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Leukemia - Acute Myeloid - AML - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Adult Acute Myeloid Leukemia. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this final full guide.

Leukemia is a cancer of the blood. Leukemia begins when normal blood cells change and grow uncontrollably. Acute myeloid leukemia (AML) is a disorder of the process that normally produces neutrophils, red blood cells, and/or platelets, which are types of normal blood cells. AML may sometimes be called acute myelogenous leukemia, acute myelocytic leukemia, or acute nonlymphocytic leukemia. Unlike chronic leukemia, acute leukemia develops quickly and generally needs immediate treatment. AML occurs in people of all ages but is most common in adults older than 65.

About neutrophils

Neutrophils fight infections caused by bacteria and other organisms. Mature neutrophils grow from immature white blood cells, also called progenitors, in a process called differentiation. The production of mature neutrophils usually is highly regulated. For example, the body rapidly makes more neutrophils during an infection and returns to a regular level of production when the infection is controlled.

About AML

In AML, damage to the genetic material or DNA, called acquired mutations, in the blood-forming cells cause problems with the normal development of the blood cells. This causes the build-up of many immature cells called myeloblasts or blasts. Blasts do not act like fully developed, healthy blood cells and do not help a person’s immune system work. These acquired mutations and the large number of blasts also reduces the production of healthy red blood cells, which carry oxygen, and platelets, cells that help the blood to clot. Therefore, people with AML are usually anemic because they do not have enough red blood cells, are more likely to get infections because they do not have enough mature neutrophils, and bruise or bleed easily because of a low numbers of platelets.

AML is usually found in the blood and bone marrow, the spongy, red tissue in the inner part of the large bones, but it can sometimes also spread to other parts of the body, such as the brain, skin, and gums. Occasionally, AML cells can form a solid tumor called a myeloid sarcoma or chloroma that can develop anywhere in the body.

This section is about AML in adults. Read about childhood AML.

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If you would like additional introductory information, explore these related items. Please note these links take you to other sections on Cancer.Net:

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Leukemia - Acute Myeloid - AML - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find information about how many people learn they have AML each year and some general survival information. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of the screen.

This year, an estimated 18,860 people of all ages (11,530 men and boys and 7,330 women and girls) in the United States will be diagnosed with AML. AML is the second most common type of leukemia diagnosed in both adults and children. An estimated 10,460 deaths (6,010 men and boys and 4,450 women and girls) from AML will occur this year.

The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases. The five-year survival rate of people with AML is approximately 24%. However, it is important to note that survival depends on several factors, including biologic features of the disease and, in particular, a patient’s age (see Subtypes for more information). Although AML is a serious disease, it is treatable and often curable with chemotherapy with or without a stem cell transplant (see the Treatment Options section).

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with AML. Because the survival statistics are measured in five-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts and Figures 2014.

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Leukemia - Acute Myeloid - AML - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find basic drawings about the common body parts affected by this disease. To see other pages, use the menu on the side of your screen.

Adult Marrow Anatomy

Larger image

Blood Anatomy

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Choose “Next” (below, right) to continue reading this guide to learn what raises a person’s risk to develop AML. Or, use the colored boxes located on the right side of your screen to visit any section.

Leukemia - Acute Myeloid - AML - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find out more about the factors that increase the chance of developing AML. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

Although the cause of AML is not known, several factors are associated with an increased risk of the disease. The following factors may raise a person’s risk of developing AML:

Age. AML is more common in older adults, but it occurs at all ages. About half of people with AML are older than 65 when diagnosed.

Smoking. The risk of AML has been linked to exposure to tobacco smoke, probably along with other causes. 

Genetic disorders. AML occurs more often in people with inherited disorders such as Down syndrome, ataxia telangiectasia, Li-Fraumeni syndrome, Klinefelter syndrome, Fanconi anemia, Wiskott-Aldrich syndrome, Bloom syndrome, and the Familial Platelet Disorder syndrome.

High doses of radiation. People who have been exposed to high levels of radiation, such as long-term survivors of atomic bombs, may be more likely to develop AML. Electromagnetic fields generated by high-voltage electrical power lines have not been shown to cause AML.

Previous cancer treatment. People who have received chemotherapy and/or radiation therapy for other types of cancer, such as breast cancer, ovarian cancer, and lymphoma, have a higher risk of developing AML in the years following treatment.

Chemicals. Long-term contact with products containing the chemical benzene, found in petroleum, cigarette smoke, and industrial workplaces, raises the risk of AML. However, exposure to industrial solvents and hair dyes has not been proven to increase a person’s risk of AML.

Other bone marrow disorders. People who have other bone marrow diseases including myeloproliferative disorders (myelo- means bone marrow and proliferative means too much), such as polycythemia vera, myelofibrosis, and essential thrombocytosis, as well as myelodysplastic syndromes can have their conditions turn into AML over time. 

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Leukemia - Acute Myeloid - AML - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

People with AML may experience the following symptoms or signs. Sometimes, people with AML do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer.

  • Fatigue
  • Weakness
  • Easy bruising or bleeding
  • Weight loss
  • Fever
  • Bone or abdominal pain
  • Difficulty breathing; shortness of breath
  • Frequent infections or infections that do not go away
  • Swollen lymph nodes or glands
  • Swollen or bleeding gums
  • Chest pain
  • Dizziness
  • Unusually long menstrual cycle for women
  • Skin nodules
  • Rash
  • Wounds or sores that do not go away
  • Headache
  • Blurred vision

If you are concerned about one or more of the symptoms or signs on this list, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

The next section helps explain what tests and scans may be needed to learn more about the cause of the symptoms. Use the menu on the side of your screen to select Diagnosis, or you can select another section, to continue reading this guide.

Leukemia - Acute Myeloid - AML - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose leukemia and determine the subtype (see Subtypes). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may also be used to learn more about the cause of your symptoms. This list describes options for diagnosing AML, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition
  • Type of cancer suspected
  • Signs and symptoms
  • Previous test results

The following tests may be used to diagnose AML:

Blood tests. To diagnose AML, a doctor will do blood tests to count the number of white blood cells and to see if they look abnormal under the microscope. Special tests called flow cytometry, or immunophenotyping, and cytochemistry are sometimes used to distinguish AML from other types of leukemia and to determine the exact subtype of AML.

Bone marrow aspiration and biopsy. These two procedures are similar and often done at the same time to examine the bone marrow. Bone marrow has both a solid and a liquid part. A bone marrow aspiration removes a sample of the fluid with a needle. A bone marrow biopsy is the removal of a small amount of solid tissue using a needle. The sample(s) are then analyzed by a pathologist. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. A common site for a bone marrow aspiration and biopsy is the pelvic bone, which is located in the lower back by the hip. The skin in that area is numbed with medication beforehand, and other types of anesthesia (medication to block the awareness of pain) may be used.

Genomic testing. Your doctor may recommend running laboratory tests on the leukemia cells to identify specific genes, proteins, chromosome changes, and other factors unique to the leukemia. Chromosome studies called cytogenetics are used to find genetic changes in the AML blasts. In addition, several specific genetic mutations in the AML cells have been found that can help determine a person’s prognosis, or chance of recovery. These molecular analyses are now being done more often when AML is first diagnosed. Results of these tests will help decide your treatment options (see the Treatment Options section).

Imaging tests. A computed tomography (CT or CAT) scan is a test that creates a three-dimensional picture of the inside of the body. A magnetic resonance imaging (MRI) is a test that uses magnetic fields, not x-rays, to produce detailed images of the body. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill to swallow. These tests may be used to learn more about the cause of symptoms or to help diagnose infections in patients with AML. They are not regularly used to find out how widespread the AML is because the disease has often spread throughout the bone marrow when it is first diagnosed.

Lumbar puncture, also called a spinal tap. A lumbar puncture is a procedure in which a doctor uses a needle to take a sample of cerebral spinal fluid (CSF) to look at the make up of the fluid and to find out is it contains cancer cells or blood. CSF is the fluid that flows around the brain and spinal cord. Doctors generally give an anesthetic to numb the lower back before the procedure. The CSF is then examined under the microscope to look for AML cells.

After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is AML, these results also help the doctor describe the disease; this is called subtyping.

The next section helps explain the different subtypes of AML. Use the menu on the side of your screen to select Subtypes, or you can select another section, to continue reading this guide.

Leukemia - Acute Myeloid - AML - Subtypes

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will learn about how doctors describe AML. This is called the subtype. To see other pages, use the menu on the side of your screen.

There are different ways to classify the subtypes of AML. Although all subtypes cause decreases in normal blood cell levels, different types of AML are associated with specific symptoms and problems. In addition, each subtype can behave differently after treatment.  

Morphology

AML is first described by its morphology, or what the cancerous cells look like under the microscope. AML is classified by the type of normal, immature white blood cell it most closely resembles.  

Most patients with AML have a subtype called myeloid leukemia, which means the cancer is in the cells that normally produce neutrophils. Other patients have a type of AML called monoblastic or monocytic leukemia. In monocytic leukemia, the cells look like white blood cells called monocytes. Leukemia cells can also be a mixture of myeloblastic and monocytic cells.

Sometimes AML seems to come from cells that produce red blood cells, called erythroid, or platelets, called megakaryocytic. Acute promyelocytic leukemia (APL) is a unique subtype of AML where the cancer cell stops maturing when the cell is at a stage called the promyelocyte or progranulocyte stage. APL is associated with a translocation between chromosomes 15 and 17 [t(15;17)].

Flow cytometry is a blood test that can identify particular proteins on the surface of abnormal cells and is sometimes used to find the difference among these subtypes.

The classification system from the World Health Organization (WHO) includes these major groups:

  • AML with recurrent genetic abnormalities, meaning with specific chromosomal changes
  • AML with multilineage dysplasia, or abnormalities in how the blood cells look
  • AML, related to therapy that is damaging to cells, also called therapy-related myeloid neoplasm
  • AML that is not otherwise categorized

The French-American-British (FAB) classification is an older system for describing AML, but it is still commonly used and is listed below for reference.  

M0: Myeloblastic without differentiation
M1: Myeloblastic with little or no maturation
M2: Myeloblastic with maturation
M3: Promyelocytic
M4: Myelomonocytic
M4eo: Myelomonocytic with eosinophils
M5a: Monocytic without differentiation (monoblastic) 
M5b: Monocytic with differentiation
M6: Erythroleukemic
M7: Megakaryocytic

Cytogenetics

AML is also classified by the cytogenetic, or chromosome, changes found in the leukemia cells. Sometimes the doctor can find these changes by looking at the chromosomes in dividing cells under the microscope, while other changes can be found only with very specific molecular tests that can recognize very small changes in the DNA.

Certain chromosomal changes are closely matched with the morphology of the AML cells. More importantly, the chromosomal changes help doctors determine the best treatment options because these changes can sometimes predict how well intensive treatment will work. Chromosomal changes are commonly grouped according to the likelihood that treatment will work against the subtype of AML. (Note: all chromosomes are numbered from one to 22; sex chromosomes are called “X” or “Y.” The letters “p” and “q” refer to the “arms” or specific areas of the chromosome.)

Some of the most common chromosomal changes are grouped as follows:

Favorable. Chromosomal changes associated with more successful treatment include abnormalities of chromosome 16 at bands p13 and q22 [t(16;16)inv(16)(p13q22)], a translocation (exchange of genetic material) between chromosomes 8 and 21 [t(8;21)].

Intermediate. Changes associated with a less favorable prognosis include normal chromosomes, where no changes are found and a translocation between chromosomes 9 and 11 [t(9;11)]. Many other subtypes are considered part of this group, particularly those with one or more specific molecular changes. Sometimes, extra copies of chromosome 8 or trisomy 8 may be classified as intermediate risk over unfavorable (see below).

Unfavorable. Examples of chromosomal changes that are associated with less successful treatment or with a low chance of curing the AML include extra copies of chromosomes 8 or 13 [for example, trisomy 8 (+8)], deletion of all or part of chromosomes 5 or 7, complex change on many chromosomes, and changes to chromosome 3 at band q26.

In general, the favorable changes occur more commonly in younger patients, while the unfavorable changes are more common in patients older than 60. How well treatment works still varies widely in each of these groups. Treatment is successful in the long term for 50% to 60% of patients younger than 60 with AML that is classified as favorable and for less than 10% of patients younger than 60 with AML that is classified as unfavorable. Prognosis in patients older than 60 years of age is significantly worse. How well treatment works also depends on other factors, including the patient’s age and the number of white blood cells. It is not possible to predict exactly the likelihood of successful treatment for a person with AML.

Molecular changes

Mutations in genes that are too small to be seen with a microscope and cannot be found with cytogenetic tests have been found using tests called molecular assays. For example, patients with changes in the NPM1 or CEBPalpha genes have a better long-term outcome, while chemotherapy (see the Treatment Options section) does not work as well for patients with changes in the FLT3 gene. Therefore, testing for these changes at diagnosis helps determine a patient’s treatment options. 

Recurrent AML

Recurrent or relapsed AML is cancer that has come back after treatment. If there is a recurrence, the cancer may need to be subtyped again using the system above.

Information about the subtype will help the doctor recommend a treatment plan for you. The next section helps explain the treatment options for this type of cancer. Use the menu on the side of your screen to select Treatment Options, or you can select another section, to continue reading this guide. 

Leukemia - Acute Myeloid - AML - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will learn about the different ways doctors use to treat people with AML. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also strongly encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Descriptions of the most common treatment options for AML are listed below. Treatment options and recommendations depend on several factors, including the subtype, morphology, and cytogenetics of AML (see Subtypes), possible side effects, and the patient’s preferences and overall health. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.

The most successful treatment for AML depends on the results of the first treatment, so it is important for patients to have their first treatments at a center experienced with AML.

Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Intensive chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. The drugs travel through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication, or a hematologist, a doctor who specializes in treating blood disorders.

Chemotherapy is the primary treatment for AML. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle, or injected into the cerebral spinal fluid, or in a pill or capsule that is swallowed (orally). Chemotherapy may also be given by an injection under the skin, called a subcutaneous injection. When chemotherapy is given by IV, it may be given into a larger vein or a smaller vein, such as in the arm. When it is given into a larger vein, a central venous catheter or port may need to be placed in the body. A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time. Several drugs are used to treat AML, which are discussed below.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Chemotherapy by phase

Chemotherapy for AML can be divided into three phases: Induction, post-remission, and consolidation.

Induction therapy. This is the first period of treatment after the diagnosis is made. The goal of induction therapy is a complete remission (CR), which means that the blood counts have returned to normal, the leukemia cannot be found in a bone marrow sample when examined under the microscope, and the signs and symptoms of AML are gone.

The combination of cytarabine (Cytosar-U) given over four to seven days and an anthracycline drug, such as daunorubicin (Cerubidine) or idarubicin (Idamycin), given for three days is used most often. Patients may also be given hydoxyurea (Droxia, Hydrea) to help lower white blood cell counts. In addition to killing leukemia cells, these drugs also damage healthy cells, increasing the risk of infection and bleeding (see below). Most patients will need to stay in the hospital for three to five weeks during induction therapy before their blood counts return to normal. Sometimes, two rounds of therapy are needed to achieve a CR. Approximately 75% of younger adults with AML and about 50% of patients older than 60 achieve a CR after treatment. 

Some older adults may not be able to have induction therapy with the standard drugs, and the drugs decitabine (Dacogen), azacitidine (Vidaza), and clofarabine (Clolar) may be used instead. A clinical trial is also an option.

Post-remission therapy. After induction therapy, a variety of different drugs are used to destroy undetectable AML cells that remain. AML will almost certainly recur if no further treatment is given after a CR. For some patients, bone marrow/stem cell transplantation (see below) is recommended as part of post-remission therapy.

Consolidation chemotherapy. Younger adults in remission are commonly given two to four rounds of high-dose cytarabine or other intensive chemotherapy at monthly intervals, while several different regimens are used for older patients. Although chemotherapy is usually given in the hospital, most of the recovery time can be spent at home. A stem cell transplantation is often recommended as consolidation therapy for younger patients in whom cytogenetic or molecular studies predict a poorer outcome using chemotherapy alone.

Stem cell transplantation/bone marrow transplantation. A stem cell transplant is a medical procedure in which bone marrow that contains leukemia is destroyed and then replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy bone marrow. Hematopoietic stem cells are blood-forming cells found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is the stem cells in the blood that are typically being transplanted, not the actual bone marrow tissue.

Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the type of cancer, results of any previous treatment, and patient’s age and general health.

There are two types of stem cell transplantation depending on the source of the replacement blood stem cells: allogeneic (ALLO) and autologous (AUTO). ALLO uses donated stem cells, while AUTO uses the patient’s own stem cells. ALLO transplants are generally used for AML.

The goal is to destroy all of the cancer cells in the marrow, blood, and other parts of the body using high doses of chemotherapy and/or radiation therapy and then allow replacement blood stem cells to create healthy bone marrow. Learn more about stem cell and bone marrow transplantation.

Side effects of chemotherapy

Chemotherapy for AML attacks rapidly dividing cells, including those in normal tissues, such as the hair, lining of the mouth, intestines, and bone marrow. People with AML receiving chemotherapy may lose their hair, develop mouth sores, or have nausea and vomiting. Hair will regrow after treatment is finished, and effective drugs help prevent and control nausea and vomiting. The side effects of chemotherapy may be different depending on the drugs used. Patients are encouraged to talk with their doctors about short-term and long-term side effects before treatment begins.

Because of the effect on normal blood cells in the bone marrow, chemotherapy used for AML will lower the body’s ability to fight infection for a short time, and increased bruising, bleeding, and fatigue may be common. People with AML often receive antibiotics to prevent and treat infections and will need transfusions of red blood cells and platelets throughout chemotherapy. Chemotherapy may also affect the patient’s fertility, or ability to have a child in the future. Patients concerned about this are encouraged to talk with a fertility specialist before treatment begins.

Acute promyelocytic leukemia (APL) treatment

The treatment of the APL subtype of AML is very different. This subtype is very sensitive to the effects of all-trans retinoic acid (ATRA), a drug that is similar to vitamin A and is given by mouth. People with the APL subtype who receive a combination of ATRA and chemotherapy (see above) with idarubicin or daunorubicin are very likely to have a CR. Occasionally, the drug cytarabine may also be used. Arsenic trioxide (Trisenox) is another drug that works well for APL, either during initial induction therapy alone or in combination with ATRA, during post-remission therapy, or for APL that has come back after treatment. The combination of ATRA and arsenic trioxide is now often used as the initial and consolidation treatment of APL, avoiding the use of drugs that can be more damaging to healthy cells.

Mild to severe bleeding is a common symptom of APL, and patients with this subtype often need many platelet and blood transfusions during initial treatment. Compared with other subtypes of AML where maintenance therapy is not used, some patients with APL benefit from use of ATRA for one to two years after the initial treatment.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation therapy is called external-beam radiation therapy, which is radiation given from a machine outside the body. A radiation therapy regimen usually consists of a specific number of treatments given over a set period of time. Because AML is found throughout the blood, radiation therapy is generally used only when leukemia cells have spread to the brain or to shrink a myeloid sarcoma, which is a mass of tissue in only one area of the body.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. Learn more about radiation therapy.

Getting care for symptoms and side effects

Leukemia and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the disease, an important part of care is relieving a person’s symptoms and the side effects of treatment. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the leukemia and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the leukemia, such as chemotherapy and radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. Learn more about palliative care.

Refractory AML

If leukemia is still present after initial treatment, the disease is called refractory AML. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this type of leukemia, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.

Your health care team may recommend a treatment plan that includes new drugs being tested in clinical trials. An ALLO stem cell transplant should also be considered as part of the treatment plan. Supportive care will also be important to help relieve symptoms and side effects.

For most patients, a diagnosis of refractory leukemia is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when the leukemia cannot be detected in the body, there are no symptoms, and a patient’s blood counts are normal. This may also be called “no evidence of disease” or NED.  

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the disease will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the leukemia returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the disease does return. Learn more about coping with the fear of recurrence.

If the leukemia does return after the original treatment, it is called recurrent or relapsed leukemia. When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the subtype has changed. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above, such as chemotherapy, stem cell transplantation, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent leukemia.

The treatment for recurrent AML often depends on the length of the initial remission. If the AML comes back after a long remission, the original treatment may work again. If the remission was short, then other drugs are used, often through a clinical trial. An ALLO stem cell transplant may be the best option for patients whose leukemia has come back after initial treatment. However, many drugs and other approaches are being evaluated in clinical trials.

People with recurrent leukemia often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

If treatment fails

Recovery from leukemia is not always possible. If treatment is not successful, the disease may be called advanced or terminal leukemia.

This diagnosis is stressful, and it may be difficult to discuss because the advanced leukemia is incurable. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients with advanced leukemia who have no more effective treatment options available may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.

Leukemia - Acute Myeloid - AML - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

Doctors and scientists are always looking for better ways to treat patients with AML. To make scientific advances, doctors create research studies involving volunteers, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments, such as new chemotherapy before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating AML. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with AML.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

For specific topics being studied for AML, learn more in the Latest Research section.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. 

Cancer.Net offers a lot of information about clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

The next section helps explain the areas of research going on today about AML. Use the menu on the side of your screen to select Latest Research, or you can select another section, to continue reading this guide. 

Leukemia - Acute Myeloid - AML - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will read about the scientific research being done now to learn more about AML and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about AML, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Most cancer centers are actively involved in clinical trials focused on increasing the number of people cured of AML. Always talk with your doctor about the diagnostic and treatment options best for you.

Understanding AML biology. Research on the biology of AML is ongoing to learn more about how leukemia develops and to improve its treatment, particularly for older patients.

New drugs and treatment regimens. Researchers are looking at the use of existing drugs given in different doses and schedules, as well as new drugs. Specific research includes the use of drugs called hypomethylating therapy, such as azacitidine or decitabine. A new drug combination is also being researched called CPX-351, which combines the drugs cytarabine and daunorubicin.

Targeted therapy. Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. Researchers are studying ways to block how specific genetic changes found in AML cells affect the body. For example, about 30% of patients with AML have changes in the FLT3 gene, which can increase the growth of AML cells. Quizartinib is a drug that stops the changed FLT3 gene from working that is being tested in clinical trials. Other targeted therapies are being researched that stop AML cells from becoming resistant to chemotherapy when the chemotherapy stops working. Specific targeted therapy drugs being researched include midostaurin, lenalidomide (Revlimid), sorafenib (Nexavar), Histone Deacetylase inhibitors (HDAC inhibitors) and other drugs that are targeted to specific gene mutations such as IDH1 and IDH2, c-KIT and RAS.

Immunotherapy. Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the leukemia. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Researchers are specifically looking at vaccines and the use of antibodies directed against the AML cells

Stem cell/bone marrow transplantation. Different ways to make stem cell transplantation safer, easier, and more effective are also being studied (see Treatment Options).

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current AML treatments in order to improve patients’ comfort and quality of life.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding AML explore these related items that take you outside of this guide:

The next section addresses how to cope with symptoms of the disease or the side effects of its treatment. Use the menu on the side of your screen to select Coping with Side Effects, or you can select another section, to continue reading this guide. 

Leukemia - Acute Myeloid - AML - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of leukemia, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for AML are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the subtype, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with AML. Learn more about caregiving.

In addition to physical side effects, there may be emotional and social effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies, including concerns about managing the cost of your cancer care

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the After Treatment section or talking with your doctor.

The next section helps explain medical tests and check-ups needed after finishing cancer treatment. Use the menu on the side of your screen to select After Treatment, or you can select another section, to continue reading this guide.

Leukemia - Acute Myeloid - AML - After Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will read about your medical care after treatment is finished and why this follow-up care is important. To see other pages in this guide, use the colored boxes on the right side of your screen, or click “Next” at the bottom.

After treatment for AML ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

People in remission should receive regular follow-up examinations for several years to watch for a recurrence of the AML or late effects of chemotherapy. Patients are also encouraged to tell the doctor about any new symptoms they have.

People recovering from AML are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes.

The next section offers a list of questions you may want to ask. Use the menu on the side of your screen to select Questions to Ask the Doctor, or you can select another section, to continue reading this guide. 

Leukemia - Acute Myeloid - AML - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care.

  • What is my diagnosis? What does it mean?
  • Do I need to start treatment right away?
  • What subtype of AML do I have?
  • Can you recommend a leukemia specialist?
  • Where is the best place for me to receive treatment?
  • What are my options for treatment?
  • What clinical trials are open to me? Where are they located, and how do I find out more about them?
  • What treatment plan do you recommend? Why?
  • What is the goal of each treatment? Is it to eliminate the leukemia, manage the symptoms or side effects, or both?
  • How likely is it that my AML will go into remission?
  • Who will be part of my health care team, and what does each member do?
  • Who will be coordinating my overall treatment and follow-up care?
  • What are the possible side effects of this treatment, both in the short term and the long term?
  • Could this treatment affect my sex life? If so, how and for how long?
  • Could this treatment affect my ability to become pregnant or have children? If so, should I talk with a fertility specialist before cancer treatment begins?
  • How will the treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
  • Can you explain my pathology report (laboratory test results) to me?
  • What follow-up tests will I need, and how often will I need them?
  • What support services are available to me? To my family?
  • Whom should I call for questions or problems?

The next section offers some more resources that may be helpful to you. Use the menu on the side of your screen to select Additional Resources, or you can select another section, to continue reading this guide. 

Leukemia - Acute Myeloid - AML - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2014

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about care and treatment. This is the final page of Cancer.Net’s Guide to Adult Acute Myeloid Leukemia. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of leukemia, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond. Here are a few sections that may get you started in exploring the rest of Cancer.Net:

- Search for a specialist in your local area using this free database of doctors from the American Society of Clinical Oncology.

- Review dictionary articles to help understand medical phrases and terms used in medical care and treatment.

- Read more about the first steps to take when newly diagnosed with leukemia.

- Find out more about clinical trials as a treatment option.

- Learn more about coping with the emotions that leukemia can bring, including those within a family or a relationship.

- Find a national, not-for-profit advocacy organization that may offer additional information, services, and support for people with AML.

- Explore next steps a person can take after active treatment is complete.

This is the end of Cancer.Net’s Guide to Adult Acute Myeloid Leukemia.
Use the menu on the side of your screen to select another section to continue reading this guide.