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How is it diagnosed?
Usually it begins by seeing the family doctor (GP),
who will do an examine and take a blood test. If the
results of the test are abnormal in any way, the GP
will refer the patient to hospital for advice and
treatment from a doctor who specialises in the
treatment of blood problems (known as a
haematologist).
At the hospital
Most people with AML are referred for treatment at a
specialist heamatology unit where a group of
specialist doctors work together. This is known as a
multidisciplinary team and includes one or more
haematologists, a medical oncologist (chemotherapy
specialist) and a clinical oncologist (radiotherapy
specialist). The team will also include specialist
nurses, social workers, dietitians and
physiotherapists. The doctor at the hospital will take
the full medical history before doing a physical
examination and a more specific blood test, which
checks the numbers of all the different types of blood
cell. If the blood test shows that leukaemia cells are
present, the doctor will want to take a sample of bone
marrow. This is the most important test for finding
out if the patient has leukaemia, and gives
information that the doctors need to plan the best
treatment.
Bone marrow sample/biopsy
A sample of bone marrow is taken from the back of the
hipbone (pelvis) or, less commonly, the breastbone
(sternum). It is looked at under a microscope by a
pathologist to see if it contains any abnormal white
blood cells. The pathologist will be able to tell
which type of leukaemia it is by identifying the type
of abnormal white cell. The bone marrow sample is
taken under a local anaesthetic (except for infants
who are given a general anaesthetic). A small
injection is given to numb the area and a needle is
passed gently through the skin into the bone. A small
sample of the marrow is drawn out into a syringe for
examination under the microscope. The test can be done
on the ward or in the outpatients department. The
whole procedure takes about 15 minutes. It may be
uncomfortable but it only lasts a short time as the
marrow is drawn into the syringe. Some hospitals give
a short-acting sedative which makes the patient feel
drowsy or sleepy while the biopsy is taken. Sometimes
a small core of marrow is needed (a trephine biopsy).
This procedure takes a few minutes longer. A special
type of needle is passed through the skin to the bone
marrow. The needle has a tip that can cut out a sample
of the bone marrow. The doctor may ask to have further
tests, which may include a chest x-ray to check that
the lungs and heart are healthy.
Cytogenetics
Within each cell of the body are chromosomes which are
made up of genes. The genes control all activities of
the cell. In myeloid leukaemia there are often changes
in the structure of the chromosomes within the
leukaemic cells, but not the normal cells of the body.
The tests on the blood and bone marrow sample will
include a chromosome analysis to look for any
particular changes in the chromosomes. These tests,
known as cytogenetic tests, can help to decide on the
best treatment and predict how well the leukaemia may
respond to that treatment.
Treatment
The aim of treatment for acute myeloid leukaemia is to
destroy the leukaemia cells and allow the bone marrow
to work normally again. When there is no sign of the
leukaemia it is known as remission.
Types of treatment
Chemotherapy is the main treatment used, as research
has shown that certain types of chemotherapy drugs can
be very effective in treating AML. Most patients with
acute myeloid leukaemia go into remission after
chemotherapy and more and more people are being cured.
People who have promyelocytic AML (type M3) will also
be treated with a drug called ATRA (all trans-retinoic
acid). It is a specialised form of vitamin A and is
also known as tretinoin (Vesanoid(r)). ATRA is given
for up to three months alongside chemotherapy
treatment as it makes the leukaemic cells mature
(differentiate) and so can reduce the leukaemic
symptoms very quickly. See page 29 for more
information about ATRA. The doctor will plan the
treatment by taking into account a number of things,
including age, general health, and the type of genetic
abnormality present in the leukaemia cells. Some
people have a greater risk of the leukaemia not going
into remission or of coming back after treatment. This
is known as high-risk AML. Factors which make the
leukaemia less likely to respond to treatment, or to
come back, include:
-
being over 60 years of age
-
having a very high number of abnormal white blood
cells
-
particular types of genetic changes (chromosomal
changes).
The treatment for people with 'high-risk leukaemia'
may vary slightly from people who do not have these
factors. A research trial (AML-HR) is currently being
carried out to test new types of treatment against the
standard treatments for high-risk AML and the doctor
may ask to enter the trial. People over 60 with AML
may be asked to consider taking part in a research
trial to see whether more intensive chemotherapy is
more effective in treating the leukaemia than less
intensive chemotherapy. The trial is known as AML-14.
Many people who are under 60 with AML may be asked if
they would like to take part in the AML-15 trial,
which is comparing the effectiveness of the current
treatments used for AML. The main treatment for AML is
chemotherapy. Some people may also go on to have
high-dose chemotherapy with a stem cell or bone marrow
transplant
Giving consent
Before any treatment the doctor will explain the aims
of the treatment and will usually ask to sign a form
saying that permission (consent) is given for the
hospital staff to give the treatment. No medical
treatment can be given without consent
The benefits and disadvantages of treatment
Many people are frightened at the prospect of cancer
treatments, particularly because of the potential side
effects. Some people ask what would happen if they did
not have any treatment. Although many of the
treatments can cause side effects, knowledge about how
these treatments affect people and improved ways of
reducing or avoiding many of these problems, have made
most of the treatments much easier to cope with.
Treatment can be given for different reasons and the
potential benefits will vary depending upon the
individual situation. In people with AML, chemotherapy
is usually done with the aim of curing the cancer.
Occasionally additional treatments, such as high-dose
chemotherapy with stem cell or bone marrow
transplants, are also given to reduce the risks of it
coming back. If the leukaemia has returned after
initial treatment, more treatment may be given to get
the leukaemia into remission again. If the leukaemia
is at a more advanced stage, the treatment may only be
able to control the disease, leading to an improvement
in symptoms and a better quality of life. However, for
some people in this situation the treatment will have
no effect upon the leukaemia and they will have the
side effects without any of the benefit. If treatment
is offered that is intended to cure the leukaemia, the
decision whether to accept treatment may not be a
difficult one. However, if a cure is not possible and
the treatment is being given to control the leukaemia
for a period of time, it may be more difficult to
decide whether to go ahead with treatment or not.
What is chemotherapy?
Chemotherapy is the use of anti-cancer (cytotoxic)
drugs to destroy the leukaemia cells. They work by
disrupting the way leukaemia cells grow and divide. As
the drugs circulate in the blood they can reach
leukaemia cells all over the body. The main aim of
treatment for acute myeloid leukaemia is to try to
cure it. The first step is to achieve a remission.
This means that the abnormal, immature white cells or
blasts can no longer be detected in the blood or bone
marrow and normal bone marrow has developed again.
When in remission there may still be a small number of
abnormal cells in the body even though doctors can no
longer detect any signs of the leukaemia, so there
will be further chemotherapy once in remission. The
doctors will continually be checking how well the
leukaemia is responding to the chemotherapy, and will
use this to plan which further treatment is necessary.
Research trials have shown that certain chemotherapy
drugs are very effective in treating many people with
AML.
How the chemotherapy is given
The chemotherapy drugs are usually given by drip or
injection through a fine plastic tube that is inserted
under the skin into a vein near the collarbone
(central line) or passed through a vein in their arm
(PICC line). Chemotherapy is usually given as several
sessions (cycles) of treatment, each lasting for 5-10
days followed by a rest period of 3-4 weeks. This rest
period allows the body to recover from any side
effects of the treatment. The patient may be able to
go home between treatments if well enough. The number
of doses of chemotherapy will depend on how well the
chemotherapy drugs get rid of the leukaemia cells.
Most people have four or five doses (cycles) of the
chemotherapy. The complete course of treatment can
last about six months. These first cycles of
chemotherapy are called induction chemotherapy. The
most commonly used induction chemotherapy drugs are
cytosine arabinoside (ara-C) , daunorubicin,
etoposide, fludarabine and mitoxantrone. Currently a
national trial (the AML-15 trial) is being carried out
to compare different combinations of chemotherapy and
see whether additional treatment with a type of
monoclonal antibody called gemtuzumab (Mylotarg(r))
can improve the results of chemotherapy alone. See
newer treatments for information about gemtuzumab. If
the first course of chemotherapy does not destroy all
of the leukaemia cells, further cycles of chemotherapy
will be given aimed at getting the leukaemia into
remission. If there is no sign of the leukaemia after
the induction chemotherapy (in other words if there
are no signs of the leukaemia in the bone marrow),
there will probably be further cycles of chemotherapy
aimed at reducing the chance of the leukaemia coming
back. This period of chemotherapy is known as
consolidation treatment. The extra cycles involve
further stays in hospital. The most commonly used
drugs for consolidation chemotherapy are cytosine
arabinoside, etoposide, daunorubicin and mitoxantrone.
For some people, high-dose chemotherapy with a stem
cell or bone marrow transplant may be helpful. The
doctor will consider whether chemotherapy alone is
likely to cure the leukaemia. If there is a high risk
that the leukaemia will come back after chemotherapy,
the doctor may suggest that the patient have very
high-dose chemotherapy, or chemotherapy with
radiotherapy, followed by a transplant. The transplant
may be carried out using either the patients own, or a
donor's, bone marrow or stem cells.
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