Treatment options for acute myeloid leukaemia (AML)

People with AML usually start treatment quite quickly after being diagnosed. Treatment is generally divided into intensive and non intensive treatment. The main treatment in both situations is chemotherapy. 

Your treatment team

A team of doctors and other professionals discuss the best treatment and care for you. They are called a multi disciplinary team (MDT).

Your MDT might include:

• blood cancer specialists called consultant haematologists
• haematology nurse specialists, also called clinical nurse specialists (CNS)
• dietitians
• doctors specialising in reporting bone marrow or lymph node biopsies (haematopathologists)
• doctors specialising in reporting x-rays and scans (radiologists)
• doctors specialising in diagnosing and controlling infection (microbiologists)
• social workers
• symptom control specialists called palliative care doctors and nurses
• pharmacists

Deciding which treatment you need

Your MDT will discuss your treatment, its benefits and the possible side effects with you. Your treatment will depend on:

• the type of AML you have
• your age, general health and level of fitness
• the number of white blood cells at diagnosis
• if you have gene changes (mutations) in the leukaemia cells
• where your leukaemia has spread to

Intensive treatment

Treatment for AML is generally divided into intensive and non intensive treatment.

Intensive treatment aims to cure your AML. As this treatment is more intense, the side effects can be quite severe and possibly life threatening. Your healthcare team will monitor you closely during and after treatment. You usually have intensive treatment if your doctor believes you are fit and well enough to cope with these side effects.

The main intensive treatment for AML is chemotherapy. Other treatments you might have include:

• targeted cancer drugs

• growth factors

• a stem cell or bone marrow transplant

• radiotherapy

If you have a very high white blood cell count at diagnosis you might have leukapheresis. This removes white blood cells from the blood. You won't have this if you have a type of AML called acute promyelocytic leukaemia. It can cause severe bleeding in this type of AML.

Intensive treatment is split into different phases of treatment:

• remission induction

• consolidation

• maintenance

Remission induction

The aim of this phase is to get rid of all the leukaemia cells. In remission there is no sign of the leukaemia in your blood or bone marrow.

The main treatment is chemotherapy. You may also have a targeted drug with your chemotherapy.

The chemotherapy drugs kill off many of your bone marrow cells as well as the leukaemia cells. So you usually stay in hospital for about a month until you have recovered.

Some people need more than one round of induction treatment before the leukaemia goes into remission. These people may have a stem cell transplant afterwards.

Consolidation

When there is no sign of the leukaemia (remission) you have consolidation treatment. This aims to lower the risk of leukaemia coming back.

Consolidation treatment might include chemotherapy or targeted drugs. You might have a stem cell transplant. 

To decide the right consolidation treatment for you, your healthcare team consider:

• if your AML is in full remission

• if you have AML after treatment for another cancer

• whether you had chronic leukaemia that has changed into acute leukaemia

• how many times you had chemotherapy before your AML went into remission

• your general level of fitness and health

• your wishes about treatment

A stem cell transplant is an intensive treatment but is the best chance of cure for some. Side effects can be severe and sometimes life threatening. Your specialist team will discuss this treatment with you and those close to you. They will explain the benefits and risks in your situation. Do ask any questions you might have.

Maintenance

Not everyone with AML will have maintenance treatment. The aim is to keep the AML away in the long term. This is usually for people with a high risk of it coming back. You might have chemotherapy or targeted drugs in this phase.

Non intensive treatment

Non intensive treatment aims to control your leukaemia for as long as possible.

This treatment generally causes less severe side effects. You might have non intensive treatment if you have other health conditions that could affect your ability to cope. For example, heart or lung problems.

You may be frail and quite weak so you may not be fit enough to cope with intensive treatment. It might do more harm than good.

Non intensive treatment is usually a combination of a chemotherapy drug with a targeted cancer drug. The chemotherapy drugs might be:

• azacitidine
• low dose cytarabine (LDAC)
• decitabine

The targeted cancer drug you usually might have is venetoclax. 

Supportive treatments

Supportive treatments are part of intensive and non intensive treatment. They can, for example, help to prevent or treat side effects. Some of the supportive treatments include:

• anti sickness medicines

• red blood cell and platelet transfusions

• antibiotics, antifungals and antivirals to help prevent or treat infection

• medicines to protect your kidneys from a condition called tumour lysis syndrome

• fluid through a drip to keep you hydrated

• mouth washes and painkillers to help with the side effect of ulcers and sores in the mouth

• treatment to remove high numbers of leukaemia cells (leukapheresis)

• medicine to stop your periods

• regular assessment of your diet to help manage any diet problems such as loss of appetite and weight loss. Your healthcare team can refer you to a dietician to help with any problems you might have

Treatment for AML that has spread

Some people have a collection of AML cells that might form a lump in other areas of the body. Or they might have AML cells that have spread to the fluid around the brain or spinal cord. The treatments for these might include:

• radiotherapy to the area where the AML cells have collected to form a lump
• intrathecal chemotherapy to treat the cells that have spread to the fluid around brain and spinal cord

Working out how well your treatment is working

You will have bone marrow tests during and after treatment. These look at the number of leukaemia cells left behind in your bone marrow after treatment. This is called measurable residual disease (MRD).

Checking the MRD helps your doctor decide how well treatment is working. It also helps them to work out whether your disease is likely to come back. This helps them to plan future treatment.

There are two main techniques for finding MRD:

• molecular testing - looking for genetic changes in cells which are specific to your leukaemia

• immunophenotyping - looking for certain proteins on the surface of your leukaemia cells

AML that comes back or resists treatment

Sometimes tests find leukaemia cells in the bone marrow while you’re having treatment. This means the leukaemia isn’t responding to the drugs you’re having. It’s called resistant or refractory leukaemia. Your doctor might recommend you have:

• more chemotherapy or targeted drugs

• a stem cell transplant

• treatment as part of a clinical trial

If you have had a stem cell transplant you might be able to have donor lymphocyte infusions (DLI). These are white blood cells from your donor to help boost your immune system and fight the leukaemia.

Sometimes the leukaemia comes back after treatment. This is called a relapse. Treatment for relapsed leukaemia depends on:

• how long you were in remission

• your age, general health and level of fitness

• if you have gene changes (mutations) in the leukaemia cells

• what treatment you’ve had before

Your doctor will discuss all your treatment options with you.

Clinical trials to improve AML treatment

You usually have treatment for AML as part of a clinical trial. Doctors and researchers do trials to:

• improve treatment

• make existing treatments better

• develop new treatments