Acute myeloid leukemia (AML) treatment isn't one-size-fits-all. Your doctor has many ways to treat this cancer. Some treatments are aggressive and intense. Others are less intense. Your doctor will choose the one that's best suited to your age and health.
AML treatment often starts with intensive induction therapy. It uses high doses of chemotherapy and other medicines to kill as many leukemia cells as possible in the blood and bone marrow. The goal is to put the cancer into remission.
Intensive induction therapy is a very aggressive treatment. It may not be safe for you if you're 75 or older or you aren't in good health. The risks of serious side effects from the medicine could be greater than the benefits. More than half of people who are newly diagnosed with AML can't tolerate this treatment because of their age or health.
You do have other treatment options if high intensity induction therapy isn't right for you or you don't want it. "We usually give lower intensity therapy. It's not necessarily a less effective therapy, but it looks different," says John Mascarenhas, MD, a hematologist-oncologist and director of the Center of Excellence for Blood Cancers and Myeloid Disorders at Mount Sinai Tisch Cancer Center in New York, New York.
Even people who are under 75 and healthy might benefit from lower intensity induction therapy. Some research shows that less intense treatment leads to longer survival without a relapse compared with intense treatment. And people who get lower intensity therapy have fewer serious complications, spend less time in the hospital, and have a better quality of life during treatment.
Low-Intensity Induction Therapy
With this treatment you'll get two or more medicines. The cancer drugs are a lower dose and less toxic than the ones used for intensive chemotherapy.
Often one of the medicines is a hypomethylating agent (HMA) like azacitidine (Vidaza) or decitabine (Dacogen). HMAs kill abnormal blood cells in your bone marrow and help new, healthy blood cells grow. You'll go to a hospital or clinic for treatment. A nurse or doctor will inject the medicine under your skin or into a vein.
The other part of treatment is a BCL2 inhibitor, usually venetoclax (Venclexta). It's a pill that you take at home every day with food. Venclexta works differently from chemotherapy, which directly kills cancer cells. BCL2 is a protein that stops cancer cells from self-destructing and helps them survive. BCL2 inhibitors block this protein, which restarts the self-destruct process and makes the cancer cells die.
This drug combo is a "one-two punch," Mascarenhas says. The HMA kills cancer cells. And the BCL2 inhibitor makes the cancer cells self-destruct.
The FDA recently approved a new oral treatment -- decitabine and cedazuridine (Inqovi) in combination with venetoclax. It's for people newly diagnosed with AML who aren't able to take intensive induction chemotherapy.
Other treatments your doctor might prescribe with or instead of these medicines are:
- Low-dose cytarabine (Cytosar-U), a chemotherapy drug
- Glasdegib (Daurismo), which blocks a protein that helps cancer cells divide and grow
Some AML cells have changes to certain proteins or genes. If tests show that you have one of these changes, you will also get a targeted drug:
- IDH1 gene mutation: Ivosidenib (Tibsovo)
- IDH2 gene mutation: Enasidenib (Idhifa)
- FLT3 gene mutation: Quizartinib (Vanflyta) or sorafenib (Nexavar)
- CD33 protein: Gemtuzumab ozogamicin (Mylotarg)
People who are on high-intensity induction therapy need to stay in the hospital for about a month. The strong medicines lower blood counts and increase the risks for infection and bleeding. Doctors and nurses at the hospital can check for these problems and treat them.
With lower intensity induction therapy, you may not have to stay in the hospital for as long or at all. "The intensity is less, so the amount of blood count lowering tends to be less," Mascarenhas says.
What to Expect
Intensive AML treatment aims to put the cancer into remission quickly. Once someone is in remission, they get consolidation therapy to destroy any cancer cells that were left behind and keep them in remission. Consolidation therapy could include high-dose chemotherapy followed by a stem cell transplant to try to cure the cancer. Treatment ends when the cancer is cured.
Consolidation therapy is different after less intensive treatment. "We don't cure patients with HMA-venetoclax," says Mascarenhas. "We extend survival."
Low intensity treatment doesn't ever end. Even if your cancer is in remission, you'll stay on treatment to stop the cancer from coming back.
Side Effects
Even though low-intensity induction therapy is less intense, it can still cause side effects. The most common ones are:
- Nausea and vomiting
- Diarrhea
- Constipation
- Tiredness
- Swelling from fluid buildup under the skin
- Pain in the belly, bones, or joints
- Dizziness
- Low blood pressure
This treatment also lowers the number of white blood cells, red blood cells, and platelets in bone marrow. Your doctor calls this myelosuppression. Low numbers of blood cells increases your risk for infections, bleeding, and anemia.
When a Cure Isn't Possible
The news that your cancer isn't curable can be hard to hear. "It's life-altering. It's definitely overwhelming for the patient, their loved ones, and for us as a care team to have to give this kind of news," Mascarenhas says.
Know that your doctor will do everything possible to improve your outcome. "Our goals are to try to induce a response and maintain that response for as long as possible," he adds. If a stem cell transplant is possible — and sometimes it is possible after lower intensity induction therapy — your doctor will do it.
You may have read or heard about AML median survival. This number shows how long people with your cancer can live, but it's just an average. Some people don't live as long as the median survival time. Others live longer.
The idea of measuring your lifetime in months instead of years can cause a lot of anxiety. Your medical team is there to help. Talk to your doctor. Ask questions. Discuss your worries with a therapist or counselor at your cancer hospital.
Your doctor might suggest palliative care. If not, you can ask for it. The palliative care team will help you understand what to expect going forward, manage your symptoms, and help improve your quality of life during treatment.
Palliative care is different from hospice, which is end-of-life care. But at some point, you may need hospice if you and your doctor make the decision to stop treatment. For example, if you're in your 80s and you have a serious medical condition like heart failure or kidney disease, treatment may not extend your life enough to be worth the side effects. "We might just extend suffering and not quality of life," Mascarenhas says. “Sometimes patients don’t want to live like that.”
Making the Choice
The benefits of lower intensity induction therapy are less severe side effects and more flexibility. You don’t have to stay in the hospital long-term, so you can spend more time at home with family.
The downside is that treatment will never stop. “It is indefinite therapy,” Mascarenhas says. “Getting into a response doesn’t mean that you’re done. It’s the first good step, but then you have to get a cycle of treatment each month.” You will also need to visit a hospital or clinic often for blood count checks and treatment.
You don't have to go through AML treatment at all. If your doctor thinks the medicine will cause severe side effects but it won't prolong your life much, you can decide not to have it.
Whether to choose intensive induction therapy, less intensive induction therapy, or no treatment is a decision you will make together with your treatment team. Have a talk with your doctor. Make sure you understand what to expect with each option. Then you can choose the treatment that offers you the best possible outcome with the fewest risks and side effects.
Show Sources
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SOURCES:
American Cancer Society: "Typical Treatment of Acute Myeloid Leukemia (Except APL)."
American Society of Hematology: "Results from Paradigm - a Phase 2 Randomized Multi-Center Study Comparing Azacitidine and Venetoclax to Conventional Induction Chemotherapy for Newly Diagnosed Fit Adults with Acute Myeloid Leukemia."
ASH Clinical News: "Azacitidine, Venetoclax Effective as Treatment for Acute Myeloid Leukemia."
Dana-Farber Cancer Institute: "BCL2 Inhibitors: What's the Latest Research?"
FDA: "Highlights of Prescribing Information: Venclexta."
Frontiers in Oncology: "Unmet Needs in Patients with Acute Myeloid Leukemia Ineligible for Intensive Approaches: Perspectives from a European Expert Panel."
Future Oncology: "Therapies for Acute Myeloid Leukemia in Patients Ineligible for Standard Induction Chemotherapy: A Systematic Review."
HealthTree Foundation: "Palliative and Hospice Care for AML Patients."
John Mascarenhas, MD, hematologist-oncologist; director, Center of Excellence for Blood Cancers and Myeloid Disorders, Mount Sinai Tisch Cancer Center, New York, New York.
MedlinePlus: "Azacitidine Injection," "Decitabine Injection," "Glasdegib."
National Cancer Institute: "Acute Myeloid Leukemia Treatment (PDQ)—Health Professional Version."
