Overview
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The first phase is remission induction. Chemotherapy drugs are used to achieve a remission, the state in which there is no clinical evidence of disease and blood counts are normal. The remission induction therapy for children is generally daunorubicin and cytarabine given over seven to ten days. Other drugs such as thioguanine or etoposide may be added.
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Even if the central nervous system (CNS) shows no clinical evidence of disease, treatment of that area with cytarabine is also recommended. This drug is usually administered directly to the cerebrospinal fluid. Preventive chemotherapy for the CNS is commonly recommended for children. Irradiation is used to treat disease that has entered the CNS and may also be used to prevent CNS involvement.
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Treatment following remission induction may be bone marrow transplantation using an HLA-matched sibling. To learn more about stem cell transplants, you may wish to order the Memorial Sloan-Kettering Cancer Center CD-ROM program Bone Marrow and Stem Cell Transplantation. Transplantation may not be recommended for the rare children who generally do well with standard treatment. In this case, they may receive intensive-dose cytarabine followed by two to six months of combination chemotherapy.
Drugs that might be used to treat AML are listed at the bottom of the page. Click on the drug(s) you will be receiving to get more information.
Treatment Decisions
Most patients, adults and children, will be treated according to cooperative group protocols. Often, these will be clinical trials seeking to improve outcomes. Some drugs are more effective against specific subtypes of leukemia and treatments are often based on the gene mutation. The doctor will discuss this during the treatment consultation following immunophenotyping and other diagnostic tests.
During Treatment
Side effects during remission induction can be significant and patients usually remain in the hospital for four to six weeks. Treatment for AML is aimed at the leukemic blood cells, but normal blood cells are also affected. All patients will have lowered blood counts that lead to a variety of symptoms. Low white blood cell counts put patients at increased risk of infection. Treatment with antibiotics to prevent or treat infections is likely. In some situations, you will be in isolation and visitors to the room may need to wear gowns, masks, and gloves. Low white blood cell counts generally also lead to inflammation of the mucous membranes in the mouth and gastrointestinal tract. This is called mucositis. The tissues become very dry and may crack or bleed. Specific oral care regimens help minimize discomfort and prevent secondary infections. Mouth sores can make eating painful. The mouth sores themselves can cause pain that requires pain medication. Nausea and vomiting and diarrhea are side effects for which effective treatments exist. Hair may fall out and this is can be an especially upsetting side effect. Wigs and scarves may help minimize the distress hair loss causes. Low platelet counts lead to easy bruising and bleeding. Care to prevent injuries is very important. Low red blood cell counts causing anemia make patients feel tired and weak. Sometimes, patients are short of breath or have a fast heart rate. Transfusions will be necessary to replace red blood cells and platelets. Many patients are given stimulating factors called G-CSF or GM-CSF. These stimulate the development of new white blood cells so that cell counts are low for a shorter period of time. The initial treatment and the severity of side effects can be very difficult and wearing. While blood counts are low, your child may find it difficult to carry on normal activities. Simple exercise, such as walking, may seem overwhelming. Your doctors and nurses will do everything in their power to minimize the discomfort, sadness, and boredom that are common during this initial phase of treatment. Social workers, psychiatrists, and psychologists can help you and your child with depression and the ups and downs you will experience during treatment. Social workers can also help with financial issues related to treatment. Finally, all hospitals have clergy who are available to speak to you and provide spiritual guidance.
Resuming Activities
After the initial hospitalization, patients will slowly begin to resume their normal activities, but school may have to be postponed for many months. Subsequent shorter hospital stays, ranging from one to two weeks, may be necessary to administer chemotherapy and treat infections that result from low white blood cell counts. Strength and stamina will return gradually. The doctors and nurses will provide more specific guidelines on what to expect based on individual treatment regimes and responses.
Clinical Trials
Many leukemia patients are asked to participate in a clinical trial. A clinical trial is a research program that attempts to find better treatments. A phase I clinical trial aims to find the safest way to give a new treatment. Patients are watched closely for side effects. Once the phase I trial is completed, the new treatment may be evaluated in a phase II clinical trial. At this stage the doctors are looking for anti-cancer activity, as well as side effects. After that, a phase III clinical trial will compare the new treatment to a standard treatment, randomly assigning patients to either group. Patients may be offered the chance to take part in any of the three types of trials. Some people worry that they will receive only a placebo, such as an ineffective sugar pill, in a clinical trial, but that is very rarely done in cancer treatment clinical trials. Patients are not required to take part in clinical trials. Those who choose to, however, may gain satisfaction from helping to evaluate new treatments, and may also have access to therapies that are not yet available to the general public. Patients may leave a clinical trial at any time, for any reason. Your doctor will explain why you may or may not be a candidate for a clinical trial. For a listing of current clinical trials, see the following website: http://www.nci.nih.gov/clinical_trials/
