Intensive treatment for AML

• Induction and consolidation are the two stages to intensive treatment.
• Expect AML treatment to be a rollercoaster, with ups and downs.
• Many different drugs are used to treat AML, and more are on the way.
• Stem cell transplants are an option, if the benefits outweigh the risks.

Induction therapy aims to kill as many leukaemia cells in your blood and bone marrow as possible. It usually takes around one month.

You’ll be in hospital for this treatment and will have repeated infusions of chemotherapy spread over 5 to 10 days. The chemotherapy will damage your healthy blood cells as well as the leukaemia cells. You might need to go to different hospitals during your treatment.

After this treatment, it will take about three weeks for your healthy blood cells to grow back. You’ll probably stay in hospital during this time although some people might be allowed to go home and come back to the hospital regularly.

Once your normal blood cell counts have recovered, you’ll have blood and bone marrow samples taken, to check for leukaemia cells.

If less than 5 out of 100 (5%) of the cells in your bone marrow are leukaemia cells under the microscope, you are in remission. This is the first step towards curing AML. We explain more about what remission means on our page about measuring your response to treatment.

• Some people go into remission after just one round of chemotherapy. Others need two rounds of chemotherapy before they are in remission.
• If after two rounds of induction chemotherapy, you are not in remission, this is called refractory AML. There are different treatment options if this happens. We explain these in our section about treating refractory AML.

If you do get into a remission after induction therapy, you’ll move on to consolidation therapy – explained next.

Consolidation therapy is the next step. First, you need to have reached remission from induction therapy. This means no leukaemia cells are visible in your bone marrow or blood under the microscope. Consolidation therapy gives you the best chance of staying in remission.

At this stage, your doctors will perform a full assessment. They’ll look at the genetic profile of the AML and its response to treatment so far. Their aim is to work out the risk of the leukaemia coming back in the future:

• If your leukaemia has a low risk of coming back, it’s likely that your doctors will recommend consolidation chemotherapy only.
• If there is a high risk of the leukaemia coming back, your doctors may recommend consolidation chemotherapy followed by a stem cell transplant.

Consolidation aims to stop the AML coming back by killing any leukaemia cells that may remain. Without consolidation treatment, the AML is much more likely to come back.

Consolidation involves having more rounds (cycles) of chemotherapy, usually with similar drugs to your induction treatment.

This stage lasts several months. Each cycle of treatment lasts about one month:

• The chemotherapy is given over about one week.
• This is followed by about three weeks of recovery time. This is similar to the induction treatment.

You’ll be in hospital for a lot of this. But you may be able to go home for breaks in between the rounds of treatment.

Intensive treatment for AML lasts for several months:

• You’ll be in hospital for a lot of it.
• You might feel ill, from the AML or from the treatment.
• You’ll be at a higher risk from infections during treatment too, so there might be times when you cannot have many visitors.

We have more information about the side effects of AML treatment and tips for coping with them.

Most people can spend some time at home, in between cycles of chemotherapy. This can be a welcome break from hospital and treatment, although you might still need regular blood transfusions or tests while at home.

Many people with blood cancer describe AML treatment as a rollercoaster, both for them and their family, with lots of ups and downs. Things can be hard to predict and sometimes your treatment plan might have to change.

Other people with AML and their families have lots more tips about how they got through treatment - visit our online community forum to connect with others who’ve been where you are.

There are many different drugs that can treat AML, and research continues to find new ones.

Not everyone’s AML is the same. There are different types of AML, and different drugs work for different types.

AML is caused by changes (mutations) in the DNA inside blood cells. Different drugs work against different types of AML, depending on which genetic mutations are in the AML cells.

Below we’ve listed some of the most used drugs to treat AML, including newer drugs being looked at in clinical trials.

Clinical trials are how we find new treatments and improve current ones:

• Joining a trial can offer you the chance to try a new treatment or a new combination of treatments before it becomes routinely available. This may or may not be better than existing treatments.
• Joining a clinical trial could also help improve AML treatment for other people in the future.

During treatment, you’ll have tests to monitor your AML and how you are responding to treatment. These will often be tests on your blood or bone marrow. The results of these tests will help your doctors plan what to do next in your treatment. We have more information about the tests and what the results mean.

Lots of AML drugs are given into a vein (intravenously). To make it easier to give you treatment over several months, you’ll have a long, thin tube inserted into one of the veins:

• A PICC line goes into a vein in your arm.
• A central line or Hickman line goes into a vein in your chest.

This can stay in for the whole treatment plan. This means you will not need to keep having injections for treatments or blood tests.

When it’s not being used, it will be covered with a bandage. You need to avoid getting the line wet. So, though you’ll be able to do most things, you will not be able to go swimming, for example.

Not everyone needs a stem cell transplant. But if your doctor thinks there is a high risk of the AML coming back, they might advise you to have one.

A stem cell transplant involves having cancer treatment to get rid of the leukaemia, before having new stem cells put into your body. These come from somebody else (a donor). Stem cells are very young blood cells, which can grow into new healthy blood cells in your body. This type of transplant is called an allogeneic (donor) stem cell transplant.

In effect, a stem cell transplant aims to completely replace your immune system and your bone marrow, so they can function normally again.

A transplant is an intensive treatment that can have serious complications. This is why transplants are only recommended for people who are fit enough, and when the benefits outweigh the risks.

Although a transplant carries lots of risks, it is also one of the most effective ways to cure AML.

When you have a stem cell transplant, you first need to have chemotherapy treatment called “conditioning”. There are two levels of conditioning you can have before a transplant:

• High doses of chemotherapy (and sometimes radiotherapy) – This will wipe out all the leukaemia cells but will also wipe out your normal bone marrow (where your body makes blood cells). This method is also called myeloablative conditioning (MAC). Though it offers the best chance of a lasting remission, it carries more risks because of how strong the treatment is.
• Reduced doses of chemotherapy – This has slightly lower success rates in terms of people staying in remission but has less treatment-related risks. This method is also called reduced-intensity conditioning (RIC). It allows people who otherwise would not be able to have a transplant because of the risks of high dose chemotherapy to have one.

After conditioning, the new stem cells are given to you into a vein, in a similar way to having a blood transfusion. Once in your bloodstream, they travel to your bone marrow and begin growing into new blood cells.

The stem cells usually come from either a family member or an unrelated donor. The donor needs to have a similar “tissue type” to you. This means their genes are like yours. The more similar they are, the closer the match.

There are different options for stem cell donors:

• Unrelated donor (from the stem cell register) – Your healthcare team will look for a match on registers of volunteer donors.
• Sibling (brother or sister) – A brother or sister has a 1 in 4 chance of being perfectly matched to your tissue type. They have a 1 in 2 chance of being a half-match to your tissue type.
• Haploidentical donor (half-match) – Your parents and children if you have them will be half-matched to your tissue type.
• Cord blood (from someone who donated their umbilical cord after giving birth) – Cord blood is rich in stem cells, and you do not need as close a match as with an adult donor.

Our booklet, Allogeneic (donor) stem cell transplants: the seven steps explains what happens before, during and after a stem cell transplant.

The African Caribbean Leukaemia Trust (ACLT) is a charity dedicated to getting more donors on the stem cell register. They also support people and families before and after a stem cell transplant.

As well as the treatment you have for the leukaemia, you’ll need other treatments to deal with symptoms of leukaemia and side effects of treatment. This is sometimes called supportive care.

AML and its treatment affect your healthy blood cells and immune system. You might need antibiotics to reduce your risk of getting an infection during treatment.

You will probably also need to have transfusions of red blood cells and platelets. These are taken from healthy blood donors and used to replace the cells that your body cannot make.

You may also have anti-sickness medicines, to help prevent feeling sick (nausea).

Maintenance therapy means having more long-term treatment, for one or more years, after you finish consolidation therapy and you are in remission. The aim of maintenance therapy is to further reduce the risk of AML coming back (relapse).

Maintenance therapy is not always used in AML, although it is often used for people with a FLT3 mutation who have had a complete remission after consolidation therapy.

In this case, midostaurin can continue to be taken once a day for up to 12 months with the aim of preventing relapse. Quizartinib is also an option for maintenance therapy and can be taken after a transplant. Other maintenance treatments that work against the FLT3 mutation might also be considered for patients who have had a transplant.

Maintenance therapy might also be recommended for some patients without the FLT3 mutation who have not had a transplant. This is normally recommended for older patients with intermediate or high-risk AML. They might be advised to take oral azacitidine.

Maintenance therapy is not usually given to other patients with AML, because there is limited evidence about how much it helps to prevent relapse, make remissions longer or improve survival. But several clinical trials are looking into this.