Best Practices for the Management of Acute Myeloid Leukemia - Episode 2
Risk Factors for the Development of AML
Yehuda Deutsch, MD, and Amanda Brahim, PharmD, BCOP, BCPS, BCACP, review the risk factors for developing acute myeloid leukemia (AML) and the clinical presentation.
Katie Culos, PharmD, BCOP: Yehuda, can you comment on some of the risk factors for developing AML?
Yehuda Deutsch, MD: There are certain risk factors for the development of AML. Some of these include exposure to chemicals, chemotherapy, radiation, [and] tobacco. AML, as we mentioned, can also be associated with other preexisting or antecedent hematologic disorders, such as myelodysplastic syndrome or myeloproliferative neoplasm. And, as we increase in age, the risk of developing [AML] increases significantly.
Katie Culos, PharmD, BCOP: Thank you. Amanda, when we have a patient who presents with a new diagnosis for AML, what are some of the common signs and symptoms that these patients will present with?
Amanda Brahim, PharmD, BCOP, BCPS, BCACP: Due to the nature of the disease, these myeloid blasts are crowding out other cells that would normally be produced in the bone marrow. So, patients oftentimes come with signs and symptoms of anemia. That could be things like shortness of breath, weakness. They could have easier bruising, bleeding, [or] fatigue that could last for weeks up to months prior to the diagnosis. Then, on some more rare occasions, they could have things like gingival hyperplasia. That’s normally seen in the monocytic variety, and sometimes you can see extramedullary disease.
Katie Culos, PharmD, BCOP: Are there any specific factors that can affect the prognosis or potentially the recovery from different treatments for AML?
Amanda Brahim, PharmD, BCOP, BCPS, BCACP: Yes, absolutely. We generally divide those two into either patient-specific or disease-specific risk factors. Patient-specific factors are kind of the normal thing; so a patient, as they grow older, that confers a poor risk, as does their performance status at time of diagnosis, as well as any comorbidities that they may have. Then with disease-specific factors, as you, Yehuda, mentioned earlier, we know that the disease, if it is considered a secondary AML, is generally more difficult to treat.
Katie Culos, PharmD, BCOP: Great. Yehuda, depending on whether or not we have a patient that presents with their new diagnosis of AML or potentially someone who is presenting with recurrent or relapsed disease, can you walk us through what your different approaches or strategies are, looking at intensity of therapy, that are different options to select for your patients.
Yehuda Deutsch, MD: There are numerous phases of treatment for acute myeloid leukemia. Of course, this depends on whether or not this is a new diagnosis of AML or a recurrence or relapse. So, starting with a new diagnosis of AML, the first part of therapy is to try and induce a remission. This is typically with intensive chemotherapy. We have to determine if the patients are candidates or they are fit for this type of chemotherapy.
If patients are determined to be candidates for intensive chemotherapy, these patients are typically given intensive chemotherapy over the course of 5-7 days, usually in the hospital. This is very aggressive chemotherapy, and patients typically have to be in the hospital for about a month. The goal of this treatment is to induce a remission. However, if left untreated after being in remission, the leukemia most likely will relapse. Therefore, patients need to continue on therapy with something called post-remission therapy.
Post-remission therapy can either be more standard chemotherapy or can be with an allogeneic stem-cell transplant. The decision of proceeding with post-remission chemotherapy or with allogeneic stem-cell transplant does depend on some patient characteristics, as well as characteristics of the leukemia itself.
For patients that are not candidates for intensive chemotherapy, they typically receive more of an outpatient, or less intensive, therapy. This therapy also has a great chance of response and long-term control.
However, this type of therapy also has great potential for response and control of the leukemia it’s typically not a curative type of therapy.