Although each patient is treated on an individual basis, intensive chemotherapy is normally appropriate if you’re under 75 years of age and you have good medical fitness.
You’ll have intensive treatment in two phases called remission induction therapy and consolidation therapy. This treatment involves strong chemotherapy, sometimes with targeted therapy drugs. The treatment often successfully kills the leukaemia cells, but it’s associated with more severe side effects.
You’ll usually have three to four courses (sometimes called blocks or cycles) of treatment over four to six months. Each course lasts a few days, and you’ll normally recover from each course in about three to six weeks.
You’ll have most of your remission induction and consolidation treatment as an inpatient in hospital, but nearly all patients will get some time at home, even if it’s just for a few days.
Most patients get to go home for a week or so in between courses, usually just after chemotherapy has finished. During this time you’ll be monitored closely a couple of times a week. If you need them, you’ll be given blood and platelet transfusions, to support your body and reduce some of your symptoms.
Remission induction therapy
The remission induction phase aims to clear leukaemia cells from your blood and bone marrow and quickly get your bone marrow working normally again. This treatment involves a combination of chemotherapy drugs and sometimes targeted therapy drugs. You’ll usually have two courses of chemotherapy in this phase of your treatment. The chemotherapy will be given to you by intravenous (IV) infusion, into a large vein in your arm via a long, flexible tube. There are two types of lines that may be used for the infusion:
- a PICC (peripherally inserted central catheter) line, which will go through a vein in your arm at the end of your elbow
- a tunnelled central line (also known as a Hickman line), which will go through a vein under your skin on the upper part of your chest.
After you’ve finished remission induction therapy, you’ll start on consolidation therapy. The aim of this phase of treatment is to reduce your risk of relapse. Without consolidation therapy, there’s a higher risk of relapse in the year after your initial treatment.
During consolidation therapy, you’ll have more chemotherapy – usually one or two courses. You may also continue to have targeted therapy.
Some patients will also have a stem cell transplant. If you do have a transplant, you might not have any more chemotherapy after your remission induction treatment, or you just might just have one more course.
There are lots of different options for consolidation therapy, which are chosen on an individual basis. You’ll get to discuss this with your consultant.
You may also be given targeted therapy drugs as part of your induction and consolidation therapy. There are two types of targeted therapy drug offered to people with AML: gemtuzumab ozogamicin (Mylotarg®) and midostaurin (Rydapt®).
If the immunophenotyping tests you have at diagnosis detect a protein called ‘CD33’ on the surface of your leukaemia cells (most people with AML have this), your doctors may recommend that you also have gemtuzumab ozogamicin alongside chemotherapy. Gemtuzumab ozogamicin is given through an intravenous (IV) infusion on specific days of your induction therapy and consolidation therapy.
If you have a mutation called ‘FLT3’ (between 25% and 30% – just under a third – of people with AML have this) your doctors may recommend that you have midostaurin with chemotherapy. You’ll have tests to check for this mutation during the first week following your diagnosis. Midostaurin is a tablet that you take twice a day for two weeks just after each course of induction and consolidation therapy.
If you have AML caused by treatment you’ve had for another cancer or related condition, or your doctor has identified changes in your bone marrow known as myelodysplasia-related changes, you may be offered a different type of chemotherapy to the one that’s usually used for induction and consolidation therapy, called ‘liposomal chemotherapy’. It’s given in the same way as standard chemotherapy – by intravenous (IV) infusion, into a large vein in your arm.
Liposomal chemotherapy is given over three days during your first course of induction therapy. Some patients will then have a few more days of treatment during subsequent courses of induction and consolidation therapy.
Remission after intensive treatment
Your doctors will measure how well you’ve responded to treatment. During treatment you’ll have blood tests to see if your blood looks normal and if your blood cell count is normal. You’ll then have another bone marrow sample taken, to see if this looks normal too. You’ll have other genetic tests, similar to the ones you had when you were diagnosed, to look for any changes treatment has caused.
If your intensive treatment is a success, this is called remission. In remission, your bone marrow produces blood cells normally and you’ll have fewer than 5% of blast cells in your bone marrow. The DNA in your cells will also be back to normal.
If you have the FLT3 mutation, after achieving remission you’ll continue to take midostaurin on its own to help stop the cancer coming back.