Treating acute myeloid leukaemia

When a child is diagnosed with leukaemia, they will be referred immediately to one of the UK’s 21 specialist paediatric oncology centres for treatment.

Before treatment begins

Treatment needs to begin as quickly as possible but in order to make sure the child receives the best, most appropriate treatment, doctors will first complete a range of tests.

Blood and bone marrow samples will be taken in order to identify the type of acute myeloid leukaemia (AML) and to profile the genetic changes to the leukaemic cells. This helps doctors determine the best treatment for each child.

Children will have a lumbar puncture to see if there are any leukaemic cells in the fluid surrounding the spine. Some children will also have an x-ray or scan to see if the leukaemia has spread to other parts of the body.

Before treatment begins, doctors will explain exactly what to expect over the months ahead. They will provide information about the different treatments that will be used, about possible side-effects and any longer term implications.

Children (or parents) will usually be invited to participate in a clinical trial. Trials aim to improve our understanding of the best way to treat childhood cancers – they usually compare the standard treatment with a new or modified version of the standard treatment. Taking part in a trial is entirely voluntary – the medical team will provide detailed information and you will be given plenty of time to decide whether it is right for your child. Children who do not take part will receive the current standard treatment.

Treatment

The aim of treatment for childhood acute myeloid leukaemia (AML) is to rid the body of leukaemic cells and restore normal blood cell production.

Children with AML will usually be admitted to hospital for the duration of their treatment. This is because the intensive treatment can make children very unwell and they need a high level of supportive care.

The total duration of treatment is around six months, much shorter than the treatment for ALL which can last up to three years.

The main treatment is chemotherapy. A combination of chemotherapy drugs and steroid medicines is given according to a treatment plan (also called a protocol or regimen). Some children may also require radiotherapy and/or a stem cell (bone marrow) transplant.

There are two phases of treatment for childhood AML – remission induction and post-remission treatment.

i) Remission induction

The initial aim of treatment for AML is to achieve a state called remission where almost all leukaemic cells have been killed, allowing production of normal blood cells to resume.

Remission induction usually includes one or two blocks of a combination of chemotherapy drugs in high doses given over a few days at intervals of one or two weeks.

Children with AML are usually given intrathecal chemotherapy after each of the first two blocks of chemotherapy. This involves injecting chemotherapy drugs into the spinal fluid to prevent leukaemic cells from surviving in the brain and spinal cord. Occasionally radiotherapy to the brain may also be necessary.

ii) Post-remission treatment

Post-remission treatment (also known as consolidation or post-induction treatment) aims to destroy any remaining leukaemic cells and to prevent the disease from returning. This phase usually involves two or three more blocks of the same drugs used in remission induction.

Sometimes it is necessary to use additional drugs or higher doses of the same drugs; this is known as intensification. Stem cell (bone marrow) transplantation is a special case of intensification. It enables doctors to give higher doses of drugs than would otherwise be possible.

Supportive care

The intensity of treatment needed to treat AML causes severe bone marrow suppression. Expert supportive care is therefore necessary and the child will usually need to remain in hospital, even during the gaps between treatment blocks.

The supportive care includes barrier nursing to protect against infection and intensive treatment with intra-venous antibiotics or antifungal drugs if infection occurs. Children will usually also require transfusions of red blood cells and platelets.

The role of stem cell transplantation in treatment of AML

Stem cell (bone marrow) transplantation is used more often in children with AML than children with ALL. However its use is still largely limited to children who have experienced relapse.

Children with high-risk disease and some children with standard-risk disease may be considered for a transplant whilst in first remission.

Read more: Stem cell transplantation

The role of radiotherapy in treatment of AML

Radiotherapy is not routinely used in the treatment of childhood AML. Some children who are found to have leukaemic cells in their central nervous system may need to have radiotherapy.

Children who are undergoing stem cell transplantation will need radiotherapy as part of the preparation for the transplant.

Side effects of treatment

Treatment often causes side effects and these will be discussed with you before treatment starts.

Most side effects are temporary and can be minimised with good supportive care. The most common effects include:

nausea and vomiting
hair loss
reduced resistance to infection
bruising and bleeding
tiredness and
diarrhoea.

There is a risk of kidney damage as a result of the high levels of uric acid released when the leukaemic cells are killed. Drugs can be given to guard against this but sometimes the destruction of cells is so rapid that a condition called tumour-lysis occurs. Temporary use of an artificial kidney may be required.

Read more: Side effects of treatment

What to expect after treatment

All children will continue to be monitored following completion of treatment – for the first year they will be checked every two or three months. Checks will then gradually become less frequent.

The main purposes of follow-up are detection of relapse and detection of treatment complications.

Most children with AML are cured. If the disease comes back, it normally does so within the first three years after treatment. Further treatment can then be given (see below).

Treatment complications (known as ‘late effects’) are relatively rare and most children who survive AML will grow and develop normally.

The main risk of long-term effects is in children who receive cranial and spinal irradiation to prevent central nervous system (CNS) relapse. Cranial and spinal irradiation is associated with impairment of growth and educational achievement and with premature onset of puberty. In order to minimise the risk, only a minority of children now receive cranial irradiation routinely and those that do receive the absolute minimum dose of radiotherapy necessary to prevent CNS relapse.

Other documented problems include cardiac problems, fertility problems and a small elevated risk of second cancers.

Read more: Long-term and late effects of treatment

Relapse

A high proportion of children with AML will achieve remission but up to a quarter of these children will relapse – their disease will return.

Relapsed AML tends to be more resistant to treatment but many children can be successfully re-treated.

The timing of relapse is significant. Children who relapse a long time after treatment has finished have a better chance of responding to re-treatment. These children will be considered for a stem cell transplant if they have not already received one. In children who have already received a transplant, it may be possible to use immune cells from the original donor to treat a relapse; this is known as donor lymphocyte infusion (DLI)

The likelihood of a relapse progressively decreases with time, however late relapses do occur.

Read more: Commonly used terms in treatment | Childhood leukaemia

Hear from families affected by childhood cancer

Coping with the diagnosis of cancer and the subsequent treatment and uncertainties is extremely difficult for children and their families.

A number of families have kindly offered to share their experiences to help others understand what it’s like to live with childhood leukaemia.

Read more: Patient stories

Related Topics treatment, Stem cell transplantation, acute myeloid leukaemia, radiotherapy, remission, chemotherapy, AML, relapse

Treating acute myeloid leukaemia

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