When diagnosed with Acute Myeloid Leukemia (AML), understanding available treatment options can be overwhelming. Dr. Alice Mims, an AML specialist, provides an overview of AML therapies and discusses factors to consider when deciding on an appropriate therapy with your healthcare team.
Dr. Alice Mims is a hematologist specializing in acute and chronic myeloid conditions. She serves as the Acute Leukemia Clinical Research Director at The Ohio State University Comprehensive Cancer Center – James.
For the past 30 years, we’ve had the same treatment options, which have been standard intensive induction chemotherapy that weren’t really tailored to individual patients and had significant toxicity. And not necessarily effective for all AML genomic subtypes.
Now we have quite a bit added to the treatment arsenal for AML, including continuing intensive induction chemotherapy for patients who are appropriate. There’s also been the addition for newly diagnosed patients for hypomethylating agents and a new BCL-2 inhibitor called Venetoclax. IDH inhibitors for patients with IDH1 and IDH2 mutations. The addition of FLT3 inhibitors for patients either newly diagnosed or with relapse or refractory disease.
And liposomal daunorubicin and cytarabine in for patients with AML with MDS related changes or therapy related AML that are newly diagnosed. Lastly, there’s also a hedgehog inhibitor, glasdegib, that’s been approved for newly diagnosed AML patients in combination with low dose cytarabine.
So, when working with patients, there are multiple factors that we take into consideration when coming up with a treatment decision together and it really should be a team approach. But one of the most important things is trying to understand the patient’s goals of care.
Because different treatments have different expectations, side effects, toxicities that we want to be sure we’re all aligned when we’re making a treatment decision together. Also, other features that we take into account can be age. Other comorbidities, including other diagnosis such as cardiovascular disease, diabetes and other medical issues patients may have.
So, for roles that patients have in making these decisions, they should know that they’re their own best advocate. And so, as you’re getting to learn your oncologist who’s helping you make these treatment decisions, it’s very important that you talk about things that are important to you in regards to quality of life, overall goals for your life. Ask questions in regard to side effects and expectations for outcomes for potential treatment. Whether they’re curative or more palliative, which can extend life. And for quality of life, it may not be curative for AML.
So, AML really was considered a single disease 30, 20 years ago. Now we really know it’s likely dozens of diseases based off of looking at molecular features of an individual patient’s AML. So, it’s very important to try to understand what genomic features your AML may have, meaning DNA mutations that are just present in the leukemia cells. Chromosomal changes as well. And then understanding if, based off that information, that that may afford you additional treatment options other than the current standards of care.
With advances in AML research and a number of new treatments, can older therapy types still play a role in care? Dr. Alice Mims discusses pairing early AML treatments with new agents to boost their effectiveness.
Dr. Alice Mims is a hematologist specializing in acute and chronic myeloid conditions. She serves as the Acute Leukemia Clinical Research Director at The Ohio State University Comprehensive Cancer Center – James.
So, in regards to older treatments and being effective, seven plus three, which is an intensive chemotherapy, is still the standard of care treatment for patients with favorable risk AML, if they’re candidates for intensive treatments because it is potentially curative. And 7 + 3 is also the backbone for newly diagnosis for patients with FLT3 mutations, we add a FLT3 inhibitor called Midostaurin onto that, as it’s shows to improve overall survival with the addition of that compared to just the chemotherapy alone.
And also, hypomethylating agents, which are a less intensive treatment, were the standard of care for patients who couldn’t tolerate intensive chemotherapy.
And now we’re seeing the addition of other agents being added to this, like the BCL2 inhibitor of Venetoclax.
And recent data in phase 3 trial comparing the hypomethylating agent alone versus adding that agent did show an overall survival advantage. And so, these are definitely evolving, and I think as we are learning more about targeted therapies and how they can best be used in combination with chemotherapy other than single. Agent. But you give two targeted therapies together and having even better outcomes. We hope we continue to make improvements from where we were even just five years ago and do a better job for.
https://powerfulpatients.org/pen/wp-content/uploads/Effective-AML-Combination-Treatment.png600600PEN Editorial Staffhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngPEN Editorial Staff2020-07-07 09:35:302020-07-09 15:46:34Effective AML Combination Treatment
Leukemias are cancers that start in cells that would normally develop into different types of blood cells. It is a cancer of the body’s blood-forming tissues, including the bone marrow and the lymphatic system. Most often, leukemia starts in early forms of white blood cells, but some leukemias start in other blood cell types.
There are several types of leukemia, which are divided based mainly on whether the leukemia is acute (fast growing) or chronic (slower growing), and whether it starts in myeloid cells or lymphoid cells. The main types of leukemia include:
Acute Lymphocytic Leukemia (ALL)
Acute Myeloid Leukemia (AML)
Chronic Lymphocytic Leukemia (CLL)
Chronic Myelogenous Leukemia (CML)
Other – Other, rarer types of leukemia exist, including hairy cell leukemia, myelodysplastic syndromes and myeloproliferative disorders
In this article we will be focusing on Acute Myeloid Leukemia (AML) since it is the most frequent acute leukemia in adulthood.
What is Acute Myeloid Leukemia?
Acute myeloid leukemia (AML) is a cancer of the blood in which the bone marrow makes abnormal cells. The “acute” in Acute Myeloid Leukemia denotes the disease’s rapid progression In AML, myeloid stem cells usually mature into abnormal myeloblasts, or white blood cells. But, they sometimes become abnormal red blood cells or platelets. As they multiply, they overwhelm the normal cells in the bone marrow and blood. The cancer cells can also spread to other parts of the body.
This type of cancer usually gets worse quickly if it is not treated. It is the most common type of acute leukemia in adults. AML can also be referred to as:
Acute myelogenous leukemia
Acute myeloblastic leukemia
Acute granulocytic leukemia
Acute nonlymphocytic leukemia
Types of Acute Myeloid Leukemia
Knowing the subtype of AML can be very important, as it sometimes affects both a patient’s outlook and the best treatment. Most types of AML are based on how mature (developed) the cancer cells are at the time of diagnosis and how different they are from normal cells. The different types of AML include:
The French-American-British (FAB) Classification
M0 – Undifferentiated acute myeloblastic leukemia
M1 – Acute myeloblastic leukemia with minimal maturation
M2 – Acute myeloblastic leukemia with maturation
M3 – Acute promyelocytic leukemia (APL)
M4 – Acute myelomonocytic leukemia
M4 eos – Acute myelomonocytic leukemia with eosinophilia
M5 – Acute monocytic leukemia
M6 – Acute erythroid leukemia
M7 – Acute megakaryoblastic leukemia
World Health Organization (WHO) Classification
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
Myeloid proliferations related to Down Syndrome
Undifferentiated or biphenotypic acute leukemias
AML can also be classified by the cytogenetic, or chromosome, changes found in the leukemia cells. Changes in certain chromosomes help diagnose cancer, plan treatment, or find out how well treatment is working. Chromosomal changes are commonly grouped according to the likelihood that treatment will work against the subtype of AML.
All chromosomes are numbered from 1 to 22. And, 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 types of genetic changes found in AML include:
A translocation, which means that a chromosome breaks off and reattaches to another chromosome
Extra copies of a chromosome
A deletion of a 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)(p13;q22), inv(16)(p13q22)] and a translocation 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 1 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 changes on many chromosomes, and changes to chromosome 3 at band q26.
Symptoms of AML
The signs and symptoms of AML vary based on the type of blood cell affected. They are generally nonspecific and warrant investigations for proper diagnosis. The signs and symptoms of AML are:
Pain in bones and joints
Easy bruising and contusions
Unusual bleeding, epistaxis, bleeding gums
Causes and Risk Factors for AML
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 becomes more common as people get older
Being Male – AML is more common in males than in females
Smoking – Cancer-causing substances in tobacco smoke are absorbed by the lungs and spread through the bloodstream to many parts of the body
Genetics – Researchers are finding that leukemia may run in a family due to inherited gene mutation
Chemicals – Long-term exposure to chemicals like benzene, found in petroleum, cigarette smoke, and industrial workplaces, raises the risk of 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.
Other Bone Marrow Disorders – People who have other bone marrow diseases can develop AML over time
How is Acute Myeloid Leukemia Diagnosed?
No screening exams exist for leukemia.
Doctors often discover that a person has chronic leukemia through routine blood testing. They may also rely on their experience and current knowledge of the disease.
If your doctor suspects you may have leukemia, he or she will order specific diagnostic tests such as a:
Bone marrow biopsy
Is Acute Myeloid Leukemia Hereditary?
Leukemia does not usually run in families, so in most cases, it is not hereditary. However, people can inherit genetic abnormalities that increase their risk of developing this form of cancer.
For example having a family history of other blood disorders increases your risk of getting AML. These disorders include:
Some syndromes that are caused by genetic mutations (abnormal changes) present at birth seem to raise the risk of AML. These include:
Familial Platelet Disorder syndrome
Newly Diagnosed AML Advice from an Expert
Dr. Elizabeth Bowhay-Carnes of UT Health San Antonio MD Anderson Cancer Center provides advice for patients facing an AML diagnosis, including:
Understand who your care team is including the main attending physician and the main nursing contact/support person would be
Designate a family member or friend to play the main supportive role
Preparing for Your AML Appointment
Your first appointment can be overwhelming and can be hard to grasp the realistic expectations of life during the AML treatment phase. Here are some tips and tricks to prepare you for your first appointment:
Write down any and all questions you have before coming to the doctor’s office
Bring a notepad to the appointment to jot down notes about what is said during the appointment or ask if you can record your visit
Consider your values and expectations of your quality of life
Keep copies of your medical records
Bring a friend or a family member to your appointments to help you retain all the information discusses
Consider all your treatment options, including any clinical trials available to you
Treating Acute Myeloid Leukemia
Treatment of AML depends on several factors, including the subtype of the disease, your age, your overall health and your preferences. The types of treatment include:
Chemotherapy – the primary treatment options that uses chemicals to kill cancer cells
Targeted therapy – medications that target cancer cells, but don’t affect healthy cells. This type of treatment usually has less side effects
Other drug therapy
Stem Cell transplant – also called a bone marrow transplant, helps re-establish health stem cells by replacing unhealthy bone marrow with leukemia-free stem cells that will regenerate health bone marrow
Clinical trials – can involve therapy with new drugs and new drug combinations or new approaches to stem cell transplantation
it is often a good idea to seek a second opinion. A second opinion can give you more information and help you feel more confident about the treatment plan you choose.
What You Can Expect From AML Treatment
Based on your treatment options that you have discussed with your care team, it Is important you understand how treatment may affect you. Some things you should discuss with your care team and loved ones include:
Your personal goals and values
Results you can expect
Potential side effects
How treatment may affect your life
The financial costs of treatment
Recovery and Survival
Leukemia represents 3.5 percent of all new cancer cases in the United States, and it is the seventh leading cause of cancer death. The outlook for leukemia patients depends on which type of leukemia they have, their overall health, and their age.
In the case of AML, it makes up 32% of all adult leukemia cases and there will be about 19,940 new cases of AML in the United States this year. Remission in AML is usually defined when the bone marrow contains fewer than 5% blast cells. For most types of AML, about 2 out of 3 people with AML who get standard treatment go into remission. The 5-year survival rate for people 20 and older with AML is about 25%. For people younger than 20, the survival rate is 67%.
“Adult Acute Myeloid Leukemia Treatment (PDQ®)–Patient Version.” National Cancer Institute, www.cancer.gov/types/leukemia/patient/adult-aml-treatment-pdq.
“Acute Myeloid Leukemia (AML) Subtypes and Prognostic Factors.” American Cancer Society, www.cancer.org/cancer/acute-myeloid-leukemia/detection-diagnosis-staging/how-classified.html.
“Leukemia – Acute Myeloid – AML – Subtypes.” Cancer.Net, 18 Aug. 2017, www.cancer.net/cancer-types/leukemia-acute-myeloid-aml/subtypes.
“Leukemia Types, Symptoms, and Treatments.” UPMC HIllman Cancer Center, hillman.upmc.com/cancer-care/blood/types/leukemia.
“Treating Acute Myeloid Leukemia (AML).” American Cancer Society, www.cancer.org/cancer/acute-myeloid-leukemia/treating.html.
“Acute Myelogenous Leukemia.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 27 Dec. 2017, www.mayoclinic.org/diseases-conditions/acute-myelogenous-leukemia/diagnosis-treatment/drc-20369115.
“Treatment Response Rates for Acute Myeloid Leukemia (AML).” American Cancer Society, www.cancer.org/cancer/acute-myeloid-leukemia/treating/response-rates.html.
As with many other cancers, leukemia is not a singular disease.
There are many types of leukemia, and while it is a common childhood cancer,
leukemia actually occurs more often in older adults. Leukemia is the most
common cancer in people under the age of 15, but it is most likely to affect
people who are 55 or older. There are more than 60,000 cases of adult leukemia
diagnosed each year, and it is more common among men than women.
Leukemia is a broad term that describes cancer of the blood or
bone marrow. It starts when the DNA of developing blood cells are damaged and
the bone marrow makes abnormal cells. The abnormal blood cells are the leukemia
cells which grow and divide uncontrollably. Unlike healthy cells that follow a
life cycle, the leukemia cells don’t die when they are supposed to so they
continue to build up, eventually overcrowding the blood. They crowd out normal
white blood cells, red blood cells, and platelets so those normal cells can’t
grow and function. Eventually, there are more cancer cells than healthy cells
in the blood. The type of leukemia is determined based on which blood cells are
affected by the abnormal cells. Leukemia usually affects the white blood cells,
called leukocytes, but can occur in other blood cells. There are four main
types of leukemia: chronic, acute, lymphocytic, and myelogenous.
Leukemia that grows slowly is called chronic leukemia. The
cancer cells form very slowly so the body can also continue to form healthy
cells, but over time the cancer cells continue to grow and the leukemia
Acute leukemia grows very quickly and gets worse really fast. It
has been identified as the most rapidly progressing cancer, and it can develop
and grow in a matter of days or weeks.
Lymphocytic leukemia forms in the part of the bone marrow that
makes lymphocytes, which are white blood cells that are also immune cells.
Chronic lymphocytic leukemia (CLL) is most common in older adults and makes up
about 25 percent of adult leukemia cases. It is more common in men than women
and is very rare in children. Acute lymphoblastic leukemia (ALL) also affects
older adults, but children younger than five have the highest risk of
Myelogenous leukemia forms in the bone marrow cells that produce
blood cells, rather than forming in the actual blood cells. Chronic myelogenous
leukemia (CML) accounts for about 15 percent of all leukemia cases in the
United States. CML develops mostly in adults and is very rare in children.
Acute myelogenous leukemia (AML) is a rare cancer that develops quickly with
symptoms of fever, difficulty breathing, and pain in the joints. It can be
caused by environmental factors, and develops more often in adults than
children, and more often in men than women.
There are also several less common types of leukemia. Most of these types are chronic, and each year in the United States, about 6,000 cases of these less common leukemias are diagnosed.
myelomonocytic leukemia (CMML) develops from myeloid cells.
myelomonocytic leukemia (JMML) is typically found in very young children and is
another type of myeloid leukemia.
promyelocytic leukemia (APL) is a subtype of AML.
cell leukemia is slow growing, chronic, and makes too many B cells that appear
hairy wen viewed under a microscope.
Leukemia Possible Risk Factors
There are several risk factors linked to leukemia. There are
environmental factors and genetic reasons why some people might develop
leukemia. Some of the factors can be controlled while others can not. Age,
smoking history, and exposure to hazardous chemicals are all possible risk
factors. Other risk factors may include exposure to chemicals or medical
treatments, personal health history, and family history. Some of the possible
risk factors need more study to determine a definite link to leukemia, but
being aware of your potential risk is important.
If you were exposed to chemotherapy or radiation therapy for
another cancer you have a higher chance of getting leukemia later in life.
Also, children who took medications to suppress their immune systems, such as
after an organ transplant, may develop leukemia. Exposure to chemicals such as
benzene and formaldehyde, often found in cleaning products, hair dyes, and
embalming fluid, may also increase your risk of developing leukemia. Smoking
and exposure to workplace chemicals like gasoline, diesel and pesticides could
also be a risk factor.
There are several syndromes, conditions, and genetic disorders
that can also increase leukemia risk. Li-Fraumeni syndrome, a hereditary
disorder, is linked to leukemia, and children with Down syndrome have a two to
three percent increased risk of developing acute myeloid or acute lymphocytic
leukemia. Other genetic disorders that increase leukemia risk are Fanconi
anemia, and dyskeratosis congenita (DKC). The inherited immune system
conditions ataxia-telangiectasia, Bloom syndrome, Schwachmai-Diamond syndrome,
and Wiskott-Aldrich syndrome also increase the risk of leukemia. Risk is also
increased in patients with a history of blood disorders such as myelodysplastic
syndrome, myeloproliferative neoplasm, and aplastic anemia. There are also
viruses, such as the human T-lymphotropic virus (HTLV-1), linked to leukemia.
Family history can also play a role in the development of
leukemia. Having a sibling with leukemia is a risk factor, and having an
identical twin with leukemia gives you a one in five chance of developing it
There are no known ways to prevent leukemia; however, being
aware of risk factors and attempting to reduce them could help. Studies have
linked leukemia to smoking and obesity, so quitting smoking and having a
healthy body weight could help prevent leukemia. In addition, avoiding heavy
exposure to dangerous chemicals might decrease your risk.
Signs and Symptoms
There are no reliable early screening methods for leukemia and,
especially in chronic leukemia, the symptoms may not be very noticeable early
on. Symptoms such as fatigue and fever may not be alarming at first, and could
be mistakenly attributed to other causes. Acute leukemia symptoms come on
faster and are typically more noticeable. All types of leukemia can have
similar symptoms, but the symptoms each individual patient has can help
determine the type of leukemia. Any symptoms should be checked by a doctor.
The most common symptoms of leukemia are:
Extreme fatigue that doesn’t respond to a good night sleep
Enlarged lymph nodes that are swollen and tender as a result of leukemia cells building up
Unexplained fever higher than 101 degrees that occurs frequently or lasts more than three weeks with no explanation
Night sweats that can also occur during the day, and can drench the sheets through to the mattress
Bruising and excess bleeding such as frequent nose bleeds caused by poor blood clotting which is also a symptom
Poor blood clotting is apparent when small red or purple spots, called petechiae, appear
Abdominal pain occurs when white blood cells accumulate in the liver or spleen
Bone and joint pain usually occurs in the hips or sternum where there is a lot of bone marrow that is being crowded by abnormal cells
Headaches and other neurological symptoms such as seizures, dizziness, visual changes, nausea, vomiting can occur due to leukemia cells in the fluid around the brain and spinal cord
Unintentional weight loss of five percent or more of your body weight in 12 months or less. Weight loss can sometimes be a result of having a swollen liver or spleen which can lead to loss of appetite
Frequent infections occur because white blood cells aren’t working properly to fight infections
Anemia, or iron deficiency, occurs when there is a lack of hemoglobin in the blood to transport iron in the body. Iron deficiency can cause labored breathing and pale skin. Symptoms of anemia are nausea, fever, chills, night sweats, flu-like symptoms, weight loss, bone pain, and tiredness
Complications from Leukemia
Leukemia can cause several serious complications due to the
nature of the disease and treatment. Complications such as life-threatening
infections can occur when white blood cells are damaged or reduced. When white
blood cells aren’t fully functioning, the body can’t properly fight infections,
so any infections a leukemia patient gets, such as urinary tract infections or
pneumonia, can become very serious. Low platelet counts make bleeding in areas
such as the brain, the lungs, and the stomach or intestines very dangerous,
while high white blood cell counts can cause leukemia cells to spill over from
the blood into other organs possibly causing respiratory failure, stroke, or
There are other complications that are related to specific types
of leukemia. Notably, the development of secondary cancers and blood cancers
are more likely in CLL patients. Another complication of CLL is called a
Richter transformation in which the cells can transform into an aggressive form
of lymphoma. Kidney failure can be a treatment-related complication of AML or
Leukemia can’t be diagnosed based solely on symptoms, but if
leukemia is suspected, in a general exam, the doctor will look for an enlarged
spleen or liver and take a blood sample. Further diagnostic testing may include
a bone marrow test where a long needle is used to extract marrow from the
center of a bone (usually the hip). The bone marrow test will help determine if
the patient has leukemia and the type of leukemia.
Staging is used to identify the size and location of cancer in
the body. Typically cancers have four stages with Stage I usually indicating
the cancer is in one location and is not very large. Stage IV indicates the
cancer has grown large and spread far from the original location. Most
leukemias aren’t usually staged because they are in the blood and therefore
have already spread throughout the body. Instead, leukemia can be considered
untreated, active, in remission, or recurrent. The exception is CLL, which can
spread through the lymph nodes or the blood or bone marrow, so it does have
The earlier treatment starts for leukemia, the better chance of
remission. However, thanks to some exceptional advancements in leukemia
treatment medications, doctors are often able to take the time they need to
come up with the best treatment plan for each individual with leukemia, even in
cases of acute leukemia if life-threatening complications are not present. When
coming up with a treatment plan, doctors consider the patient’s age, overall
health, and most importantly, the type of leukemia the patient has.
Leukemia treatment options vary for each type of cancer:
Watchful Waiting is used when treatment for slower growing
leukemias, such as CLL, may not be necessary;
Chemotherapy is the primary treatment for AML, and sometimes a
bone marrow transplant is needed;
Targeted therapies are medications that are tyrosine kinase
inhibitors which target cancer cells, but don’t affect healthy cells. Targeted
therapies have less side effects. Many CML patients have a gene mutation that
responds very well to targeted therapy;
Interferon therapy is a drug that acts similar to a naturally
occurring immune response which slows and then stops the leukemia cells. This
therapy can cause severe side effects;
Radiation therapy is often used in ALL to kill bone marrow
tissue before a transplant is done;
Surgery to remove the spleen may be necessary, depending on the
type of leukemia;
Stem cell transplant is effective in treating CML and is usually
more successful in younger patients. After chemotherapy or radiation or both
are used to destroy the bone marrow, new stem cells are implanted into the bone
marrow so noncancerous cells can grow.
Treatment for acute leukemia can take up to two years. It is
usually done in phases. In the first phase the goal is to use chemotherapy for
several weeks to kill the cancer cells and put the patient in remission. The
second phase is designed to kill any remaining cancer cells using chemotherapy
or stem cell transplant or both. The treatments and their side effects can be
pretty harsh for older patients so researchers have been focusing on finding
targeted therapies for acute leukemia, which have fewer side effects.
Researchers are also hoping CAR T-cell therapy, which uses the patient’s own
immune system to treat cancer, could be an eventual replacement for stem cell
replacement therapy in older ALL patients. AML is more aggressive and often
harder to treat, but several new targeted medications have been approved to
treat AML. Researchers continue to look at other targeted therapy options and
other drugs for AML.
In some cases of chronic leukemia, a stem cell transplant might
be required, but the main treatment is oral medications that patients will
probably take for the rest of their lives. Some research is investigating
whether or not patients could potentially stop taking the medications at a
CML treatments have really advanced and there are now several
drugs that target the abnormal protein that causes CML. Thanks to these
targeted medications CML patients now have a close to normal life expectancy
and a 90 percent five-year survival rate. Clinical trials are looking at using
targeted therapies to treat CLL as well and CAR T-cell therapies are also being
considered for CLL treatment.
Recovery and Survival
Leukemia represents 3.5 percent of all new cancer cases in the
United States, and it is the seventh leading cause of cancer death. The outlook
for leukemia patients depends on which type of leukemia they have, their
overall health, and their age. Leukemia is more likely to be fatal in older
patients. The average age of those who die from leukemia is 75. However, the
many advances in treatment options and medications, such as targeted therapies,
have created a better prognosis for many. Leukemia has a 62.7 percent five-year
survival rate, and some people with leukemia can now achieve complete
AML experts Dr. Pinkal Desai, Assistant Professor of Medicine at Weill Cornell Medical College and Assistant Attending Physician at the New York-Presbyterian Hospital, and Dr. Tapan M. Kadia Associate Professor, Department of Leukemia at The University of Texas MD Anderson Cancer Center, share research-based insight on how AML is diagnosed, including the symptoms and recommended tests, and disease management strategies.
These experts give an overview of currently approved AML therapies and share clinical trial updates on treatments in development. The panel discusses AML management and how you can ask questions and talk to your doctor to feel confident with your care. Additionally, you will hear from an AML patient who shares their experience and advice for approaching the decision-making process.
https://powerfulpatients.org/pen/wp-content/uploads/Acute-Myeloid-Leukemia_-Your-AML-Your-Treatment-Your-Decision.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-10-29 10:45:462019-10-29 10:48:59Acute Myeloid Leukemia: Your AML, Your Treatment, Your Decision
Absolutely. So, targeted therapy – while meant to be specific, because a target is meant to be specific – targeted therapy has become a relatively broad characterization of additional treatments. We think about targeted therapy as the addition of agents that specifically inhibit or target an abnormality associated with the leukemia. The most prominent targeted therapies right now involve specific mutations seen in Acute Myeloid Leukemia.
For instance, about 30% of adults who have newly diagnosed AML will have a mutation in something called FLT3, or F-L-T-3. There is now an approved drug that is combined with standard intensive induction chemotherapy that improves the
response rate and overall survival in adults with AML with a FLT3 mutation. In addition, there is now an approved agent for relapsed and refractory FLT3 mutating leukemia.
What about molecular testing? What can you say about that?
Molecular testing is part of the workup for an adult or a child when they’re newly diagnosed Acute Myeloid Leukemia. And molecular abnormalities look for specific known mutations that occur in Acute Myeloid Leukemia cells.
For instance, that FLT3 that I mentioned. In addition, the IDH mutation. Looking for those mutations has always been important in understanding the prognosis, but it’s now especially important because some specific mutations, we have additional therapies that we can give as part of initial treatment or for relapsed disease that target those mutations. So, not only do they have a prognostic role, but they have a treatment impact as well.
https://powerfulpatients.org/pen/wp-content/uploads/What-is-Targeted-AML-Therapy_-1.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-10-07 14:44:162020-02-05 16:45:55What is Targeted AML Therapy?
This podcast was originally published on The Bloodline With LLS on April 22, 2019, here.
Join Alicia and Lizette as they speak with Dr. Martha Arellano, Associate Professor of Hematology and Oncology and Program Director of the Hematology and Medical Oncology Fellowship Program at the Winship Cancer Institute of Emory University in Atlanta, Georgia. On this episode, Dr. Arellano defines acute myeloid leukemia (AML) and how it is diagnosed. She addresses questions about cause and prevention and how treatment is determined for younger vs older patients. Dr. Arellano also explains the importance of a patient getting a second opinion to not only increase their education about diagnosis and treatment options but also as a way to move forward with a team they trust.
The Lifeline Fund provides support to patients who often lack the financial resources necessary to afford the often overlooked living and ancillary expenses that can present considerable financial obstacles—or prohibit the transplant altogether. Funding from the Bone Marrow & Cancer Foundation’s Lifeline Fund helps to cover the myriad costs associated with transplants, such as donor searches, compatibility testing, bone marrow harvesting, medications, home and childcare services, medical equipment, transportation, cord blood banking, housing, and other expenses associated with the transplant. Health insurance often does not cover these vital support services, and many patients cannot afford them on their own.
Our partnership with Airbnb’s Open Homes Medical Stays program provides free temporary accommodations to patients diagnosed with any form of cancer or undergoing a hematopoietic stem cell transplant, as well as housing for their caregivers, family members, and donors.
A One-to-One Fund is a personal fund created for a specific patient. It is a simple and effective way for a patient’s family, friends, and community to raise money on a patient’s behalf with all money raised going directly to their benefit. All donations are tax-deductible. The Bone Marrow & Cancer Foundation administers and maintains the fund, and can offer support with fundraising ideas.
Scholarship Grants help make educational aspirations a reality for bone marrow, stem cell and cord blood transplant survivors. Transplants affect all aspects of life and often prohibit the pursuit of educational opportunities. To address this, the Bone Marrow & Cancer Foundation offers survivors support towards an academic future so their hopes and dreams remain intact. Scholarship Grants support students of all ages as they pursue their educational goals.
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So, when you’re talking with your patients, what kind of things are you considering when determining how to best treat AML?
Dr. Jessica Altman:
So, that’s a great question. This is something that is the basis for the entire conversation that I have with my patients and their family members.
I consider patient goals and patient fitness, other medical conditions, and a lot about the biology of the leukemia. If someone has an acute leukemia that is expected to be highly sensitive to intensive chemotherapy, then that is something that we want to think about. Versus if the patient has a disease that is not expected to be as sensitive to intensive chemotherapy, we frequently like to consider other alternatives in that space.
So, in terms of options, as a patient what kind of things should I be thinking about when I’m working with you as my doctor about what the best treatment for me might be going forward?
Dr. Jessica Altman:
So, I think the goal of the initial meetings and the initial consultation between a patient and their healthcare provider is to explore those things. We take a detailed history, understanding patients’ other medical issues. In addition to that, the social history and patients’ goals are very important, as things are not always a yes or no.
They’re not dichotomous choices. And to be able to understand a patient’s goals, and for the healthcare provider to be able to explain what the intent of treatment is helps both parties come to the right decision for that individual patient.
https://powerfulpatients.org/pen/wp-content/uploads/How-is-an-AML-Treatment-Approach-Determined_-1.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-09-17 08:32:532020-02-05 17:26:28How is an AML Treatment Approach Determined?
Understanding the cytogenetics of your acute myeloid leukemia (AML) can help determine which treatment option might be best for you. Registered nurse Mayra Lee defines this complex term and the role it plays in AML care.
Mayra Lee, RN, is an outpatient clinic nurse at Moffitt Cancer Center. Learn more about Mayra Lee.
Cytogenetics would be the term that I would say patients are unaware of and don’t understand it quite often. It’s probably the first time you hear it when you come and sit down and we talk about the disease because the first thing you want to know is what is my prognosis and what is the treatment. Well, a lot of that is made through the cytogenetics of the disease.
We use these terms and we don’t often explain what all of that means. And what that means is that the disease itself has chromosomes, has mutations, has genetic information that will help us determine which treatment is a better option for you or is there a genetic mutation that you perhaps have that we now have medications that are used to treat that genetic mutation as a said just a few seconds ago. Like for the three, if you have that mutation, we now have medication to treat that where we didn’t have that five years ago or even four years ago.
So, that terminology of cytogenetic and biomarkers are very new. They’re not something that the general public knows or understands very well.
But when you come to academic centers like where I’m at right now that is all we’re going to talk to you about because we want to do personalized medicine. And personalized medicine means what is it that your disease looks like because your disease does not look like the other AML patients. Your disease is your disease and it looks different and it’s going to behave differently. And so, we want to know about those mutations. So, so much of your treatment, so much of the prognosis is so closely linked to that that I think it’s an important thing to know. It’s important to understand it. It’s important to ask. It’s important to pause your doctor and your nurses and say, “I don’t understand what you mean by that. What does that word mean? Can you explain that to me?”
https://powerfulpatients.org/pen/wp-content/uploads/What-Is-the-Impact-of-Cytogentics-on-AML-Care_-1.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-09-17 07:07:052020-03-19 10:57:04What Is the Impact of Cytogenetics on AML Care?
AML expert, Dr. Pinkal Desai, outlines the reasoning behind the necessity of cytogenetics and molecular testing when managing an AML diagnosis. Want to Learn More? Download Your AML Navigator Resource Guide, here.
Dr. Pinkal Desai is an Assistant Professor of Medicine at Weill Cornell Medical College and Assistant Attending Physician at the New York-Presbyterian Hospital. More about this expert here.
So for patients who are undergoing molecular testing or any diagnosis of AML, both cytogenetics and molecular profiling are important, so they do not supersede each other. This is the conglomerate information that we need from the diagnosis to make important medical decisions. Usually the diagnosis would include: looking at the cells under the microscope by the pathologist; flow cytometry, which is a way to identify the subtype of leukemia; chromosomes or karyotypic analysis, which is to look at the individual chromosomes and whether they are abnormal in these leukemia cells; and the last one would be the molecular mutations, which would be single-gene profiling of the leukemia cells.
All of these are important, and it’s not that one can be omitted. They’re all part and parcel of the diagnosis of AML, and all of them should be done.
So my advice to patients whenever this topic comes up of molecular mutations is always an unequivocal – there should be no question that this should not be done. The advice is plain and simple. This has to be done at diagnosis and, in certain cases, at relapse as well in order to figure out the best treatment possible. If they’re at a site or a clinic where this molecular testing is not available, then they should seek a second opinion to a site that would do this testing because in this day and age of leukemia, there is no treatment and diagnosis that can be done without all of these components in place.
In the old days, we didn’t have a lot of treatment in AML. It was either chemotherapy or hypomethylating agents, and that’s it. But now we have several drugs, five or six of them, that were just approved in the past two years specifically for leukemia and targeting some of these mutations. We have Midostaurin, Gilteritinib, Ivosidenib, Enasidenib, and I don’t want to go on and on about these drugs, but the most important thing is that in this day and age where you have so many drugs, how to incorporate these drugs into the management for patients, both upfront and in the relapse setting, it’s extremely relevant to do this testing, and this is highly encouraged and should be done as part of the diagnosis and treatment.
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Dr. Pinkal Desai:
So we at Weill Cornell are a big leukemia center, and we are leading a lot of the clinical trials in AML, both in the upfront and the relapse setting. There are several research initiatives that we are highly interested in. One of them is how to incorporate some of these targeted treatments, both in the upfront and in the relapse setting.
The most important one that we’re actively working on is to monitor these patients, so MRD testing, or minimal residual testing, is extremely relevant in order to figure out whether the treatments are working in the right fashion, and would you change treatment or would it impact the patient’s overall survival if some of these mutations persist or not.
And we are really interested in monitoring these patients and these mutations to figure out a plan which is targeted not only for the mutation but also for the specific patient, and that is one of the things that we are very interested in and doing at Cornell.
We’re also looking at pre-disease mutations. There are several mutations – this is personally my research interest as well – there are certain people who are at risk of developing leukemia; for example, people who are undergoing chemotherapy for other cancers, and the presence of some of these mutations before the diagnosis of leukemia would highly be relevant because if we’re monitoring some of these people and figuring out who can develop this leukemia and can you do something about it, so this is sort of more on the prevention aspect of leukemia or secondary leukemia, which is also something we are interested in at Cornell and ongoing research is for us.
But the most important things is obviously for patients who actually have the diagnosis of AML, the best available agents as part of clinical trials, the best way to monitor them and design treatments so that we can achieve the best possible results for the patient is what we are striving for at Cornell, and it would be extremely helpful for patients to enroll into these trials and contribute both to their own treatment outcomes and also to the AML community at large.
https://powerfulpatients.org/pen/wp-content/uploads/What’s-Next-in-AML-Research_-Square.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-09-06 13:08:372020-03-23 12:16:11What’s Next in AML Treatment and Research?
In the spring of 2016, I was looking forward to a final year of teaching sociology before a retirement promising new adventures. I felt great and had no reason to think I had any health problems. When my doctor suggested some routine blood work, I readily complied. When the results showed abnormally low white blood cell counts and he recommended a hematologist, I readily complied. When the hematologist ordered a bone marrow biopsy, I still readily complied. When the results came in, my life changed forever.
The biopsy revealed that I had acute myeloid leukemia. Since this disease can kill within months, they recommended immediate treatment. The next day I checked into a hospital and started chemotherapy. I received the standard treatment for this disease for the preceding 40 years: a “7 + 3” cocktail of cytarabine and idarubicin. I spent five and a half weeks in the hospital dealing with various infections brought on by immunosuppression and patiently waiting for my blood counts to recover. As they did, I received the best possible news. The chemotherapy had achieved a temporary remission that bought me time to explore my options for longer term treatment.
As I awaited the molecular and cytogenic data on my cancer, I was told to expect two possibilities. If there was a relatively low risk of relapse, I might get by with additional chemotherapy. If there was a high risk of relapse, a stem cell transplant was in order. When the results placed me in an intermediate risk category, I had a tough choice to make. After researching my options, getting second opinions, gathering advice, and reading my doctor’s cues, I settled on the transplant. My logic was that if I opted for more chemo and it didn’t work out, I would deeply regret not having the transplant. If I had the transplant and it didn’t work out, at least I would feel as if I gave it my best shot and it just wasn’t meant to be. Despite the 15-20% mortality rate from the transplant itself, I was at peace with my decision to proceed.
My benefactors were two anonymous sets of parents who had donated their newborn infants’ umbilical cords to a transplant bank. Once we found two good matches, the cords were shipped to my transplant hospital, the cord blood was extracted, and it was transfused into my bloodstream. These stem cells just “knew” where to go to engraft in my bone marrow and begin producing a healthy new immune system. For the second time, I received the best possible news. Three weeks after transplant, one of my donor’s cells were 99% engrafted. With that result, I returned home for a prolonged recovery.
For the next few weeks, I faced daily clinic visits, blood tests, transfusions of platelets and red blood cells, growth factor injections, and lingering effects of my conditioning chemotherapy and radiation as well as the engraftment process itself. As the weeks turned into months, my recovery proceeded apace. It eventually became clear that I could claim the best possible news for the third time, as my new cells and old body got along with each other and there was no evidence of graft-vs.-host disease. Looking back over the entire process, my oncologist summarized it by saying “this is as good as it gets.”
Many people wanted to give me credit for surviving this disease. While it is tempting to claim such credit, I remain agnostic about whether anything I did had a material effect on my positive outcome. I think my survival was largely a matter of luck, chance, and random variation across AML patients. Nonetheless, there were several practices I engaged in throughout my treatment that deserve mention. At the very least, they brought me peace during a difficult time. And at the most, they may indeed have contributed to a positive outcome for which I am eternally grateful.
The first set of practices that sustained me was mindfulness, meditation and yoga. To the greatest extent possible, these practices helped me let go of ruminations about the past or fears about the future and focus on the present moment. Focusing on my breathing kept me centered as – like my breaths – each moment flowed into the next. Maintaining a non-judgmental awareness and acceptance of each passing moment kept my psyche on an even keel.
Rather than extended periods of formal meditation, I simply sought a mindful awareness of each moment, hour, day and week. I also went through a daily yoga routine even while receiving chemotherapy. Doing so helped me retain my identity as I weathered the toxic treatment and its inevitable side-effects. In the evenings, I used a technique called a body scan to relax and prepare me for a peaceful sleep. The cumulative effect of these practices was a calm acceptance of circumstances I could not change alongside a serene hope that all would work out for the best.
A second practice involved being a proactive patient. Perhaps it was my training as a social scientist that allowed me to bring an analytical curiosity to my disease and the treatments my doctors were deploying. I asked lots of questions during their all too brief visits, and they patiently responded to all my queries.
On several occasions, my proactive stance made a positive contribution to my treatment. When I developed a nasty, full body rash, it took a collaborative conversation between me, my oncologist, and infectious disease doctors to isolate the one drug among so many that was the culprit. I identified it, they switched it out, and the rash abated. On another occasion, I was able to identify two drugs that were causing an unpleasant interaction effect. I suggested changing the dosing schedule, they concurred, and the problem resolved. The sense of efficacy I received from this proactive stance also helped me retain a positive mood and hopeful stance during my prolonged treatment.
A third practice involved maintaining a regimen of physical activity. During my first, five-week hospital stay, I felt compelled to move and get out of my room for both physical and social reasons. I developed a routine of walking the halls three times a day, trailing my IV pole behind me. They tell me I was walking roughly 5 miles a day, and every excursion felt like it was keeping my disease at bay and connecting me with all the nurses and staff members I would encounter as I made my rounds.
When I moved to my transplant hospital, I was confined to my room but requested a treadmill that met the physical need for activity even as I sacrificed the social benefits of roaming the halls. But throughout both hospital stays and later at home, I maintained stretching activities, exercise workouts, physical therapy routines, and yoga to keep my body as active and engaged as my circumstances would allow. These activities also gave me a welcome sense of efficacy and control.
A fourth practice involved maintaining my sense of humor. I have always appreciated a wide variety of humor, ranging from bad jokes, puns and double entendre to witty anecdotes and stories to philosophical musings. Cancer is anything buy funny, which is precisely why humor has the power to break through the somber mood and fatalistic worldview that so often accompanies the disease. Using humor became another way of keeping the cancer at bay. It was a way of saying you may make me sick and eventually kill me, but I’m still going to enjoy a good laugh and a bad joke along the way.
Alongside these practices I could control, there were also beneficial circumstances beyond my control that worked in my favor. These included the privilege of being a well-educated white male that led to my being treated respectfully and taken seriously by all my health care providers. In addition, my doctors and nurses consistently combined skill and expertise with compassion and empathy in ways I will never forget or could ever repay. And finally, my privileged status and excellent care played out against a backdrop of strong social support from a dense network of family, friends, colleagues and neighbors.
A final practice that integrated everything else was writing my story as it unfolded. Upon my first hospitalization, I began sending emails to an ever-expanding group of recipients documenting and reflecting upon my disease, treatment and recovery. Narrating my story for others required me to make sense of it for myself. The ostensible goal of keeping others informed became a powerful therapeutic prod for my own understanding of what was going on around me and to me. While my doctors’ ministrations cured my body, my writing preserved my sense of self and a coherent identity.
I eventually sent over 60 lengthy reports to a group of roughly 50 recipients over a 16-month period. This writing would eventually serve three purposes. It was a sense-making procedure for me. It was a communication vehicle with my correspondents. And finally, I realized it could be a resource for others in the broader cancer community. With that insight, I did some additional writing about lessons learned and identity transformations and published the resulting account.
As I mentioned at the start, I will never know if any of these practices or circumstances made a material contribution to my survival. But they maintained my sanity and preserved my identity during the most challenging experience of my life. Regardless of the eventual endings of our journeys, sustaining and nurturing ourselves along the way is a worthy goal in itself.
Steve Buechler is a peer volunteer who regularly visits hospitalized transplant patients. This experience has convinced him that telling our stories is vital to sustaining us through treatment and into recovery. He is also on the community advisory board of the WISE (Writing for Insight, Strength and Ease) Study to promote writing by and for cancer patients.
His memoir How Steve Became Ralph: A Cancer/Stem Cell Odyssey (with Jokes) provides a fuller version of his cancer story, and it is available from writtendreams.com as well as Amazon or Barnes and Noble.
Dr. Daniel Pollyea, an AML specialist, dispels common myths around the causes and symptoms of AML and shares advice so that you can identify credible resources for information. Download the Program Guide here.
Dr. Daniel A. Pollyea is Clinical Director of Leukemia Services in the Division of Medical Oncology, Hematologic Malignancies and Blood and Marrow Transplant at University of Colorado Cancer Center. More about this expert.
I’m Ross Reynolds. Today we’re gonna be debunking some common misconceptions about the causes and symptoms of AML.
And joining me is Dr. Daniel Pollyea. Dr. Pollyea, could you introduce yourself?
Yeah. Hi. Good morning, everyone. I’m Dan Pollyea. I’m an Associate Professor of Medicine here at the University of Colorado, where I am the Clinical Director of Leukemia Service.
I wanna emphasize to you that this program is not a substitute for medical advice, so be sure to consult your healthcare team when it comes to solid information about it. But you will get some background that I think you’re gonna find useful. And you might have some questions as we go along.
Dr. Pollyea, let’s start out with the basics. What are the causes of AML?
Yeah. So, Acute Myeloid Leukemia, it’s a disease, a cancer of the bone marrow.
And it’s the result of an accumulation of mutation and chromosomal abnormalities that affect the DNA of a precursor cell in the bone marrow, otherwise known as a stem cell.
And those abnormalities accumulate until that cell can no longer properly mature, and it also can’t properly die. And so, a cell like that just makes copy after copy after copy of a cell until it crowds out the whole bone marrow with these sorta useless, immature cells.
And the end result of that is the failure of the bone marrow, which causes all of the problems associated with this disease. So, biologically, that’s sort of what happens to make this disease occur.
What are some of the myths that you hear from patients that come in and they say, “Oh, this must’ve caused my AML,” but you have to tell them that’s not so?
Right. So, I mean, this is one of the most frustrating issues for patients and their families after diagnosis. I mean, it’s a rare disease, only about 30,000 cases a year in the United States. And so, trying to associate a rare disease with external or environmental factors is difficult to impossible. So, although there are a variety of exposures that probably contribute to this disease, we have very little understanding of what those exposures typically are or how that all works.
So, there’s a few things that we know pretty well; large doses of radiation, either associated with like industrial accidents like the Chernobyl disaster, or some of the radiation therapies that patients receive for other types of cancer. Other types of chemotherapy that are used to cure other cancers can contribute to this disease in later years.
We know that there are certain precursor conditions that can evolve to AML, so a person with myelodysplastic syndrome, for instance, has a fairly high chance of someday evolving to develop Acute Myeloid Leukemia. But beyond these sort of a few associations, there isn’t a whole lot that’s known or proven.
Now there is radiation associated with X-rays, and some people think that X-rays can cause AML. Is that true?
So, I mean, I think a priori no because millions of people get X-rays every day, and only 30,000 people a year get AML. So, clearly it’s not a simple association between getting an X-ray and developing AML. But I think that there is an unknown interaction between environmental exposures and a person’s individual genetic makeup that makes a person more or less susceptible to developing something like AML with respect to exposure to the environment or X-rays and things.
So, while you cannot say that getting an X-ray will lead to AML, certainly there are some people who are more sensitive to the damage that’s done by something like an X-ray. And so, the best course of action is to be cautious and judicious about your exposure to these things, but not to not get these things when they are medically necessary.
So, that’s the challenging balance.
Here’s something else we’ve heard, that weed killers can be a risk factor for AML. Is that true?
I mean, I think there’s a lot coming out now about weed killers and their association with other types of cancers. Again, I go back to the limitation we have in that in only 30,000 people a year in the United States get AML. Millions of people are exposed to weed killers.
We’re statistically never going to be able to make a clear association. I think that there are certainly some risks for some people. Whether you’re that person who’s more susceptible to developing leukemia or any other cancer because of exposure to a weed killer is impossible to know.
So, like all of these things, I think the advice we have is you have to live your life. You have to do your best to sort of avoid things that you can avoid that you think would be… Or that may cause problems. But not to let those things prevent you from living a normal life.
I know that’s not a satisfying answer, but at the moment that’s the best answer we have.
Is formaldehyde exposure another risk factor for AML?
Yeah. We think that it is, and kind of along the lines of benzene. But, again, we think that those studies that have shown those types of association show it in very high amounts, amounts that most people in this country would not be exposed to. But I do think, or we do think that there is something to that, to formaldehyde somehow contributing to this.
What’s the difference between a risk factor for AML and a cause of AML?
Yeah. So, I think risk factors by definition are things that may contribute to AML. And a risk factor for AML by that definition could be walking down the street and having some exposure to radiation from the sun. A cause of AML is something that is a much more solid sort of well-understood factor.
Like I said before, having myelodysplastic syndrome, there is a high chance that that can evolve to Acute Myeloid Leukemia. And if that happens then the MDS, the myelodysplastic syndrome, could be considered or would be considered the cause of your AML. So, very, very different in terms of the amount of evidence that goes into making those determinations
Is there a genetic component to this? Can this run in a family?
Yeah. So, this is a disease of the genome.
So, I mean, in a lot of respects it is a genetic disease. But the question is very different when you ask is this an inherited genetic disease? Is this disease due to a gene that I inherited from a parent or could pass along to a child?
For many, many years, the answer from the medical community was, “No.” This was not considered to be a disease that clustered in families or that could be inherited. We now know that that’s not necessarily the case. There are some very rare cases where this does seem to travel in families or cluster in families. And we’re now beginning to understand who those people are and what those genes are.
But the vast majority of people with this disease did not inherit a gene to contribute to it and cannot pass this along to a child. This is a random, spontaneous event that occurred within one person’s own body and is not traveling within family. So, we’re learning more and more about this, but really, the vast majority of this is not an inherited genetic condition.
You’ve mentioned gene mutations. What mutates a gene? What causes that to happen that could lead down the line to AML?
Yeah. Yeah. That’s a great question. Most of the time we do not know the answer to that. These gene mutations occur spontaneously, randomly, and we don’t understand why they happen when they do happen.
And I know that’s, again, not a satisfying answer. It’s very frustrating, particularly patients come in, and, “I’ve lived a healthy lifestyle. I’ve done everything right. I exercise. I eat right. How could this have happened?”
These are things that for the most part are out of the control of a person. These aren’t impacted by your diet or your activity levels, what you eat or don’t eat, what you do or don’t do. That’s a real frustration. In the end, in almost all cases we don’t know or understand why these gene mutations or these, I call them mistakes in the body, occur when they occur. We don’t understand them.
And, Dr. Pollyea, someone asked if benzene can be a risk factor for AML.
Yeah. So, benzene is one of the sort of rare environmental exposure associations that we do have clear associations with AML.
But the level of benzene that a person would need to be exposed to is really something that hasn’t been seen in this country in a very long time.
We’d be talking about like an industrial accident type exposure in almost all cases, so being exposed to a cleaning solution or some other fairly minor exposure to benzene, we don’t think is enough, in most cases, to prompt this disease. But benzene in very high doses, like an industrial accident, yes, that is something that we understand can certainly contribute or cause AML.
Autoimmune diseases, such as arthritis, can they increase the risk of AML?
Oh, boy. That is a really interesting one. So, there are papers in the literature that do support those associations. And I know in my own practice I certainly see that trend. So, I do think that there is something there. There is a proven association between autoimmune conditions and myelodysplastic syndrome, which I said before can be a clear precursor condition to AML. So, certainly, that is an association that is a possibility.
It can be a little difficult to tease out whether it’s those diseases that are associated with ultimately developing AML, or the treatments that people get for some of those autoimmune diseases. Those treatments can modulate the immune system in certain ways that may, in fact, contribute or drive the disease. So, that’s a difficult thing to tease out.
But in general terms, yes, I think there are some associations. Now not by a long shot everyone with an autoimmune disease gets AML. It’s a teeny, tiny fraction. But I think there is an association there.
How easy is it to diagnose AML?
Well, I mean, I think there’s very clear diagnostic criteria for AML. But I guess that doesn’t really answer the question. And we certainly have patients who come to us after many months of frustration without a clear diagnosis.
So, those scenarios can play out. Many times AML’s a very dramatic presentation, so people get very, very sick very, very quickly with extraordinarily high white blood cell counts and suppression of all the other blood counts that come from the bone marrow like red blood cells and platelets.
In those cases it’s pretty clear that there is a type of acute leukemia going on. There can be some difficulty distinguishing Acute Myeloid from Acute Lymphoblastic Leukemia; those are sort of like cousins, but very different and treated differently. So, it kinda runs the gamut. I mean, it can be pretty clear, but it’s sometimes missed, so yeah.
This is a great lead-in to my next question, which is about the symptoms of AML. What should be the warning signs that this might be something you need to get looked at?
Right. So, at presentation, the main symptoms are reflective of the fact that the bone marrow, the organ that makes all the cells of the blood, has failed.
So, that can cause severe anemia. Signs of anemia: a white sort of appearance, feeling dizzy or lightheaded when standing, short of breath, weak, tired, fatigue. Those are all pretty clear presenting symptoms for AML. Because the bone marrow also is responsible for making platelets that clot the blood, some people will present with a bleeding complication, or a very subtle rash made up of these particular red dots. We call that a petechial rash. And that rash can come on when the platelet count gets very low.
Sometimes a person will present with an infection or infections that don’t go away or don’t clear because of decrease in white blood cells, the infection-fighting cells of the bone marrow. Those are made in the bone marrow and can fail in the setting of this disease. So, those are the most common symptoms at presentation, symptoms that are reflective of bone marrow failure.
You mentioned that sometimes the presentation could be very dramatic, and it sounds like the symptoms are very severe, very quickly. Is that always the case? Is that often the case?
That is the case in, I would say, a minority of times. That’s usually the case. It’s more often seen in younger patients with AML. Typically, older patients with AML have a more smoldering course and a much less dramatic presentation, although this sort of very dramatic and dangerous presentation can happen in older patients, but it’s probably something like a third of the time that those very dramatic and medical emergency presentations occur.
How important is early diagnosis?
Well, I mean, it’s crucial. I mean, in particular in those cases where it’s a very dramatic and proliferative diagnosis, or presentation. A quick diagnosis and recognition of this condition is very important because the sooner a person starts effective treatment the better the ultimate outcome is.
I would say in general terms that applies to all AML patients, but certainly there’s some degrees of variation. So, there’s some AML patients that when I hear about their case on the phone from a referring doctor, it’s appropriate to see them next week in the clinic.
So, it’s not always a medical emergency, but we would never, even in those next-week-in-the-clinic patients, this isn’t something that can wait for weeks or certainly months. This is something that needs to be addressed fairly quickly.
What are the best ways to manage those symptoms?
Right. So, I mean, at presentation, all those symptoms, the best way to manage those are to start treatment as quickly as possible. So, impacting the underlying cause of this disease is the most important and critical factor to getting a person feeling better because all of these problems stem from the disease in the bone marrow, and so everything else that you do to sort of help a person’s symptoms are Band-Aids when you’re not talking about getting to the root cause.
So, that’s at presentation. Now once we start treatment, there are many potential side effects to any number of treatments. And it all is dependent on what treatment you’re getting and other things about you that will make this a significant problem in some cases. And in that setting, we do have ways that we can aggressively manage a person’s side effects.
Can you manage all of the symptoms? Or can people still be experiencing symptoms even after they’re in treatment?
Absolutely. So, a person with this disease, depending on how long they’ve had it and some of the features, may not be feeling back to their baseline self for potentially weeks or months after treatment starts in the best-case scenario. So, that can be very frustrating, but a person needs to sort of be able to continue to have a good outlook and stay positive.
Because we are able in many cases to make a big impact on this disease and return a person to their pre-disease quality of life.
What are some of the myths that you hear, Dr. Pollyea, about the treatment? Some things that people come in to you saying they think that it helps, but there’s no science to back that up?
So, myths about treatment, so many people have a lot of preconceived notions about the intensity of a therapy that they’re going to be asked to withstand. And although sometimes we do treat this disease very intensively, that’s not always the case, and now we have some very effective lower-intensity regimens that can be used in a variety of different scenarios.
There are a lot of people who have a lot of preconceived notions about a stem-cell transplant or a bone-marrow transplant and whether or not they would be eligible for this based on maybe what they’ve heard from friends or family, or what they’ve seen in the internet.
And those are often incorrect. And so, keeping an open mind about treatment options, and discussing those in detail with your doctor are really, really important.
You mentioned sometimes it presents in young people, sometimes in older people. What’s sort of typical?
This is a disease of predominantly older patients, so the median age of presentation is 68. So, that means that over half of the patients are over 68 years old at diagnosis. So, while this does happen, can happen in younger patients, that’s really an unusual situation. This disease is, like I said, it is predominantly a disease of older patients.
There are some patients who I understand think that supplements can deal with the symptoms of AML. Is that accurate?
You know, I mean, I think the supplement question is always a challenge. A lot of these supplements, or most of these supplements have never been tested with the rigor of treatments that we’re accustomed to in the medical establishment.
That being said, I won’t deny that some of the supplements can help patients based on what patients’ experiences are and what they tell me. I think what’s really important is just be very open and honest with your doctor about the supplements that you’re taking or want to take to ensure that there are no sort of unanticipated interactions with treatments.
Because I think most doctors are very open to having their patients care for themselves in the ways that they’ve become accustomed to, and they know their bodies very well, and we’re very open to that. But there are sometimes that a drug or a supplement might have a bad interaction with the treatment.
And so, a good example in my practice is antioxidants. So, there’s a lot of literature, a lot of interest in antioxidants as cancer-prevention treatment.
And a lot of that is not well-established, but still I don’t see much harm. But when it comes time to treating a cancer, that’s a very different situation. When we give a patient treatment to try to kill the cancer cells, many times we’re trying to provoke oxidation. That’s part of how these drugs and these treatments work.
So, if you’re taking those treatments, but also at the same time taking antioxidants, there’s the potential you could sort of be cutting your therapy off at the knees, fighting it with one hand behind your back. So, for the period of time when my patients are getting an active treatment, I ask that they don’t take it antioxidant.
And they can resume that in the future in the hopes of preventing another cancer. But the time to prevent with an antioxidant isn’t appropriate when you’re dealing with an active cancer. So, that’s just one example.
Fatigue could be a symptom of AML, but there are a lot of causes of fatigue.
How do you differentiate between something that really could be AML and something that isn’t?
Yeah. That’s a challenge because I think these are, as I said, older patients. And older patients have a lot of other medical problems. And older people get fatigued, just that’s unfortunately part of the normal aging process. So, we would usually make an assumption that a person’s fatigue and diagnosis is due to the leukemia, the anemia as a result of the leukemia.
But as we successfully treat a patient if they are responding based on their numbers and other objective criteria, but the fatigue is not improving then I think that’s where we would start to look at other contributing factors, and there can be many, so having an open mind at that point is important.
But at the beginning, this is such a monster of a disease, it’s so overwhelming, I think the focus is usually on assumption that the fatigue is due to the disease or to a treatment associated with this disease.
This question: is loss of appetite a symptom of AML?
Yeah. I definitely see that, hear that, so sometimes people come in and they say that. Sometimes it may not be a loss of appetite, but an extreme weight loss, so a lot of different types of cancer, including AML, can cause that, just basically unintentional weight loss.
A person’s not trying to lose weight. They’re eating what they think is their normal amount and they’re losing tremendous amounts of weight. So, those are both potential presenting symptoms with AML. And loss of appetite, unfortunately, can be associated with some of the treatments for this disease. And taste changes, things not tasting good, can all contribute to that as well, so those are all challenges that our patients face.
How important is to get a second opinion? I mean, are all doctors like you pretty much on the same page when it comes to symptoms and treatment?
So, this is a challenge. So, the answer to the second question first is unfortunately, no. A lot of this hasn’t quite been standardized. And some doctors, oncologists, cancer doctors, they’ll predominantly be treating the things that are common: colon cancer, breast cancer, prostate cancer. And they will probably only have a few cases of acute leukemia a year.
And so, their approach to this is going to be different than somebody who spends all day seeing patients with AML and thinking about AML.
So, a second opinion is a very nice thing to be able to do. The problem with this disease is that most times it doesn’t afford that opportunity. So, with other conditions you have some time to go out, read about it, talk to some different doctors, get a good plan together.
With AML, often that’s not a possibility. A person is so urgently sick that you have to sorta deal with the resources where you are. The best recommendation I have there, if you do find yourself in a situation where there’s not a lot of expertise is to ask your doctor to just call somebody in the region or email somebody in the region who may have that expertise.
And most doctors all over the country have that sort of resource or partner that they will go to and talk the case through with them, and maybe a transfer to one of those high-volume centers is appropriate.
And maybe that’s not a possibility or appropriate, but maybe you would benefit from just talking… Maybe your doctor would benefit from talking this through. But in cases where it’s not such a dramatic presentation, then yeah, for sure, I think a second opinion can be appropriate. But this isn’t something that can be sort of drawn out for long period of time.
You know, when you find out something like this, your tendency might be to jump on the web and start searching for AML. How do you vet those sources that you look at? How do you figure out that their – what would be a sign that they’re bogus sources?
Yeah. I mean, I think this field is so rapidly changing and the treatment that we have, that I would, for the most part, assume that what you’re finding on the web is not relevant and is not an up-to-date resource. So, the resources that I listed, the NCCN, UpToDate, the Leukemia & Lymphoma Society, I should mention.
A very important resource that has up-to-date information, and they have even phone numbers for patients and their families to call to get connected with the proper people in a particular city, so that is a really important resource. But I’d be really, really cautious about what you find on the internet because things are changing so fast in this field. There’s a lot of outdated and misinformation on the internet.
Well, then there’s outright scams. One of the things you mentioned before we went on is be cautious if someone’s asking you to put money upfront, or if it’s a nonmedical facility. What are some things that people should watch out for?
Yeah. So, one of the things that is so important in our area is clinical trials and participating in clinical trials. Patients who opt to do this and receive experimental therapies can sometimes get the treatment of the future, get a drug that’s not currently available through the FDA, but may have a lot of promise.
And this is the way that we fight this disease. We’ve recently had an onslaught of approvals for AML and that’s because the patients being willing to participate in sanctioned clinical trials. So, participating in a sanctioned clinical trial is crucial, and it’s always a recommendation of all leukemia doctors.
When you participate in a conventional clinical trial, you’re asked to sign a consent form that explains what you’re doing and why. There is a confirmation that this has been vetted by an institution’s regulatory board that is prioritizing the safety and well-being of you, the patient. This has been approved by the FDA as a clinical trial. Nobody would ever ask you to pay money. That’s not ethical to participate in a clinical trial. Insurance covers whatever standard of care. And the clinical trial covers anything that isn’t.
So, if you find yourself in a situation where you’re not being asked to sign a consent form, where a clinical trial has not been reviewed by a regulatory board, where your doctor is not a leukemia specialist, where the FDA has not sanctioned the treatment, all of those are alarm signs.
Because there are people out there that are preying on patients in a desperate situation, a very difficult time in their life, and giving them sort of false hope and leading them down paths that are not legitimate.
One easy thing to do to sorta check to see if a clinical trial is legitimate is to go onto clinicaltrials.gov.
This is a resource set up by our national healthcare system that now feeds in every legitimate clinical trial from all over the world, needs to be registered on clinicaltrials.gov. So, if you can’t find your clinical trial on clinicaltrials.gov, I would have a lot skepticism and caution about that.
Like what advice do you have for people when they’re first diagnosed? What are the first things they should try to do?
Yeah. I mean, that reaction is totally normal and natural. I mean, many times these people are perfectly healthy or have been perfectly healthy, and this news is a complete shock.
And so, it is normal and appropriate to have some period of grieving for the healthy life that you are losing. But I would also, while giving yourself that time to grieve, first, draw on your support system, your family, your friends. Allow them to help you. Accept that assistance that they have. And to be optimistic because we are getting so much better at treating this disease.
I had mentioned before, there has been an onslaught of approvals for drugs in this area the likes of which hasn’t been seen in decades. We have new tools and weapons in our arsenal that we couldn’t have dreamed of even a few years ago.
We in our community are very excited and hopeful about the future and we hope that that will translate ultimately to patients, but being depressed or being down, being scared, all of that is normal.
All of that is expected. Anyone would feel like that. Allowing yourself to have those feelings and emotions is important, as long as it doesn’t get in the way of doing what you need to do to fight this disease.
It sounds like you’re hopeful about new treatments for the disease. How about a cure? What’s the science? What’s the medical science say about that? Are we getting any closer to that?
We are getting closer to curing this in more cases. So, like I mentioned before, as bad as this is, we can already cure some subsets of patients. There’s one type of Acute Myeloid Leukemia called Acute Promyelocytic Leukemia, APL. It’s an uncommon form of AML, less than 10 percent.
But we can cure close to 99 percent of people with APL. And APL, 15 years ago, was universally the worst form of acute leukemia to get. So, that dramatic 180 that we’ve seen in APL, we are hoping to translate into other forms of AML.
Some other forms of AML have cure rates as high as 50 percent, 60 percent, 70 percent in the right setting. Sometimes we can cure patients with a stem cell transplant fairly reliably. So, we are very, very hopeful about our ability to continue to make progress and cure more and more and more of these patients. That’s the future that we see.
Dr. Pollyea, thank you so much. And thank you so much for ending on such a positive note. We really appreciate it. And thank you for joining us for this program today.
To learn more about AML and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Ross Reynolds. Thanks for joining us.
https://powerfulpatients.org/pen/wp-content/uploads/Pollyea-1.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-06-05 15:38:122020-02-05 16:27:13Fact or Fiction? AML Causes & Symptoms
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