APL treatment explained
In this section we talk about the specific treatments used for APL. You might also want to read our general information section about how blood cancer treatment is planned and managing your treatment.
Treatment planning
If your doctor thinks you have APL, you will probably start treatment while your doctor is doing more tests to confirm your diagnosis. This is because until you start treatment, you’re at risk of serious bleeding. If your diagnosis and treatment plan then change, the treatment you’ve already received won’t do you any harm.
Your doctor will recommend a treatment plan and talk to you about what it will involve. Treatment plans are tailored to each person. You might not have the same treatment as someone else with APL. What’s right for you depends on your age, your general health and the type of APL you have.
Treatment stages
The treatment you have first is called ‘first-line treatment’ or ‘first-line therapy.’
You will have first-line treatment in two stages:
- remission induction
- consolidation
Remission induction stage
The aim of this treatment is to put you into ‘complete remission’. Your healthcare team may call this ‘morphological remission’. This means that the level of leukaemia cells in your bone marrow is less than 5% and doctors can’t see any leukaemia cells under the microscope. You’ll probably spend a lot of this stage in hospital, with your healthcare team close by.
Consolidation treatment
You will then have more rounds (or cycles) of treatment to clear any leukaemia cells that might remain in your blood and bone marrow (the spongy material inside your bones, where blood cells are made). These cells can’t be seen through a microscope but can be picked up by a PCR test which you’ll have after each round of treatment. When the PCR test can’t pick up any leukaemia cells, this is called ‘complete molecular remission’.
You might be able to have some of these treatments as an outpatient, which means you won’t need to stay in hospital overnight. But you will still have to go to hospital for treatment and check-ups.
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Treatment types
There are several different treatment options, depending on the type of APL you have.
The treatment you have will also depend on how high your blood count is when you are diagnosed.
Most people with APL (around 95%) have the PML/RARA gene. If you have this gene, then it’s more likely the common treatments described here will get rid of the leukaemia.
If you have a very rare type of APL, where the PML/RARA gene isn’t present, then standard treatments might not be as effective. Your treatment may involve trans retinoic acid (ATRA) with chemotherapy or one of the drug combinations used to treat acute myeloid leukaemia (AML), which can also work for APL.
If you have a lower white blood cell count when you're diagnosed, you’ll usually be treated with two drugs that work together: ‘arsenic trioxide’ and ‘all-trans retinoic acid’ (ATRA).
You will take ATRA as a capsule that you swallow. It works by stopping your white blood cells from getting “stuck” as immature promyelocytes (leukaemia cells), by helping them mature into healthy white blood cells.
Arsenic trioxide works in a similar way, but you will have this through a drip (intravenously).
If your doctor recommends this treatment option, you’ll start taking ATRA capsules straight away. Once your doctors have the results of tests that confirm you have APL, you’ll then start having your arsenic trioxide treatment.
You’ll receive arsenic trioxide in combination with ATRA as remission induction therapy for two months.
You will then have the same treatment as consolidation therapy, which means you will have it every two months with short breaks in between, for eight months.
You may have heard that arsenic is poisonous and be worried. Arsenic is only poisonous when used in high doses. Smaller doses of arsenic are safe when used in medicine. Arsenic trioxide is a very effective treatment for APL.
If you have a higher white blood cell count when you're diagnosed, you'll usually be given ATRA with chemotherapy to kill the leukaemia cells.
The group of chemotherapy drugs used to treat APL are called ‘anthracyclines’. You will have these through a drip (intravenously), usually into a vein in your arm.
If you’re treated with a combination of ATRA and anthracyclines, you will have:
- one cycle of induction treatment
- a further three cycles of consolidation treatment.
Each cycle of treatment will last a few days, and you’ll usually have a four-week recovery period before moving on to the next cycle.
You may start taking anthracyclines at the same time as ATRA or you may start a few days afterwards.
After treatment
Follow-up appointments are an important way to look out for signs of relapse and any problems caused by your treatment for APL.
For the first year after your treatment, you’ll normally have a check-up every one or two months.
After a year, you will have check-ups less often, normally every three to four months for the next two years.
If you had ATRA and arsenic trioxide treatment, you’ll have a very low risk of relapse (where the leukaemia returns). Your doctors won’t normally monitor you for relapse using a PCR test.
If the test you had at the end of treatment did pick up any leukaemia cells, you’ll have regular blood tests so doctors can measure your full blood count.
If you had ATRA and chemotherapy, your risk of relapse is slightly higher. Your doctors will use the PCR test to monitor you throughout your follow-up. This is to try to pick up a relapse early if it happens.
You might also have regular bone marrow biopsies like you had when you were diagnosed.
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