Treating acute myeloid leukaemia

Acute myeloid leukaemia (AML) is an aggressive condition that develops rapidly, so treatment will usually begin a few days after a diagnosis has been confirmed.

As AML is a complex condition, it's usually treated by a multidisciplinary team (MDT) a group of different specialists working together (see below).

Your treatment plan

Treatment for AML is often carried out in two stages:

• Induction the aim of this initial stage of treatment is to kill as many leukaemia cells in your blood and bone marrow as possible, restore your blood to proper working order and treat any symptoms you may have.
• Consolidation this stage aims to prevent the cancer returning (relapsing), by killing any remaining leukaemia cells that may be present in your body.

The induction stage of treatment isn't always successful and sometimes needs to be repeated before consolidation can begin.

If you have a relapse after treatment, both re-induction and consolidation may need to be carried out. This may be the same as your first treatment, although it's likely to involve different medications or a stem cell transplant (see below).

If you're thought to have a high risk of experiencing complications of AML treatment for example, if you're over 75 years of age or have another underlying health condition less intensive chemotherapy treatment may be carried out. This is less likely to successfully kill all of the cancerous cells in your body, but it can help control your condition.

Induction

The initial treatment you have for AML will largely depend on whether you're fit enough to have intensive chemotherapy , or whether treatment at a lower dosage is recommended.

Intensive chemotherapy

If you can have intensive induction chemotherapy, you'll usually be given a combination of chemotherapy medication at a high dose to kill the cancerous cells in your blood and bone marrow.

This stage of treatment will be carried out in hospital or in a specialist centre, as you'll need very close medical and nursing supervision.

You'll have regular Blood transfusion because your blood won't contain enough healthy blood cells.

You'll also be vulnerable to infection, so it's important that you're in a clean and stable environment where your health can be carefully monitored and any infection you have can be promptly treated. You may also be prescribed antibiotics to help prevent further infection.

Depending on how well you respond to treatment, the induction phase can last from four weeks to a couple of months. You may be able to leave hospital and receive treatment on an outpatient basis if your symptoms improve.

For intensive treatment, the chemotherapy medications will be injected into a thin tube that's inserted either into a blood vessel near your heart (central line) or into your arm (a peripherally inserted central catheter, or PICC).

In very rare cases, chemotherapy medication may also be directly administered into your cerebrospinal fluid to kill any leukaemia cells that may have spread to your nervous system. This is done using a needle that's placed into your spine, in a similar way to a lumbar puncture .

Side effects of intensive chemotherapy for AML are common. They can include:

• nausea
• vomiting
• diarrhoea
• loss of appetite
• sore mouth and mouth ulcers ( mucositis )
• tiredness
• skin rashes
• hair loss
• infertility which may be temporary or permanent (see complications of AML for more information)

Most side effects should resolve once treatment has finished. Tell a member of your care team if side effects become particularly troublesome, as there are medicines that can help you cope better with certain side effects.

This involves using an alternative type of chemotherapy to the standard intensive therapy, whichis designed more to control leukaemia rather than cure it.

The main aim of this treatment is to control the level of cancerous cells in your body and limit any symptoms you have, while reducing your risk of experiencing significant side effects of treatment.

The medications used during non-intensive chemotherapy may be given through a drip into a vein, by mouth or by injection under the skin, and can often be given on an outpatient basis.

All Trans-Retinoic Acid (ATRA)

If you have the sub-type of AML known as acute promyelocytic leukaemia, you'll usually be given capsules of a medicine called ATRA, in addition to chemotherapy.

ATRA works by changing the immature white blood cells (blast cells) into mature healthy cells, and can reduce symptoms very quickly.

Side effects of ATRA can include headaches , nausea, bone pain, and dry mouth , skin and eyes.

Consolidation

If induction is successful, the next stage of treatment will be consolidation.

This often involves receiving regular injections of chemotherapy medication that are usually given on an outpatient basis, which means that you won't have to stay in hospital overnight. However, you may need some short stays in hospital if your symptoms suddenly get worse or if you develop an infection.

The consolidation phase of treatment lasts several months.

Other treatments

Many other treatments are used for AML, asdescribed below.

Radiotherapy

Radiotherapy involves using high doses of controlled radiation to kill cancerous cells. There are two main reasons why radiotherapy is usually used to treat AML:

• to prepare the body for a bone marrow or stem cell transplant (see below)
• to treat advanced cases that have spread to the nervous system and/or brain, although this is uncommon

Side effects of radiotherapy can include hair loss, nausea and fatigue. The side effects should pass once your course of radiotherapy has been completed.

Bone marrow and stem cell transplants

If chemotherapy doesn't work, a possible alternative treatment option is a bone marrow or stem cell transplant .

Before transplantation can take place, the person receiving the transplant will need to haveintensive high-dose chemotherapy and possibly radiotherapy to destroy the cells in their bone marrow. The donated stem cells are given through a tube into a blood vessel, in a similar way to chemotherapy medication.

This process can put an enormous amount of strain on the body and cause significant side effects and potential complications, so you'll usually need to stay in hospital for a few weeks.

Transplantations have better outcomes if the donor has the same tissue type as the person receiving the donation. The best candidate to provide a donation is usually a brother or sister with the same tissue type.

Transplantations are most successful when they're carried out on children and young people, or older people who are otherwise in good health, and when there's a suitable donor, such as a brother or sister.

Readabout bone marrow donation .

Azacitidine

Azacitidine is a possible alternative treatment for adults with AML who can't have a stem cell transplant.

It's recommended by the National Institute for Health and Care Excellence (NICE) for usein certain circumstances for example, depending on the characteristics of the person's blood and bone marrow.

Azacitidine is a chemotherapy medication that's given by injection under the skin. It interferes with the growth of cancer cells and destroys them, and also helps bone marrow to produce normal blood cells.

NICE hasmore information about azacitidine for the treatment of AML .

Clinical trials andnewer unlicensed treatments

In the UK, a number of clinical trials are currently underway that aim to find the best way of treating AML. Clinical trials are studies that use new and experimental techniques to see how well they work in treating, and possibly curing, AML.

As part of your treatment, your care team may suggest taking part in a clinical trial to help researchers learn more about the best way to treat yourAML, and AML in general. Search for clinical trials for AML .

If you take part in a clinical trial, you may be offered medication that isn't licensed for use in the UK and isn't normally available. However, there's no guarantee that the techniques being studied in the clinical trial will work better than current treatments.

Your care team can tell you whether there are any clinical trials available in your area, and can explain the benefits and risks involved.

Macmillan has more information about unlicensed treatments for AML .