Relapse occurs when AML returns after a patient has reached complete 

. Relapse can occur at any time after initial treatment, from several months to years, and can happen for a number of reasons, including the following:

Your initial treatment may not kill all leukemia cells.

Low levels of leukemia cells can go undetected and multiply over time.

Leukemia cells can spread to different parts of the body, which may not have been detected.

Disease relapse can be spotted during regular check-ups, which are important for early detection. If your AML comes back, your leukemia specialist can outline the possible next steps for you in terms of treatment, coping strategies, and quality of life. Read more about the treatment options available for patients who experience relapse 

AML can also be treatment-refractory, meaning that it does not respond fully to anti-leukemia therapy, and complete 

 is not achieved. Refractory AML is diagnosed when abnormal leukemia cells are still observed in the blood or bone marrow after two cycles of chemotherapy, which is detected using a blood test or bone marrow biopsy. You can find out more about refractory AML in the Know AML animation below.

In preparation for AML World Awareness Day 2024, Know AML spoke to Dorcas Hills, a caregiver for Ralph Hills, a patient with acute myeloid leukemia, and the Know AML chair.

Dorcas discusses her experience as a caregiver for Ralph, the impact on her well-being, and some of the strategies she uses to cope. As a caregiver, Dorcas also highlights the importance of acknowledging your stress and emotions.

Dorcas Hills

Caring for someone with AML

For Acute Myeloid Leukemia World Awareness Day, Eileen shares her experience of caring for her daughter when she was diagnosed with acute myeloid leukemia.

What impact did caring for someone with AML have on your well-being?

Nothing can ever prepare you for being with your 24-year-old daughter and being told that she has leukemia. My daughter insisted that I did not leave her, always greatly reassured by my physical presence, so that’s where I stayed. There was my husband, her older brother, and her long-term boyfriend to explain everything to and support. Inside, I had a constant sense of panic, I felt helpless. As a parent you can usually make everything ok, this was one time I could not. I became exhausted physically and emotionally, lost weight, and started having panic attacks; I found it difficult to concentrate. This all takes its toll and I felt broken. I quickly realized that, if I did not pause, reflect, and take care of myself, I would be of no use to anyone. My daughter often shared with us and the team that she felt great reassurance and comfort, just by being with her and explaining everything in a way she understood. The team was very supportive of my presence, I did feel great concern I would get in the way; however, the team reassured me and acknowledged the benefit of my presence. This helped me to ground myself, acknowledge it was ok to feel what I was feeling and step forward as a stronger family.

How did you take care of yourself physically and emotionally and how did it benefit you?

I am naturally a calm, reflective person and was exhausted maintaining that persona whilst by my daughter's side. After pausing as a family and being honest about our feelings, we stepped forward, and supported each other emotionally and with everyday life. Whilst my daughter was an in-patient, I went for walks every day. I went home every afternoon for a few hours. I recognized that it was important for both of us to have time to ourselves. My daughter was fearful at first; however, I was firm and this became an important part of the rhythm of the day, which was essential for my self care. Then, when she later came home for periods, it was easy to get outside—we all benefited from this. I ensured we were all eating our usual healthy balanced diet. Talking to staff was always so helpful, the team consistently took time to check on us. Having a few close friends who were always out there helped hugely and supported me.Witnessing the difference being with my daughter was making to her was the greatest benefit.

Where did you go for further information, support, and practical advice, and what would you suggest for a new caregiver?

Initially, all information came from the team. They took time to carefully explain diagnosis and treatment—which had to start immediately—and explained outcomes. I was extremely overwhelming for my daughter, for all of us. Within hours I was able to explore all the information, research and so on. Carefully, I explained everything to my daughter and close family. Close friends became a huge source of support. Our GP checked in regularly too and visited whilst she was an in-patient. Blood Cancer UK have a wealth of information, alongside other charities.

For a new caregiver, never hesitate to ask questions, there are no silly questions. Embrace the support and guidance offered, as many caregivers do not have a network around them. Through charities, there are opportunities to contact other caregivers on your terms, which can help so much. There are lots of networks for caregivers, providing advice on balancing family life, work, and caring. Importantly, recognize the importance of self-care, it is okay and essential to take a step back at times.

What did you think of Eileen's story? Let us know at

ses_knowaml@scientificeducationsupport.com

Eileen's story

Leukaemia Care. Relapse in Acute Lymphoblastic Leukaemia (ALL) 

https://media.leukaemiacare.org.uk/wp-content/uploads/Relapse-in-Acute-Lymphoblastic-Leukaemia-ALL-Web-Version.pdf

. Published Jan 2019. Accessed Mar 31, 2021.

Relapse

AML is a rare aggressive cancer of the blood and bone marrow and is the most common form of acute leukemia in adults.

In healthy bone marrow, stem cells (immature cells) go on to form all of the blood cells we need to function normally. Blood stem cells can mature into more specified myeloid or lymphoid stem cells. A myeloid stem cell can then give rise to three different types of mature blood cell. These include

 – give blood its red color and are responsible for carrying oxygen from the lungs to all parts of the body;

 – help the blood to clot and prevent excessive bleeding.

In patients with AML, one or more of these blood cell types do not develop as they should, which is due to certain changes in genetic material (DNA), known as genetic abnormalities. These abnormal cells are called leukemia cells and lack normal functionality. The leukemia cells then multiply, filling up the bone marrow and spilling into the blood, where they can spread to other parts of the body, such as the brain, skin, spleen, and gums. As a result, the production of normal blood cells is affected, and the bone marrow cannot make enough healthy blood cells.

What is AML?

The most common signs and symptoms of AML include shortness of breath, bruising, fever, weakness, and infection. Usually, AML develops quickly and worsens unless it is treated. The animation below provides a summary of the signs and symptoms of AML.

We do not fully understand why certain genetic abnormalities cause a blood cell to become abnormal and develop into a leukemia cell. However, certain risk factors may increase the chance of developing AML. Having one or more of these risk factors does not mean you will develop AML, and someone without any of these risk factors can still develop AML. The possible risk factors for AML include the following:

Old age (AML is more common as people grow older, but AML can develop at any age)

Sex (AML is more common in men than women)

Being exposed to high-dose radiation or chemicals, such as benzene (an industrial solvent) and some detergents

Previously having chemotherapy or radiotherapy for other cancers

Previously having a blood disease, such as a myelodysplastic syndrome

AML is not an inherited condition and cannot be transferred from one person to another.

Causes & symptoms

Several tests that examine cells in the blood and bone marrow are used to detect and diagnose AML. These tests include the following:

This test uses a microscope to check the number of blood cells and to look for abnormal blood cells. An abnormal blood test can suggest that a person has leukemia, but further tests are required to determine a diagnosis.

A bone marrow sample is taken from inside the bone and examined under a microscope to look for changes in the blood cells. This test can be used to diagnose leukemia and to see how well treatment is working.

Our genetic code (DNA) is packaged into structures called chromosomes—tests can identify if there are any 

. Abnormalities in chromosomes are observed in around 50–60% of patients who are diagnosed with AML. These changes can disrupt the normal processes in blood stem cells and cause a cell to make too many, too few, or defective proteins. This means the stem cells do not develop into healthy blood cells and can cause uncontrolled growth of leukemia cells.

Normally, our cells have 23 pairs of chromosomes. In AML, part or all of chromosomes 5 or 7 may be missing, there may be an extra chromosome, or a section of a chromosome may have moved. Identifying these chromosomal changes can determine the specific type of AML a patient has, allowing leukemia specialists to decide on the most appropriate treatment.

This test can be used to examine the different kinds of proteins, known as antigens, on the surface of AML cells. This can help determine the specific type of AML a patient has and help leukemia specialists decide on the most appropriate treatment.

Changes in the structure and function of certain genes (genetic abnormalities) could be the cause of abnormal leukemia cell development. Identifying these, using molecular studies, can determine the specific type of AML a patient has and help leukemia specialists decide on the most appropriate treatment.

Cancer.Net. Leukemia - Acute Myeloid - AML - Childhood: Diagnosis. 

https://www.cancer.net/cancer-types/leukemia-acute-myeloid-aml-childhood/diagnosis

Kumar CC. Genetic abnormalities and challenges in the treatment of acute myeloid leukemia. 

Diagnosis

Research into AML has advanced in recent years, making it clear that AML is not a single disease, but rather a disease that can take one of many forms. The type of AML a patient has can depend on:

how developed the abnormal leukemia cells are at diagnosis;

the shape (morphology) of the leukemia cells and specific markers (proteins) on their surface;

how much they differ from normal, healthy blood cells;

the genetic/chromosomal abnormality present; and

The type of AML a patient has can impact how well certain treatments work; knowing your AML type can guide personalized treatment decisions.

Changes to specific genes, known as mutations, are identified in many cases of AML and can result in specific types of AML. These mutations can help abnormal cells grow in an out-of-control manner. Some mutations are associated with better outcomes, while others are thought to contribute to more aggressive forms of AML and poorer outcomes.

Changes in the following genes are most commonly observed in patients with AML: 

FLT3, IDH1, IDH2, NPM1, DNMT3A, CEBPA, TET2

. It is important to know whether one or more of these genes are abnormal in your AML cells, as this can identify the type of AML you have and help to tailor a unique treatment for you.

Ask your doctor about your specific type of AML.

There are several categories of chromosomal changes that can cause specific types of AML. These can affect your outlook and how you respond to treatment. They include

 – when part of a chromosome breaks off and sticks to a different chromosome;

 – when part of a chromosome is lost, possibly leading to the loss of a gene that controls the growth of blood cells;

 – when the chromosome is flipped, resulting in faulty ‘instructions’ within the blood cell, which can lead to abnormalities; and

 – when there is an extra chromosome that can produce an abnormal gene.

Knowing the chromosomal changes that are present in your AML can help leukemia specialists decide the best treatment option for you.

Acute promyelocytic leukemia (APL) is a unique type of AML, which is most common in adults between 20 and 50 years of age.

 APL is characterized by a very specific chromosomal change, whereby sections of chromosomes 15 and 17 switch, forming an abnormal fusion gene called PML/RARα. This abnormal gene can lead to the overproduction of immature, non-functional white blood cells called promyelocytes. These promyelocytes build up in the bone marrow and reduce the number of mature healthy blood cells.

1. Cancer.Net. Leukemia - Acute Myeloid - AML: Subtypes. 

https://www.cancer.net/cancer-types/leukemia-acute-myeloid-aml/subtypes

2. Leukemia & Lymphoma Society. Acute Promyelocytic Leukemia Facts. 

https://www.lls.org/sites/default/files/National/USA/Pdf/Publications/APL_FactSheet_10_15FINAL.pdf

Types

AML causes changes to blood cell counts. The aim of any treatment for AML is to help control the abnormal leukemia cells and restore a balance of healthy blood cells.

AML cannot be defined as a single disease, your symptoms will vary depending on the type of AML you have. Therefore, a variety of therapies are used for different types of AML and result in different outcomes.

Know AML has put together the animation below summarizing the treatment options available to people with AML.

The standard treatment for most people with AML is chemotherapy. Chemotherapy involves using anticancer drugs to destroy abnormal leukemia cells, which hopefully leads to 

. Chemotherapy is usually given in two main phases: (1) induction and (2) consolidation, which are explained in more detail below.

Induction chemotherapy is used in the first phase of treatment, it aims to kill abnormal leukemia cells and stop them from multiplying in the blood and bone marrow. The most common induction chemotherapies include cytarabine and an anthracycline drug (daunorubicin, idarubicin, or mitoxantrone); these are mostly offered to people younger than 60 years old, or people who are aged over 60 years and considered ‘fit’. Another treatment used for induction chemotherapy is the combination of daunorubicin and cytarabine (CPX-351), which is approved in the United States and Europe to treat people with specific types of AML, including therapy-related AML and AML with myelodysplasia-related changes. Induction chemotherapy can sometimes be administered with other drugs that target specific changes on or in leukemia cells, known as targeted therapies. 

Consolidation chemotherapy aims to kill and remove abnormal leukemia cells that may remain after induction chemotherapy, but that cannot be detected. This reduces the risk of the leukemia cells multiplying and the subsequent return of AML. The consolidation phase involves further treatment with chemotherapy, often with the same drugs that were used in the induction phase.

Often, chemotherapy and targeted therapies are followed by a stem cell transplant. This is because some AML therapies will remove a proportion of normal, healthy blood cells along with the leukemia cells. A stem cell transplant is used to introduce stem cells that go on to produce healthy blood cells.

What treatments are available for people who are ineligible for intensive chemotherapy?

Standard intensive chemotherapy may not be appropriate for you because of additional factors, such as age or other health conditions. However, there are still several treatment options available, including glasdegib with LDAC (low-dose cytarabine), low-intensity HMAs (hypomethylating agents) such as azacitidine and decitabine, and supportive care. Venetoclax can be used in combination with LDAC or an HMA for people who are ineligible for intensive chemotherapy.

Currently, treatment approaches for relapsed or refractory AML depend on a risk–benefit assessment, which analyzes the likely benefit of further therapy as well as the potential risks associated with it. The treatment decision is based on a number of factors, including age, length of remission, genetics, any previous stem cell transplant, general health status, and the patient’s wishes.

If considered eligible for intensive chemotherapy, treatment options include the following:

IDAC (intermediate-dose cytarabine) with filgrastim and either cladribine, fludarabine, or clofarabine

IDAC with etoposide with or without filgrastim

CLAG-M (cladribine, cytarabine, and mitoxantrone)

FLAG-IDA (fludarabine, cytarabine, filgrastim, and idarubicin)

Clofarabine, cytarabine, filgrastim, and idarubicin

HDAC (high-dose cytarabine) with or without idarubicin, daunorubicin, or mitoxantrone (for people who have not previously received this combination)

If intensive chemotherapy is not considered appropriate, the following treatment options are recommended:

Venetoclax in combination with an HMA or LDAC

Enrollment into a clinical trial may also be an option for people with relapsed or refractory AML.

Maintenance therapy refers to lower intensity treatments that may be offered to you following an intensive treatment course or if you are unable to complete intensive treatment. The aim of maintenance therapy is to lower the risk of relapse and prolong survival, while minimizing side effects.

What are the advances in formulations of chemotherapy?

When talking about medicines, a formulation refers to how the different components are combined to make a product that can be given easily. Advances in chemotherapy for AML include attempts to make the treatment safer, more effective, or more convenient. With this in mind, improvements to traditional chemotherapy have been developed, such as:

: A formulation of azacitidine that can be taken orally as a maintenance therapy.

: A formulation of combined daunorubicin and cytarabine that is more easily absorbed by the body.

In recent years, a number of new drugs have been developed to target specific markers found in or on leukemia cells. These advances have resulted in targeted drugs, which work differently to standard chemotherapy and can be useful if particular abnormalities have been identified. Generally, targeted therapies have higher specificity for leukemia cells and aim to minimize side effects. Some approved targeted treatments for different types of AML are shown below.

Approximately 30% of people with AML have abnormal changes in a gene called 

. These genetic changes give rise to different forms of the FLT3 protein, which can lead to the growth of leukemia cells.

: A drug that targets the abnormal FLT3 protein and blocks its function. Midostaurin can be used with standard chemotherapy to treat people who have abnormal changes in the 

: A drug that binds to the FLT3 protein and blocks its function. Gilteritinib can be used to treat people who have abnormal changes in the 

In some people with AML, abnormal changes are detected in the 

 genes, which interfere with normal cell processes.

: A drug that blocks the function of the IDH1 protein in leukemia cells. Ivosidenib can be used to treat people who have abnormal changes in the 

: A drug that blocks the function of the IDH2 protein in leukemia cells. Enasidenib can be used to treat people with abnormal changes in the 

BCL‑2 is a protein found inside cells that helps leukemia cells to survive.

: A drug that blocks the BCL‑2 protein, resulting in increased leukemia cell death. Venetoclax can be used to treat people who are aged 75 years and older or those who have other medical conditions that prevent the use of standard chemotherapy.

In a cell, the ‘hedgehog pathway’ is a finely tuned network of signaling molecules that are important in early-life development. In AML, disturbances in this pathway can give rise to cells that are resistant to certain treatments, helping leukemia cells survive.

: A drug that blocks the hedgehog pathway. Glasdegib can be used to treat people who are aged 75 years and older or who have other medical conditions that prevent the use of standard chemotherapy.

Antibody–drug conjugates contain an antibody (a synthetic immune protein that recognizes a specific target on leukemia cells) and an anticancer drug. The antibody is used to guide the drug to the leukemia cells, where it can destroy them.

: A drug made up of an antibody that specifically recognizes CD33 (a protein found on leukemia cells) and a chemotherapy drug.

 are medical studies involving people and are a key step towards optimizing treatments for different diseases. A clinical trial may be designed with the aim of improving current therapies or to investigate how safe and effective a new treatment is. There are various ongoing clinical trials investigating treatment options for AML.

A patient with AML may not respond to the therapies that are currently approved, and certain types of AML have little to no treatment options available. Therefore, taking part in a clinical trial may be the best option for some people and could provide the opportunity for effective disease treatment/management.

What treatment side effects may be expected?

Treatments for any medical condition can cause side effects. The side effects you may experience can vary depending on the treatment, i.e., chemotherapy/targeted therapy, and your overall health. For most people, side effects are temporary and will go away after treatment has finished or following changes to the treatment regimen, such as altered dosing.

Common side effects of treatment for AML include tiredness, increased risk of infection (impaired immune system), nausea, vomiting, hair loss, rashes, and low levels of red blood cells (anemia). Your leukemia specialist should advise you of the common side effects associated with any treatment you may have.

If you have any questions or concerns regarding treatment options, clinical trials, or side effects, reach out to your leukemia specialist.

Treatment

The term ‘prognosis’ describes the predicted outcome of a medical condition, including how it may respond to treatment in a particular patient. For example, if a patient has a condition with no known treatments, they may be described as having a poor prognosis.

In AML, prognosis differs from person to person, and there are a number of factors that can influence how a patient progresses, including:

 you have, particularly the genetic/chromosomal abnormalities present;

whether AML has spread to the brain and spinal cord;

the total number of white blood cells in the blood;

infection at the time of AML diagnosis; and

Your leukemia specialist may discuss your prognosis with you after taking one or more of these factors into account.

Prognosis

A patient is said to be in ‘remission’ once there are no detectable leukemia cells in the blood and bone marrow and when blood cells are returning to normal levels. Around 2 in 3 patients with AML achieve complete remission after their initial treatment, which is a sign that that the therapy has been effective in killing the abnormal cells.

However, low levels of cancer cells can go undetected while patients are in remission, making it important to continue with treatment as advised by your leukemia specialist. While in remission, it is also essential that patients remain under close observation and attend regular follow-ups, so that if AML returns, it is detected early. Read more about AML relapse 

American Cancer Society. Treatment Response Rates for Acute Myeloid Leukemia (AML). 

https://www.cancer.org/cancer/acute-myeloid-leukemia/treating/response-rates

Remission

The following information was prepared in collaboration with the 

As a patient with AML, you may be particularly susceptible to the effects of COVID-19; therefore, measures have been put in place to minimize the risk of you contracting the virus. Patients with AML who are not showing symptoms and not receiving treatment should discuss alternatives to clinic visits with their healthcare provider. Many questions can be answered by phone or via a telemedicine visit.

Patients who are on active treatments or receiving transfusions should continue to attend any scheduled appointments unless they are contacted by a member of their healthcare team and advised otherwise. It is a good idea for patients to contact their leukemia specialist prior to each scheduled appointment to see if the appointment is essential, and to possibly conduct the visit by phone or telemedicine. Sometimes it may also be possible to have routine lab tests drawn locally or at home to avoid travel.

It is essential that patients with ANY symptoms of cough, fever, diarrhea, loss of taste/smell, or chills, contact their healthcare provider (most cancer centers have hotlines, the numbers can be found on their websites) for instructions on how to proceed BEFORE coming into the hematology clinics. This ensures that you do not potentially expose other immunocompromised patients to the virus. 

If possible, wear a mask that covers both your nose and mouth when attending hospitals or clinics.

The following general recommendations were prepared by the 

Aplastic Anemia and MDS International Foundation

Wash your hands often for at least 20 seconds with soap and water or use a hand sanitizer that contains at least 60% alcohol.

Refrain from touching your eyes, nose, or mouth.

Cover your mouth and nose with a tissue when coughing or sneezing, discarding the tissue and cleaning your hands afterwards; if a tissue is not available, cough or sneeze into your elbow.

Clean and disinfect frequently touched objects and surfaces (i.e., doorknobs, light switches, handles, toilets, faucets, laptops, keyboards, cell phones, tables/counters).

Avoid close contact with people who are unwell and discourage people from visiting your home if they have any symptoms of illness.

Avoid contact with high-touch surfaces in public places (i.e., elevator buttons, door handles, handrails, touchscreens). Flat surfaces are more likely to have viruses or bacteria.

Contact your leukemia specialist with any questions or specific concerns.

The coronaviruses are a large family of viruses, which may cause illness in animals or humans. COVID-19 is the disease caused by the most recently discovered coronavirus, which originated the current pandemic. Other coronaviruses are those causing the Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). Symptoms of COVID-19 may resemble flu as both can cause fever and cough, body aches, and fatigue. The symptoms of COVID-19 usually appear between two and 14 days after being exposed to the virus and vary between mild to severe. Some people can develop breathing difficulties caused by the virus.

COVID-19 can spread from person to person through small droplets when an infected person coughs or sneezes, which is why it is important to maintain social distancing and to wash your hands often and thoroughly.

It is important that you stay up to date with the latest information and guidelines from your country’s health authorities and other trusted sources, such as the World Health Organization (WHO).

 (guidance for patients with blood cancer – United Kingdom)

Centers for Disease Control and Prevention

Aplastic Anemia & MDS International Foundation

 (guidance for patients with bone marrow failure)

COVID-19

A caregiver is someone who provides unpaid support and care for a family member or friend who cannot manage without their help. A caregiver can be a parent, husband or wife, brother or sister, partner, or a child. In some instances, a caregiver could be a colleague, a neighbor, or a close friend. Every caring situation is different.

Caregivers play a central role in a patient’s journey. Caring can mean a variety of things and in some cases, this could be providing round-the-clock care. Caregivers can help with a patient’s daily needs and activities, including giving medications, listening to the patient’s concerns, driving them to appointments for treatment, and helping with personal care.

Caregivers can also provide comfort, encouragement, and reassurance to the person they care for. In some cases, a caregiver can be responsible for managing the health and wellbeing of the person they care for. Caregivers can also help the person they care for achieve the best possible quality of life.

Almost every caregiver makes choices that work best for their own situation. There is no universal approach to caring. You simply try to recognize how you can do your best. The following suggestions can help you to help the person you care for.

It is important to communicate clearly with the person you care for and let them know that you want to be there for them. Acknowledge that they have the right to make decisions about their life (unless they lack mental capacity) and deserve respect for their feelings and independence. Involve the person you care for in decision-making as much as possible, always giving them the opportunity to make choices. In cases where they want to speak about their feelings, try to encourage them and listen. You may also want to share your feelings in the most sensitive way possible.

Help with the things that the person you care for cannot do

It is important to give the person you care for as much independence as possible, as this will contribute to their sense of well-being. Understand that it might be emotionally difficult for the person you care for to depend on you and they may feel that they are being a burden. Try to help them in a way that doesn’t seem like you are interfering, even if they do not ask for help.

As a caregiver, you may be a central part of coordinating the patient’s care. You may be responsible for booking appointments and providing transport to and from the hospital. You may also be allowed to visit the doctor with the person you care for, giving you an opportunity to learn more about AML, such as the patient’s type of AML, the specific treatment options, and the support available for the patient. It is also an opportunity to tell the doctor about the progress of treatment, any side effects from treatment, and any issues you are aware of as the patient’s caregiver. It is useful to ask questions during doctors’ visits, as in most cases caregivers are the people who know everything that happens to the person that they care for.

In a lot of cases, the time and energy you spend caring can be overlooked by society and the people around you. As a result, you may go through a series of emotions and feelings. Sometimes, you can drain yourself by trying to handle too many responsibilities on top of daily routines and working commitments, which could lead to exhaustion and affect your social life.

Also, caring for someone can lead to extra costs, including hospital bills, transport, and other daily requirements. Trying to keep a full-time job while caring for someone can be difficult, and can lead to you reducing your hours at work or even having to quit your job. All of these could lead to a financial burden.

It is important for you to find time to look after yourself and do things that make you happy. Visit the global network section to find your local support group; they can guide you, provide support when you are overwhelmed with the responsibilities of caring, and provide financial advice.

If you’d like to learn more from a caregiver’s experience, follow the stories from caregiver Doris Hill on her experience of caring for her husband with AML.