at stages of the disease during A toxin or other foreign substance

18 www.leukaemiacare.org.uk treatment to monitor progress. marrow start multiplying uncontrollably leading to large Bone marrow biopsy numbers of abnormal, immature A bone marrow biopsy involves cells called blasts, which prevent the collection of a sample of the bone marrow from producing bone marrow from the hip bone, enough healthy blood cells of all generally under local anaesthesia. types. A bone marrow surgical instrument with a cylindrical Chronic myeloid leukaemia blade, called trephine, is used to A leukaemia in which the myeloid remove a 1 or 2cm core of bone cells start multiplying in the bone marrow in one piece. marrow leading to large numbers of abnormal, immature myeloid Cerebrospinal fluid cells called blasts, which prevent A clear, colourless fluid the bone marrow from producing surrounding the brain and spinal enough healthy blood cells of all cord. types. Chemotherapy Complete remission Drugs that work in different ways Complete remission has occurred to stop the growth of cancer cells, when: either by killing the cells or by stopping them from dividing. ••Blood cell counts have returned to normal Chromosomes ••Less than 5% of blasts An X-shaped, thread-like (abnormal, immature leukaemia structure which carries the genes, cells) are still present in the and are located in the nuclei of bone marrow every cell in the body. There are 46 chromosomes (23 pairs) in Cytarabine humans. An antimetabolite drug which Chronic lymphocytic works by disrupting the DNA of leukaemia cancer cells, thereby slowing or stopping their growth. A leukaemia in which the B-lymphocytes in the bone

Helpline freephone 08088 010 444 19 Glossary (cont.)

Cytotoxic drugs Immunophenotyping Drugs that are toxic to cancer A process that uses antibodies to cells and prevent their growth and identify cells based on the types replication. of antigens or markers on the surface of the cells. This process DNA (deoxyribonucleic acid) is used to diagnose specific types A thread-like chain of amino acids of leukaemia and found in the nucleus of each cell by comparing the cancer cells in the body which carries genetic to normal cells of the immune instructions used in the growth, system. development and functioning of the cells. Interferons A naturally occurring body protein Fatigue that sends signals to interfere Tiredness and weakness with the ability of viruses to rendering the patient unable to multiply. work or perform usual activities. Leucocytosis Ferritin An increase in the number of A blood cell protein that contains white blood cells in the blood. iron. Leukaemia Flow cytometry A group of cancers that usually Technology used to analyse begin in the bone marrow the physical and chemical and result in high numbers of characteristics of particles in abnormal white blood cells. These a fluid as it passes through at white blood cells are not fully least one laser. A flow cytometer developed and are called blasts or can rapidly measure the size and leukaemia cells. Depending on the structures of thousands of cells. type of white blood cell involved, the leukaemia will have varying Granulocyte-macrophage characteristics, such as being colony-stimulating factor acute (develop quickly) or chronic A growth factor required to (develop slowly). stimulate the growth of living cells.

20 www.leukaemiacare.org.uk Lymphocytes leukaemia at a molecular level rather than at a cell level. It Lymphocytes are a type of is measured using molecular white blood cell that are vitally techniques such as flow important to the immune cytometry and polymerase chain response. There are three types of reaction analysis. lymphocytes: B-cells, T-cells and natural killer (NK)-cells. B-cells Monoclonal antibody drugs produce antibodies that seek Antibodies created in the out invading organisms. T-cells laboratory from the same original destroy the organisms that have cell and which target specific been labelled by the B-cells, as proteins on the cancerous cells. well as internal cells that have become cancerous. NK-cells attack cancer cells and viruses. A cancer of the plasma cells Leukapheresis which are a type of white blood cell which normally produce A process that involves collecting antibodies. blood from a vein in one arm, passing it through a machine to Myelodysplastic syndromes remove an excess of white blood (MDS) cells, and then re-inserting the Also called myelodysplasia, blood back through a vein in the myelodysplastic syndromes occur other arm. when the bone marrow does not Lymphoid make enough normal blood cells. The blood cells made are not Relates to lymphocytes. fully developed and not able to Median work normally. These blood cells include red blood cells which Median is the "middle" value when supply oxygen to the body’s the data points are sorted into tissues, white blood cells which a list from the lowest to highest fight and platelets which value. help blood to clot. Minimal residual disease Myeloid (MRD) Relates to bone marrow. A measure of the presence of

Helpline freephone 08088 010 444 21 Glossary (cont.)

Myeloid cell Red blood cells A cell originating in the bone Small blood cells that contain marrow which will eventually haemoglobin and carry oxygen become the following white and other substances to all blood cells: neutrophils, tissues of the body. monocytes (present in the blood), macrophages (present in Spleen different tissues), basophils, and The largest organ of the lymphatic eosinophils. Myeloid cells can system whose function is to help also become red blood cells and rid the body of toxins, waste and platelets. other unwanted materials. The spleen is located under the ribs Obstetrician on the left of the abdomen. A doctor who specialises in the surgical field of Standard of care (pregnancy, giving birth and Treatment accepted by medical after). They will deliver the baby. experts as the most appropriate treatment for a certain disease Pancytopenia and that is widely used by A deficiency of all three types of healthcare professionals. blood cells (red cells, white cells, and platelets). Thrombocytopenia Low levels of platelets, which are Plasma cell small blood cells that help the A type of white blood cell that body form clots to prevent or stop produces antibodies and is . derived from a B-cell lymphocyte. It has a distinct appearance being Tyrosine kinase receptors ovoid (egg-shaped) with an off- Receptors present in the centre nucleus. membranes of all of the body’s cells which can be activated by Platelets the enzyme tyrosine kinase. The Small blood cells that help the system functions as an ‘on’ or ‘off’ body form clots to stop bleeding. switch in many cellular functions.

22 www.leukaemiacare.org.uk Useful contacts and further support

There are a number of helpful Bloodwise sources to support you during Bloodwise is the leading charity your diagnosis, treatment and into the research of blood cancers. beyond, including: They offer support to patients, ••Your haematologist and their family and friends through healthcare team patient services. ••Your family and friends 020 7504 2200 ••Your psychologist (ask your www.bloodwise.org.uk haematologist or CNS for a Cancer Research UK referral) Cancer Research UK is a leading Reliable online sources, •• charity dedicated to cancer such as Leukaemia Care research. Charitable organisations •• 0808 800 4040 There are a number of www.cancerresearchuk.org organisations, including ourselves, who provide expert Macmillan advice and information. Macmillan provides free practical, Leukaemia Care medical and financial support for people facing cancer. We are a charity dedicated to 0808 808 0000 supporting anyone affected by www.macmillan.org.uk the diagnosis of any blood cancer. We provide emotional support Maggie’s Centres through a range of support Maggie’s offers free practical, services including a helpline, emotional and social support patient and carer conferences, to people with cancer and their support group, informative families and friends. website, one-to-one buddy service and high-quality patient 0300 123 1801 information. We also have a nurse www.maggiescentres.org on our help line for any medical Citizens Advice Bureau (CAB) queries relating to your diagnosis. Offers advice on benefits and Helpline: 08088 010 444 financial assistance. www.leukaemiacare.org.uk [email protected] 08444 111 444 www.adviceguide.org.uk

Helpline freephone 08088 010 444 23 Leukaemia Care is a national charity dedicated to providing information, advice and support to anyone affected by a blood cancer.

Around 34,000 new cases of blood cancer are diagnosed in the UK each year. We are here to support you, whether you’re a patient, carer or family member.

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Helpline: 08088 010 444 (free from landlines and all major mobile networks) Office Line: 01905 755977 www.leukaemiacare.org.uk [email protected]

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