What is acute myeloid leukemia

Leukemia is cancer of the white blood cells. White blood cells help your body fight infection. Your blood cells form in your bone marrow. In leukemia, however, the bone marrow produces abnormal white blood cells. These abnormal white blood cells crowd out the healthy blood cells, making it hard for blood to do its work. In acute myeloid leukemia, there are too many of a specific type of white blood cell called a myeloblast. 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.

Acute myeloid leukemia is the most common type of acute leukemia in adults, making up about 80% of people with acute leukemia. In the United States, it is estimated that 3-5 people per every 100,000 people in the general population has the disease. More than half the people diagnosed with acute myeloid leukemia are 65 years of age or older. Slightly more men than women are affected by the disease, and it occurs with slightly more frequency in people of European heritage. Acute myeloid leukemia usually gets worse quickly if it is not treated. Acute myeloid leukemia starts in the bone marrow (the soft inner part of certain bones, where new blood cells are made), but most often it quickly moves into the blood, as well. Acute myeloid leukemia can sometimes spread to other parts of the body including the lymph nodes, liver, spleen, central nervous system (brain and spinal cord), and testicles. Most often, acute myeloid leukemia develops from cells that would turn into white blood cells (other than lymphocytes), but sometimes acute myeloid leukemia develops in other types of blood-forming cells.

Possible risk factors include smoking, previous chemotherapy treatment, and exposure to radiation.

Symptoms of acute myeloid leukemia include:

• Fever
• Shortness of breath
• Easy bruising or bleeding
• Bleeding under the skin
• Weakness or feeling tired
• Weight loss or loss of appetite

Tests that examine the blood and bone marrow diagnose acute myeloid leukemia. Treatments include chemotherapy, other drugs, radiation therapy, stem cell transplants, and targeted therapy. Targeted therapy uses substances that attack cancer cells without harming normal cells. Once the leukemia is in remission, you need additional treatment to make sure that it does not come back.

Normal bone marrow, blood, and lymph tissue

To understand leukemia, it helps to know about the blood and lymph systems.

Bone marrow

Bone marrow is the soft inner part of certain bones. It is made up of blood-forming cells, fat cells, and supporting tissues. A small fraction of the blood-forming cells are blood stem cells.

Inside the bone marrow, blood stem cells develop into new blood cells. During this process, the cells become either lymphocytes (a kind of white blood cell) or other blood-forming cells, which are types of myeloid cells. Myeloid cells can develop into red blood cells, white blood cells (other than lymphocytes), or platelets. These myeloid cells are the ones that are abnormal in acute myeloid leukemia.

Types of blood cells

There are 3 main types of blood cells:

• Red blood cells (RBCs) carry oxygen from the lungs to all other tissues in the body, and take carbon dioxide back to the lungs to be removed.
• Platelets are actually cell fragments made by a type of bone marrow cell called the megakaryocyte. Platelets are important in stopping bleeding. They help plug up holes in blood vessels caused by cuts or bruises.
• White blood cells (WBCs) help the body fight infections.

There are different types of white blood cells:

• Granulocytes are mature white blood cells that develop from myeloblasts, a type of blood-forming cell in the bone marrow. Granulocytes have granules that show up as spots under the microscope. These granules contain enzymes and other substances that can destroy germs, such as bacteria. The 3 types of granulocytes – neutrophils, basophils, and eosinophils – are distinguished by the size and color of their granules.
• Monocytes are white blood cells that develop from blood-forming monoblasts in the bone marrow. After circulating in the bloodstream for about a day, monocytes enter body tissues to become macrophages, which can destroy some germs by surrounding and digesting them. Macrophages also help lymphocytes recognize germs and make antibodies to fight them.
• Lymphocytes are mature white blood cells that develop from lymphoblasts in the bone marrow. Lymphocytes are the main cells that make up lymph tissue, a major part of the immune system. Lymph tissue is found in lymph nodes, the thymus (a small organ behind the breast bone), the spleen, the tonsils and adenoids, and is scattered throughout the digestive and respiratory systems and the bone marrow. The 2 main types of lymphocytes are B cell and T cells.

Figure 1. Blood composition

Note: Blood is a complex mixture of formed elements in a liquid extracellular matrix, called blood plasma. Note that water and proteins account for 99% of the blood plasma.

Figure 2. Bone marrow anatomy

Figure 3. White blood cells development. A blood stem cell goes through several steps to become a red blood cell, platelet, or white blood cell

Figure 4. White blood cells development

Figure 5. White blood cells

Acute myeloid leukemia causes

Acute myeloid leukemia is caused by damage to the DNA of developing cells in your bone marrow. When this happens, blood cell production goes wrong. The bone marrow produces immature cells that develop into leukemic white blood cells called myeloblasts. These abnormal cells are unable to function properly, and they can build up and crowd out healthy cells.

Some genes control when your cells grow, divide to make new cells, and die at the right time:

• Genes that help cells grow, divide, or stay alive are called oncogenes.
• Genes that help keep cell division under control or make cells die at the right time are called tumor suppressor genes.

The DNA inside each cell is in long strands called chromosomes. Each time a cell divides into 2 new cells, it must make a new copy of its chromosomes. This process isn’t perfect, and errors can occur that affect genes within the chromosomes. Cancers (including acute myeloid leukemia) can be caused by mutations (changes) that turn on oncogenes or turn off tumor suppressor genes. For instance, changes in certain genes such as FLT3, c-KIT, and RAS are common in acute myeloid leukemia cells. These types of changes can stop bone marrow cells from maturing the way they normally would, or help the cells grow out of control.

Mutations in many different genes can be found in acute myeloid leukemia, but larger changes in one or more chromosomes are also common. Even though these changes involve larger pieces of DNA, their effects are still likely to be due to changes in just one or a few genes that are on that part of the chromosome. Several types of chromosome changes may be found in acute myeloid leukemia cells:

• Translocations are the most common type of chromosome change. A translocation means that a part of one chromosome breaks off and becomes attached to a different chromosome. The point at which the break occurs can affect nearby genes – for example, it can turn on oncogenes or turn off genes like RUNX1 and RARa, which would normally help blood cells to mature.
• Deletions occur when part of a chromosome is lost. This can result in the cell losing a gene that helped keep its growth in check (a tumor suppressor gene).
• Inversions occur when part of a chromosome gets turned around, so it’s now in reverse order. This can result in the loss of a gene (or genes) because the cell can no longer read its instructions (much like trying to read a book backward).
• Addition or duplication means that there is an extra chromosome or part of a chromosome. This can lead to too many copies of certain genes within the cell. This can be a problem if one or more of these genes are oncogenes.

In most cases, it’s not clear what causes the DNA mutations that lead to leukemia. Radiation, exposure to certain chemicals and some chemotherapy drugs are known risk factors for acute myeloid leukemia.

Most DNA changes related to acute myeloid leukemia occur during a person’s lifetime, rather than having been inherited before birth. Some of these acquired changes may have outside causes like radiation or cancer-causing chemicals, but in most cases the reason they occur isn’t clear. Many of these gene changes are probably just random events that sometimes happen inside a cell, without having an outside cause. They seem to happen more often as we age, which might help explain why acute myeloid leukemia usually occurs in older people.

There are many types of acute myeloid leukemia, and different cases of acute myeloid leukemia can have different gene and chromosome changes, some of which are more common than others. Doctors are trying to figure out why these changes occur and how each of them might lead to leukemia. For example, some are more common in leukemia that occurs after chemotherapy for another cancer.

Some changes seem to have more of an effect on a person’s prognosis (outlook) than others. For instance, some changes might affect how quickly the leukemia cells grow, or how likely they are to respond to treatment.

Risk factors for acute myeloid leukemia

A risk factor is something that affects your chance of getting a disease, such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person’s age or family history, can’t be changed.

But having a risk factor, or even several risk factors, does not always mean that a person will get the disease, and many people get cancer without having any known risk factors.

There are some known risk factors for acute myeloid leukemia (AML).

Factors that may increase your risk of acute myeloid leukemia include:

• Increasing age: The risk of acute myeloid leukemia increases with age. Acute myelogenous leukemia is most common in adults age 65 and older.
• Your sex: Men are more likely to develop acute myeloid leukemia than are women.
• Previous cancer treatment: People who’ve had certain types of chemotherapy and radiation therapy may have a greater risk of developing acute myeloid leukemia.
• Exposure to radiation: People exposed to very high levels of radiation, such as survivors of a nuclear reactor accident, have an increased risk of developing acute myeloid leukemia.
• Dangerous chemical exposure: Exposure to certain chemicals, such as benzene, is linked to a greater risk of acute myeloid leukemia.
• Smoking: The only proven lifestyle-related risk factor for AML is smoking. Acute myeloid leukemia is linked to cigarette smoke, which contains benzene and other known cancer-causing chemicals.
• Other blood disorders: People who’ve had another blood disorder, such as myelodysplasia, myelofibrosis, polycythemia vera or thrombocythemia, are at greater risk of developing acute myeloid leukemia.
• Genetic disorders: Some syndromes that are caused by genetic mutations (abnormal changes) present at birth seem to raise the risk of acute myeloid leukemia. These include:
  • Fanconi anemia
  • Bloom syndrome
  • Ataxia-telangiectasia
  • Diamond-Blackfan anemia
  • Schwachman-Diamond syndrome
  • Li-Fraumeni syndrome
  • Neurofibromatosis type 1
  • Severe congenital neutropenia (also called Kostmann syndrome)
  • Down syndrome (being born with an extra copy of chromosome 21)
  • Trisomy 8 (being born with an extra copy of chromosome 8)

Many people with acute myeloid leukemia have no known risk factors, and many people who have risk factors never develop the cancer.

Having a family history

Although most cases of acute myeloid leukemia are not thought to have a strong genetic link, having a close relative (such as a parent, brother, or sister) with acute myeloid leukemia increases your risk of getting the disease.

Someone who has an identical twin who got acute myeloid leukemia before they were a year old has a very high risk of also getting acute myeloid leukemia.

Uncertain, unproven or controversial risk factors

Other factors that have been studied for a possible link to acute myeloid leukemia include:

• Exposure to electromagnetic fields (such as living near power lines)
• Workplace exposure to diesel, gasoline, and certain other chemicals and solvents
• Exposure to herbicides or pesticides

So far, none of these factors has been linked conclusively to acute myeloid leukemia. Research is being done in these areas.

Acute myeloid leukemia prevention

It’s not clear what causes most cases of acute myeloid leukemia (AML). Since most people with acute myeloid leukemia don’t have risk factors that can be changed, at the present time there is no known way to prevent most cases of acute myeloid leukemia.

Smoking is by far the most significant controllable risk factor for acute myeloid leukemia, and quitting offers the greatest chance to reduce a person’s risk of acute myeloid leukemia. Non-smokers are also much less likely than smokers to develop many other cancers, as well as heart disease, stroke, and some other diseases.

Treating some other cancers with chemotherapy or radiation may cause secondary (treatment-related) leukemias in some people. Doctors are trying to figure out how to treat these cancers without raising the risk of secondary leukemia. But for now, the obvious benefits of treating life-threatening cancers with chemotherapy and radiation must be balanced against the small chance of getting leukemia years later.

Avoiding known cancer-causing chemicals, such as benzene, might lower the risk of getting acute myeloid leukemia. But most experts agree that exposure to workplace and environmental chemicals seems to account for only a small portion of leukemias.

Acute myeloid leukemia symptoms

Acute myeloid leukemia can cause many different signs and symptoms. Some are more common with certain subtypes of acute myeloid leukemia.

General symptoms

People with acute myeloid leukemia often have several non-specific (general) symptoms. These can include:

• Weight loss
• Fatigue
• Fever
• Night sweats
• Loss of appetite
• Pale skin
• Tiredness
• Breathlessness
• A high temperature (fever)
• Excessive sweating
• Frequent infections
• Unusual and frequent bleeding, such as bleeding gums or nosebleeds
• Easily bruised skin
• Flat red or purple spots on the skin (petechiae)
• Bone and joint pain
• A feeling of fullness or discomfort in your tummy (abdomen), caused by swelling of the liver or spleen

These are not just symptoms of acute myeloid leukemia. More often they are caused by something other than leukemia.

Symptoms caused by low numbers of blood cells

Many signs and symptoms of acute myeloid leukemia are the result of a shortage of normal blood cells, which happens when the leukemia cells crowd out the normal blood-making cells in the bone marrow. As a result, people don’t have enough normal red blood cells, white blood cells, and blood platelets. These shortages show up on blood tests, and they can also cause symptoms.

Symptoms from low red blood cell counts (anemia)

Red blood cells carry oxygen to all of the cells in the body. A shortage of red blood cells can cause:

• Tiredness (fatigue)
• Weakness
• Feeling cold
• Feeling dizzy or lightheaded
• Headaches
• Pale skin
• Shortness of breath

Symptoms from low white blood cell counts

Infections can occur because of a shortage of normal white blood cells (leukopenia), specifically a shortage of infection-fighting white blood cells called neutrophils (a condition called neutropenia). People with acute myeloid leukemia can get infections that don’t seem to go away or may get one infection after another. Fever often goes along with the infection.

Although people with acute myeloid leukemia can have high white blood cell counts due to excess numbers of leukemia cells, these cells don’t protect against infection the way normal white blood cells do.

Symptoms from low blood platelet counts

Platelets normally help stop bleeding. A shortage of blood platelets (called thrombocytopenia) can lead to:

• Bruises (or small red or purple spots) on the skin
• Excess bleeding
• Frequent or severe nosebleeds
• Bleeding gums
• Heavy periods (menstrual bleeding) in women

Symptoms caused by high numbers of leukemia cells

The cancer cells in acute myeloid leukemia (called blasts) are bigger than normal white blood cells and have more trouble going through tiny blood vessels. If the blast count gets very high, these cells can clog up blood vessels and make it hard for normal red blood cells (and oxygen) to get to tissues. This is called leukostasis. Leukostasis is rare, but it is a medical emergency that needs to be treated right away. Some of the symptoms are like those seen with a stroke, and include:

• Headache
• Weakness in one side of the body
• Slurred speech
• Confusion
• Sleepiness

When blood vessels in the lungs are affected, people can have shortness of breath. Blood vessels in the eye can be affected as well, leading to blurry vision or even loss of vision.

Bleeding and clotting problems

Patients with a certain type of acute myeloid leukemia called acute promyelocytic leukemia might have problems with bleeding and blood clotting. They might have a nosebleed that won’t stop, or a cut that won’t stop oozing. They might also have calf swelling from a blood clot called a deep vein thrombosis (DVT) or chest pain and shortness of breath from a blood clot in the lung (called a pulmonary embolism or PE).

Bone or joint pain

Some people with acute myeloid leukemia have bone pain or joint pain caused by the buildup of leukemia cells in these areas.

Swelling in the abdomen

Leukemia cells may build up in the liver and spleen, making them larger. This may be noticed as a fullness or swelling of the belly. The lower ribs usually cover these organs, but when they are enlarged the doctor can feel them.

Symptoms caused by leukemia spread

Spread to the skin

If leukemia cells spread to the skin, they can cause lumps or spots that may look like common rashes. A tumor-like collection of acute myeloid leukemia cells under the skin or other parts of the body is called a chloroma, granulocytic sarcoma, or myeloid sarcoma. Rarely, acute myeloid leukemia will first appear as a chloroma, with no leukemia cells in the bone marrow.

Spread to the gums

Certain types of acute myeloid leukemia may spread to the gums, causing swelling, pain, and bleeding.

Spread to other organs

Less often, leukemia cells can spread to other organs. Spread to the brain and spinal cord can cause symptoms such as:

• Headaches
• Weakness
• Seizures
• Vomiting
• Trouble with balance
• Facial numbness
• Blurred vision

On rare occasions acute myeloid leukemia can spread to the eyes, testicles, kidneys, or other organs.

Enlarged lymph nodes

Rarely, acute myeloid leukemia can spread to lymph nodes (bean-sized collections of immune cells throughout the body), making them bigger. Affected nodes in the neck, groin, underarm areas, or above the collarbone may be felt as lumps under the skin.

Although any of the symptoms and signs above may be caused by acute myeloid leukemia, they can also be caused by other conditions. Still, if you have any of these problems, especially if they don’t go away or are getting worse, it’s important to see a doctor so the cause can be found and treated, if needed.

Acute myeloid leukaemia complications

If you have acute myeloid leukaemia (acute myeloid leukemia), you may experience a number of complications. These can be caused by the condition itself, although they can also occur as a side effect of treatment.

Weakened immune system

Having a weakened immune system – being immunocompromised – is a common complication of acute myeloid leukemia.

Even if your blood is restored to normal working order with treatment, many of the medications that are used to treat acute myeloid leukemia can temporarily weaken your immune system.

This means you’re more vulnerable to developing an infection, and any infection you develop could be more serious than usual. Complications arising from infection are the leading cause of death in people with acute myeloid leukemia. However, if treated early, nearly all infections respond to appropriate treatment.

Therefore, you may be advised to:

• take regular doses of antibiotics to prevent bacterial infections
• maintain good personal and dental hygiene
• avoid contact with anyone who’s known to have an infection – even if it’s a type of infection that you were previously immune to, such as chickenpox or measles
• check with your doctor to ensure that all of your vaccinations are up to date, although you won’t be able to have any vaccine that contains “live” viruses or bacteria, such as the shingles vaccine and MMR vaccine (against measles, mumps and rubella)

Report any possible symptoms of an infection to your treatment unit immediately because prompt treatment may be needed to prevent complications.

Symptoms of an infection can include:

• a high temperature (fever)
• a headache
• aching muscles
• diarrhea
• tiredness

Bleeding

If you have acute myeloid leukemia, you’ll bleed and bruise more easily due to the low levels of platelets (clot-forming cells) in your blood. Bleeding may also be excessive.

People with advanced acute myeloid leukemia are more vulnerable to excessive bleeding inside their body, which is the second most common cause of death in people with the condition.

Serious bleeding can occur:

• inside the skull (intracranial hemorrhage) – causing symptoms such as a severe headache, stiff neck, vomiting and confusion
• inside the lungs (pulmonary hemorrhage) – causing symptoms such as coughing up blood, breathing difficulties and a bluish skin tone (cyanosis)
• inside the stomach (gastrointestinal hemorrhage) – causing symptoms such as vomiting blood and passing stools (feces) that are very dark or tar-like in color

All these types of hemorrhage should be regarded as medical emergencies. Call your local emergency services number immediately and ask for an ambulance if you think a hemorrhage is occurring.

Infertility

Many of the treatments that are used to treat acute myeloid leukemia can cause infertility. This is often temporary, but in some cases can be permanent.

People particularly at risk of permanent infertility are those who have received high doses of chemotherapy and radiotherapy in preparation for a bone marrow or stem cell transplant.

Your treatment team can give a good estimation of the risk of infertility in your specific circumstances.

It may be possible to guard against any risk of infertility before you begin your treatment. For example, men can have their sperm samples stored. Similarly, women can have eggs or fertilised embryos stored, which can then be placed back into their womb, following treatment.

However, as acute myeloid leukemia is an aggressive condition that develops rapidly, there may not always be time to do this before treatment needs to start.

Acute myeloid leukemia diagnosis

If you have signs or symptoms of acute myeloid leukemia, your doctor may recommend that you undergo diagnostic tests, including:

Blood tests

Most people with acute myeloid leukemia have too many white blood cells, not enough red blood cells and not enough platelets. The presence of blast cells — immature cells normally found in bone marrow but not circulating in the blood — is another indicator of acute myeloid leukemia.

Bone marrow test

A blood test can suggest leukemia, but it usually takes a bone marrow test to confirm the diagnosis.

Leukemia starts in the bone marrow, so checking the bone marrow for leukemia cells is a key part of testing for it. Bone marrow samples are obtained from 2 tests that are usually done at the same time:

• Bone marrow aspiration
• Bone marrow biopsy

The samples are usually taken from the back of the pelvic (hip) bone, but sometimes other bones are used instead. If only an aspiration is to be done, it may be taken from the sternum (breast bone).

For a bone marrow aspiration, you lie on a table (either on your side or on your belly). The doctor will clean the skin over the hip and then numb the area and the surface of the bone by injecting a local anesthetic. This may cause a brief stinging or burning sensation. A thin, hollow needle is then inserted into the bone, and a syringe is used to suck out a small amount of liquid bone marrow. Even with the anesthetic, most patients still have some brief pain when the marrow is removed.

A bone marrow biopsy is usually done just after the aspiration. A small piece of bone and marrow is removed with a slightly larger needle that is pushed down into the bone. This may also cause some brief pain. Once the biopsy is done, pressure will be applied to the site to help prevent bleeding.

These bone marrow tests are used to help diagnose leukemia, but they might also be repeated later to tell if the leukemia is responding to treatment.

Lumbar puncture (spinal tap)

In some cases, it may be necessary to remove some of the fluid around your spinal cord to check for leukemia cells. Your doctor can collect this fluid by inserting a small needle into the spinal canal in your lower back.

Lab tests used to diagnose and classify acute myeloid leukemia

One or more of the following lab tests may be done on the samples to diagnose acute myeloid leukemia and/or to determine the specific subtype of acute myeloid leukemia.

Complete blood count and peripheral blood smear

The complete blood count (CBC) is a test that measures the amounts of different cells in the blood, such as the red blood cells, white blood cells, and platelets. The CBC is often done along with a differential (or diff), which looks at the numbers of the different types of white blood cells. For the peripheral blood smear, a sample of blood is looked at under the microscope. Changes in the numbers and the appearance of different types of blood cells often help diagnose leukemia.

Most patients with acute myeloid leukemia have too many immature white cells in their blood, and not enough red blood cells or platelets. Many of the white blood cells may be myeloblasts (often just called blasts), which are very early forms of blood-forming cells that are not normally found in the blood. These cells don’t work like normal, mature white blood cells. These findings may suggest leukemia, but the disease usually is not diagnosed without looking at a sample of bone marrow cells.

Blood chemistry and coagulation tests

These tests measure the amounts of certain chemicals in the blood and the ability of the blood to clot. These tests are not used to diagnose leukemia, but they can help detect liver or kidney problems, abnormal levels of certain minerals in the blood, or problems with blood clotting.

Routine cell exams by microscope

Samples of blood, bone marrow, or CSF are looked at under a microscope by a pathologist (a doctor specializing in lab tests) and may be reviewed by the patient’s hematologist/oncologist (a doctor specializing in cancer and blood diseases).

The doctors will look at the size, shape, and other traits of the white blood cells in the samples to classify them into specific types.

A key element is whether the cells look mature (like normal blood cells) or immature (lacking features of normal blood cells). The most immature cells are called myeloblasts (or blasts).

The percentage of blasts in the bone marrow or blood is particularly important. Having at least 20% blasts in the marrow or blood is generally required for a diagnosis of acute myeloid leukemia. (In normal bone marrow, the blast count is 5% or less, while the blood usually doesn’t contain any blasts.) acute myeloid leukemia can also be diagnosed if the blasts are found (using another test) to have a chromosome change that occurs only in a specific type of acute myeloid leukemia, even if the blast percentage doesn’t reach 20%.

Sometimes just counting and looking at the cells isn’t enough to provide a clear diagnosis. Other lab tests may be used to confirm an acute myeloid leukemia diagnosis.

Cytochemistry

For cytochemistry tests, cells are exposed to chemical stains (dyes) that react with only some types of leukemia cells. These stains cause color changes that can be seen under a microscope, which can help the doctor determine what types of cells are present. For instance, one stain can help distinguish acute myeloid leukemia cells from acute lymphocytic leukemia (ALL) cells. The stain causes the granules of most acute myeloid leukemia cells to appear as black spots under the microscope, but it does not causeacute lymphocytic leukemia cells to change colors.

Flow cytometry and immunohistochemistry

For both flow cytometry and immunocytochemistry, samples of cells are treated with antibodies, which are proteins that stick only to certain other proteins on cells. For immunocytochemistry, the cells are then looked at under a microscope to see if the antibodies stuck to them (meaning they have these proteins), while for flow cytometry a special machine is used.

These tests are used for immunophenotyping – classifying leukemia cells according to the substances (antigens) on their surfaces. Leukemia cells can have different antigens depending on which type of cells they start in and how mature they are, and this information can be helpful in acute myeloid leukemia classification.

Chromosome tests

These tests look at the chromosomes (long strands of DNA) inside the cells. Normal human cells contain 23 pairs of chromosomes, each of which are a certain size and stain a certain way. acute myeloid leukemia cells sometimes have chromosome changes that can be seen under a microscope or found with other tests. Recognizing these changes can help identify certain types of acute myeloid leukemia and can be important in determining a patient’s outlook.

Cytogenetics: In this test, the cells are looked at under a microscope to see if the chromosomes have any abnormalities. A drawback of this test is that it usually takes about 2 to 3 weeks because the cells must grow in lab dishes for a couple of weeks before their chromosomes can be viewed.

The results of cytogenetic testing are written in a shorthand form that describes the chromosome changes:

• A translocation means parts of two chromosomes have traded places with each other. For example, if chromosomes 8 and 21 have swapped pieces, it would be written as t(8;21).
• An inversion, written as inv(16), for example, means that part of the chromosome 16 is now in reverse order but is still attached to the chromosome.
• A deletion, written as del(7) or -7, for example, indicates part of chromosome 7 has been lost.
• An addition or duplication, such as +8, for example, means that all or part of chromosome 8 has been duplicated, and too many copies of it are found within the cell.

Not all chromosome changes can be seen under a microscope. Other lab tests can often detect these changes.

Fluorescent in situ hybridization (FISH): This test looks more closely at cell DNA using special fluorescent dyes that only attach to specific genes or parts of particular chromosomes. FISH can find the chromosome changes (such as translocations) that are visible under a microscope in standard cytogenetic tests, as well as some changes too small to be seen with usual cytogenetic testing.

FISH can be used to look for changes in specific genes or parts of chromosomes. It can be used on regular blood or bone marrow samples without growing them in a lab first. This means the results are often available more quickly than with regular cytogenetic testing.

Polymerase chain reaction (PCR): This is a very sensitive test that can also find some gene and chromosome changes too small to be seen under a microscope. It is helpful in finding gene changes that are in only a few cells, making it good for finding small numbers of leukemia cells in a sample (like after treatment).

Other molecular and genetic tests

Other, newer types of lab tests can also be done on the samples to look for specific gene or other changes in the leukemia cells.

Imaging tests for acute myeloid leukemia

Imaging tests use x-rays, sound waves, magnetic fields, or radioactive particles to create pictures of the inside of the body. Leukemia doesn’t usually form tumors, so imaging tests aren’t often helpful in making the diagnosis. When imaging tests are done in people with acute myeloid leukemia, it’s most often to look for infections or other problems, rather than to look for leukemia itself. In a few cases, imaging tests may be done to help determine the extent of the disease, if it’s thought it might have spread beyond the bone marrow and blood.

X-rays

Routine chest x-rays may be done if a lung infection is suspected.

Computed tomography (CT) scan

A CT scan uses x-rays to make detailed, cross-sectional images of your body. This test can help show if any lymph nodes or organs in your body are enlarged. It isn’t usually needed to diagnose acute myeloid leukemia, but it may be done if your doctor suspects the leukemia is growing in an organ, like your spleen.

CT-guided needle biopsy: In some cases, a CT can be used to guide a biopsy needle into a suspected abnormality, such as an abscess. For this procedure, you lie on the CT scanning table while the doctor moves a biopsy needle through the skin and toward the mass. CT scans are repeated until the needle is within the mass. A sample is then removed and sent to the lab to be looked at under a microscope.

PET/CT: Some machines combine the CT scan with a PET scan (PET/CT scan). For a PET scan, glucose (a form of sugar) containing a radioactive atom is injected into the blood. Because cancer cells in the body grow rapidly, they absorb large amounts of the radioactive sugar. A special camera can then create a picture of areas of radioactivity in the body. With a PET/CT scan, the doctor can compare areas of higher radioactivity on the PET scan with the more detailed appearance of that area on the CT.

Magnetic resonance imaging (MRI) scan

Like CT scans, MRI scans make detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays.

MRI scans are very helpful in looking at the brain and spinal cord, but they are not usually needed in people with acute myeloid leukemia.

Ultrasound

Ultrasound uses sound waves and their echoes to make pictures of internal organs or masses.

Ultrasound can be used to look at lymph nodes near the surface of the body or to look inside your abdomen for enlarged lymph nodes or organs such as the liver, spleen, and kidneys. (It can’t be used to look inside the chest because the ribs block the sound waves.) It is sometimes used to help guide a biopsy needle into an enlarged lymph node.

Acute myeloid leukemia stages

For most types of cancer, determining the stage (extent) of the cancer is very important. The stage is based on the size of the main tumor and how far the cancer has spread. This can be helpful in predicting a person’s outlook and deciding on treatment.

Acute myeloid leukemia, on the other hand, does not usually form tumors. Acute myeloid leukemia generally is widespread throughout the bone marrow and, in some cases, has spread to other organs, such as the liver and spleen. Therefore acute myeloid leukemia is not staged like most other cancers. The outlook for a person with acute myeloid leukemia depends instead on other information, such as the subtype of acute myeloid leukemia (determined by lab tests), the patient’s age, and other lab test results.

Knowing the subtype of acute myeloid leukemia can be very important, as it sometimes affects both a patient’s outlook and the best treatment. For example, the acute promyelocytic leukemia subtype is often treated using drugs that are different from those used for other subtypes of acute myeloid leukemia. If you’re not sure which subtype of acute myeloid leukemia you have, ask your doctor about it, and about how it might affect your treatment.

Two of the main systems that have been used to classify acute myeloid leukemia into subtypes are the French-American-British (FAB) classification and the newer World Health Organization (WHO) classification.

French-American-British (FAB) classification of acute myeloid leukemia

In the 1970s, a group of French, American, and British leukemia experts divided acute myeloid leukemia into subtypes, M0 through M7, based on the type of cell the leukemia develops from and how mature the cells are. This was based largely on how the leukemia cells looked under the microscope after routine staining.

Subtypes M0 through M5 all start in immature forms of white blood cells. M6 AML starts in very immature forms of red blood cells, while M7 AML starts in immature forms of cells that make platelets.

Table 1. French-American-British (FAB) classification of acute myeloid leukemia

World Health Organization (WHO) classification of acute myeloid leukemia

The French-American-British (FAB) classification system can be useful, but it doesn’t take into account many of the factors that are now known to affect prognosis (outlook). The World Health Organization (WHO) system, most recently updated in 2016, includes some of these factors to try to better classify acute myeloid leukemia.

The WHO system divides acute myeloid leukemia into several groups:

• Acute myeloid leukemia with certain genetic abnormalities (gene or chromosome changes)
  • Acute myeloid leukemia with a translocation between chromosomes 8 and 21 [t(8;21)]
  • Acute myeloid leukemia with a translocation or inversion in chromosome 16 [t(16;16) or inv(16)]
  • Acute promyelocytic leukemia (APL) with the PML-RARA fusion gene
  • Acute myeloid leukemia with a translocation between chromosomes 9 and 11 [t(9;11)]
  • Acute myeloid leukemia with a translocation between chromosomes 6 and 9 [t(6:9)]
  • Acute myeloid leukemia with a translocation or inversion in chromosome 3 [t(3;3) or inv(3)]
  • Acute myeloid leukemia (megakaryoblastic) with a translocation between chromosomes 1 and 22 [t(1:22)]
  • Acute myeloid leukemia with the BCR-ABL1 (BCR-ABL) fusion gene*
  • Acute myeloid leukemia with mutated NPM1 gene
  • Acute myeloid leukemia with biallelic mutations of the CEBPA gene (that is, mutations in both copies of the gene)
  • Acute myeloid leukemia with mutated RUNX1 gene. This is still a “provisional entity,” meaning it’s not yet clear if there’s enough evidence that it’s a unique group.
• Acute myeloid leukemia with myelodysplasia-related changes

• Acute myeloid leukemia related to previous chemotherapy or radiation

• Acute myeloid leukemia not otherwise specified (This includes cases of acute myeloid leukemia that don’t fall into one of the above groups, and is similar to the FAB classification.)
  • Acute myeloid leukemia with minimal differentiation (FAB M0)
  • Acute myeloid leukemia without maturation (FAB M1)
  • Acute myeloid leukemia with maturation (FAB M2)
  • Acute myelomonocytic leukemia (FAB M4)
  • Acute monoblastic/monocytic leukemia (FAB M5)
  • Pure erythroid leukemia (FAB M6)
  • Acute megakaryoblastic leukemia (FAB M7)
  • Acute basophilic leukemia
  • Acute panmyelosis with fibrosis
• Myeloid sarcoma (also known as granulocytic sarcoma or chloroma)

• Myeloid proliferations related to Down syndrome

• Undifferentiated and biphenotypic acute leukemias are not strictly acute myeloid leukemia, but are leukemias that have both lymphocytic and myeloid features. They are sometimes called mixed phenotype acute leukemias.

Prognostic factors for acute myeloid leukemia

The subtype of acute myeloid leukemia can be important in helping to determine a person’s prognosis (outlook). But other factors can also affect why some patients with acute myeloid leukemia have a better outlook than others. These are called prognostic factors. Prognostic factors help doctors determine a person’s risk of the leukemia coming back after treatment, and therefore if they should get more or less intensive treatment. Some of these include:

Chromosome (cytogenetic) abnormalities

Acute myeloid leukemia cells can have many kinds of chromosome changes, some of which can affect a person’s prognosis. Those listed below are some of the most common, but there are many others. Not all leukemias have these abnormalities. Patients whose acute myeloid leukemia doesn’t have any of these usually have an outlook that is between favorable and unfavorable.

Favorable abnormalities:

• Translocation between chromosomes 8 and 21 (seen most often in patients with M2)
• Translocation or inversion of chromosome 16
• Translocation between chromosomes 15 and 17 (seen most often in patients with M3)

Unfavorable abnormalities:

• Deletion (loss) of part of chromosome 5 or 7
• Translocation or inversion of chromosome 3
• Translocation between chromosomes 6 and 9
• Translocation between chromosomes 9 and 22
• Abnormalities of chromosome 11 (at the spot q23)
• Loss of a chromosome, so the cell has only 1 copy instead of the normal 2 (known as monosomy)
• Complex changes (those involving 3 or more chromosomes)

Gene mutations

People whose leukemia cells have certain gene mutations may have a better or worse outlook.

For instance, people with acute myeloid leukemia that has a mutation in the FLT3 gene tend to have a poorer outlook, although new drugs that target cells with this abnormal gene might lead to better outcomes. Mutations in the TP53, RUNX1, and ASXL1 genes are also linked with a worse outlook.

On the other hand, people whose leukemia cells have changes in the NPM1 gene (and no other abnormalities) seem to have a better prognosis than people without this change. Changes in both copies of the CEBPA gene are also linked to a better outcome.

Markers on the leukemia cells

If the leukemia cells have the CD34 protein and/or the P-glycoprotein (MDR1 gene product) on their surface, it is linked to a worse outlook.

Age

Generally, people over 60 don’t do as well as younger people. Some of this may be because they are more likely to have unfavorable chromosome abnormalities. They sometimes also have other medical conditions that can make it harder for them to handle more intense chemotherapy regimens.

White blood cell count

A high white blood cell count (>100,000/mm³) at the time of diagnosis is linked to a worse outlook.

Prior blood disorder leading to acute myeloid leukemia

Having a prior blood disorder such as a myelodysplastic syndrome is linked to a worse outlook.

Treatment-related acute myeloid leukemia

Acute myeloid leukemia that develops after a person is treated for another cancer is linked to a worse outlook.

Infection

Having a systemic (blood) infection when you are diagnosed is linked to a worse outlook.

Leukemia cells in the central nervous system

Leukemia that has spread to the area around the brain and spinal cord can be hard to treat, since most chemotherapy drugs can’t reach that area.

Status of acute myeloid leukemia after treatment

How well (and how quickly) the leukemia responds to treatment also affects long-term prognosis. Better initial responses have been linked with better long-term outcomes.

A remission (complete remission) is usually defined as having no evidence of disease after treatment. This means the bone marrow contains fewer than 5% blast cells, the blood cell counts are within normal limits, and there are no signs or symptoms from the leukemia. A complete molecular remission means there is no evidence of leukemia cells in the bone marrow, even when using very sensitive tests, such as PCR (polymerase chain reaction).

Minimal residual disease is a term used after treatment when leukemia cells can’t be found in the bone marrow using standard tests (such as looking at cells under a microscope), but more sensitive tests (such as flow cytometry or PCR) find evidence that there are still leukemia cells in the bone marrow.

Active disease means that either there is evidence that the leukemia is still present during treatment, or that the disease has come back after treatment (relapsed). For a patient to have relapsed, they must have more than 5% blast cells in their bone marrow.

Acute myeloid leukemia life expectancy

Generally with acute myeloid leukemia, around 20 out of 100 people (around 20%) will survive their leukemia for 5 years or more after their diagnosis.

Survival rates tell you what portion of people with the same type and stage of cancer are still alive a certain length of time (usually 5 years) after they were diagnosed. These numbers can’t tell you how long you will live, but they might help give you a better understanding about how likely it is that your treatment will be successful.

Statistics on the outlook for people with a certain type and stage of cancer are often given as 5-year survival rates, but many people live longer – often much longer – than 5 years. The 5-year survival rate is the percentage of people who live at least 5 years after being diagnosed with cancer. For example, a 5-year survival rate of 90% means that an estimated 90 out of 100 people who have that cancer are still alive 5 years after being diagnosed.

Relative survival rates are often a more accurate way to estimate the effect of cancer on survival. These rates compare people with adrenal cancer to people in the overall population. For example, if the 5-year relative survival rate for a specific type and stage of cancer is 90%, it means that people who have that cancer are, on average, about 90% as likely as people who don’t have that cancer to live for at least 5 years after being diagnosed.

But remember, the 5-year relative survival rates are estimates – your outlook can vary based on a number of factors specific to you.

Cancer survival rates don’t tell the whole story

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they can’t predict what will happen in any particular person’s case. There are a number of limitations to remember:

• The numbers below are among the most current available. But to get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. As treatments are improving over time, people who are now being diagnosed with adrenal cancer may have a better outlook than these statistics show.
• These statistics are based on the stage of the cancer when it was first diagnosed. They do not apply to cancers that come back later or spread, for example.
• Besides the cancer stage, many other factors can affect a person’s outlook, such as age and overall health, and how well the cancer responds to treatment.

Your doctor can tell you how these numbers may apply to you, as he or she is familiar with your situation.

Survival by age

Younger people tend to do much better than older people.

• In children aged 14 or younger, more than 65 out of 100 children (more than 65%) will survive their leukemia for 5 years or more after they are diagnosed.
• In people aged between 15 and 24, around 60 out of 100 people (around 60%) will survive their leukemia for 5 years or more after diagnosis.
• In people aged between 25 and 64, almost 40 out of 100 people (almost 40%) will survive their leukemia for 5 years or more after they are diagnosed.
• In people aged 65 or older, around 5 out of 100 people (around 5%) will survive their leukemia for 5 years or more after diagnosis.

Acute myeloid leukemia prognosis

With current treatment regimens, only a minority of acute myeloid leukemia patients are cured. Outcomes are particularly poor for older patients with low complete remission rates and there are few long-term survivors compared with the number of long-term survivors of younger patients. More than 50% of people with acute myeloid leukemia experience a return of cancer, called a relapse. If relapse occurs within the first year, then physicians may recommend that individuals participate in a clinical trial for a new treatment option. Another option is to try another round of induction therapy with a different chemotherapy regimen and new drugs. If a relapse is over a year later, then physicians may recommend an allogeneic stem cell transplant, or they may recommend repeating the chemotherapy used during induction therapy, or they may recommend both. People who experience a relapse or for whom further treatment is ineffective, may be encouraged to participate in a clinical trial.

What affects prognosis

Age

• Your age affects outlook. Younger people have a better prognosis.

Changes in genes

• Outlook is affected by changes in your genes. These are called cytogenetic tests.
• Some specific genetic abnormalities in your leukemia cells may make your leukemia harder to treat successfully.

How advanced the leukemia is

Survival is also affected by how advanced the leukemia is at diagnosis. If you have a high number of white blood cells in the blood at diagnosis, the outlook is poorer.

Changing from chronic to acute

The outcome depends on whether you had leukemia that changed (transformed) from a chronic form into an acute form. It can be more difficult to treat leukemia that has transformed, or if it has developed from a blood condition called myelodysplasia.

Secondary leukemia

It may also be harder to treat a leukemia that has developed after treatment for another cancer. This is called a secondary leukemia. It means that you developed leukemia after earlier chemotherapy damaged your bone marrow cells. This is rare, but it can happen. Secondary leukemia usually develops within 10 years of treatment for the first cancer.

How well leukemia responds to treatment

Your outlook is affected by how well the leukemia responds to treatment and how long it takes to get a remission. Remission means the leukemia is not active and doctors cannot find any sign of it. If it takes a long time to get your leukemia into remission, your leukemia may be more difficult to treat successfully.

Relapse

If acute myeloid leukemia comes back after initial treatment it is called relapsed leukemia. With relapsed acute myeloid leukemia, it is sometimes possible to get rid of all signs of the leukemia again (a second remission) with more chemotherapy.

Acute myeloid leukemia treatment

Treatment of acute myeloid leukemia depends on several factors, including the subtype of the disease, your age, your overall health and your preferences.

In general, treatment falls into two phases:

1. Remission induction therapy. The purpose of the first phase of treatment is to kill the leukemia cells in your blood and bone marrow. However, remission induction usually doesn’t wipe out all of the leukemia cells, so you need further treatment to prevent the disease from returning.
2. Consolidation therapy. Also called post-remission therapy, maintenance therapy or intensification, this phase of treatment is aimed at destroying the remaining leukemia cells. It’s considered crucial to decreasing the risk of relapse.

Therapies used in these phases include:

• Chemotherapy. Chemotherapy is the major form of remission induction therapy, though it can also be used for consolidation therapy. Chemotherapy uses chemicals to kill cancer cells in your body. People with acute myeloid leukemia generally stay in the hospital during chemotherapy treatments because the drugs destroy many normal blood cells in the process of killing leukemia cells. If the first cycle of chemotherapy doesn’t cause remission, it can be repeated.
• Targeted therapy. Targeted therapy uses drugs that attack specific vulnerabilities within your cancer cells. The drug midostaurin (Rydapt) stops the action of an enzyme within the leukemia cells and causes the cells to die. Midostaurin is only useful for people whose cancer cells have the FLT3 mutation. This drug is administered in pill form.
• Other drug therapy. Arsenic trioxide (Trisenox) and all-trans retinoic acid (ATRA) are anti-cancer drugs that can be used alone or in combination with chemotherapy for remission induction of a certain subtype of acute myeloid leukemia called promyelocytic leukemia. These drugs cause leukemia cells with a specific gene mutation to mature and die, or to stop dividing.
• Bone marrow transplant. A bone marrow transplant, also called a stem cell transplant, may be used for consolidation therapy. A bone marrow transplant helps re-establish healthy stem cells by replacing unhealthy bone marrow with leukemia-free stem cells that will regenerate healthy bone marrow. Prior to a bone marrow transplant, you receive very high doses of chemotherapy or radiation therapy to destroy your leukemia-producing bone marrow. Then you receive infusions of stem cells from a compatible donor (allogeneic transplant). You can also receive your own stem cells (autologous transplant) if you were previously in remission and had your healthy stem cells removed and stored for a future transplant.
• Clinical trials. Some people with leukemia choose to enroll in clinical trials to try experimental treatments or new combinations of known therapies.

Remission induction therapy

The initial treatment you have for acute myeloid leukemia will largely depend on whether you’re fit enough to have intensive chemotherapy, or whether treatment at a lower dosage is recommended.

Intensive chemotherapy

If you can have intensive induction chemotherapy, you’ll usually be given a combination of chemotherapy medication at a high dose to kill the cancerous cells in your blood and bone marrow.

This stage of treatment will be carried out in hospital or in a specialist centre, as you’ll need very close medical and nursing supervision.

You’ll have regular blood transfusions because your blood won’t contain enough healthy blood cells.

You’ll also be vulnerable to infection, so it’s important that you’re in a clean and stable environment where your health can be carefully monitored and any infection you have can be promptly treated. You may also be prescribed antibiotics to help prevent further infection.

Depending on how well you respond to treatment, the induction phase can last from four weeks to a couple of months. You may be able to leave hospital and receive treatment on an outpatient basis if your symptoms improve.

For intensive treatment, the chemotherapy medications will be injected into a thin tube that’s inserted either into a blood vessel near your heart (central line) or into your arm (a peripherally inserted central catheter, or PICC).

In very rare cases, chemotherapy medication may also be directly administered into your cerebrospinal fluid to kill any leukaemia cells that may have spread to your nervous system. This is done using a needle that’s placed into your spine, in a similar way to a lumbar puncture.

Side effects of intensive chemotherapy for acute myeloid leukemia are common. They can include:

• nausea
• vomiting
• diarrhea
• loss of appetite
• sore mouth and mouth ulcers (mucositis)
• tiredness
• skin rashes
• hair loss
• infertility – which may be temporary or permanent (see complications of acute myeloid leukemia for more information)

Most side effects should resolve once treatment has finished. Tell a member of your care team if side effects become particularly troublesome, as there are medicines that can help you cope better with certain side effects.

Non-intensive chemotherapy

If your doctors don’t think you’re fit enough to withstand the effects of intensive chemotherapy, they may recommend non-intensive treatment. This involves using an alternative type of chemotherapy to the standard intensive therapy, which is designed more to control leukaemia rather than cure it.

The main aim of this treatment is to control the level of cancerous cells in your body and limit any symptoms you have, while reducing your risk of experiencing significant side effects of treatment.

The medications used during non-intensive chemotherapy may be given through a drip into a vein, by mouth or by injection under the skin, and can often be given on an outpatient basis.

All Trans-Retinoic Acid (ATRA)

If you have the sub-type of acute myeloid leukemia known as acute promyelocytic leukaemia, you’ll usually be given capsules of a medicine called ATRA, in addition to chemotherapy.

ATRA works by changing the immature white blood cells (blast cells) into mature healthy cells, and can reduce symptoms very quickly.

Side effects of ATRA can include headaches, nausea, bone pain, and dry mouth, skin and eyes.

Consolidation therapy

If induction is successful, the next stage of treatment will be consolidation.

This often involves receiving regular injections of chemotherapy medication that are usually given on an outpatient basis, which means that you won’t have to stay in hospital overnight. However, you may need some short stays in hospital if your symptoms suddenly get worse or if you develop an infection.

The consolidation phase of treatment lasts several months.

Other treatments

Radiotherapy

Radiotherapy involves using high doses of controlled radiation to kill cancerous cells. There are two main reasons why radiotherapy is usually used to treat acute myeloid leukemia:

• to prepare the body for a bone marrow or stem cell transplant
• to treat advanced cases that have spread to the nervous system and/or brain, although this is uncommon

Side effects of radiotherapy can include hair loss, nausea and fatigue. The side effects should pass once your course of radiotherapy has been completed.

Bone marrow and stem cell transplants

If chemotherapy doesn’t work, a possible alternative treatment option is a bone marrow or stem cell transplant.

Before transplantation can take place, the person receiving the transplant will need to have intensive high-dose chemotherapy and possibly radiotherapy to destroy the cells in their bone marrow. The donated stem cells are given through a tube into a blood vessel, in a similar way to chemotherapy medication.

This process can put an enormous amount of strain on the body and cause significant side effects and potential complications, so you’ll usually need to stay in hospital for a few weeks.

Transplantations have better outcomes if the donor has the same tissue type as the person receiving the donation. The best candidate to provide a donation is usually a brother or sister with the same tissue type.

Transplantations are most successful when they’re carried out on children and young people, or older people who are otherwise in good health, and when there’s a suitable donor, such as a brother or sister.

Azacitidine

Azacitidine is a possible alternative treatment for adults with acute myeloid leukemia who can’t have a stem cell transplant.

It’s recommended by the National Institute for Health and Care Excellence (NICE) for use in certain circumstances – for example, depending on the characteristics of the person’s blood and bone marrow.

Azacitidine is a chemotherapy medication that’s given by injection under the skin. It interferes with the growth of cancer cells and destroys them, and also helps bone marrow to produce normal blood cells.

Alternative medicine

No alternative treatments have been found helpful in treating acute myelogenous leukemia. But some complementary and alternative treatments may relieve the symptoms you experience due to cancer or cancer treatment.

Alternative treatments that may help relieve symptoms include:

• Acupuncture
• Aromatherapy
• Massage
• Meditation
• Relaxation exercises

Coping and support

Acute myelogenous leukemia is an aggressive form of cancer that typically demands quick decision-making. That leaves people with a new diagnosis faced with important decisions about a disease they may not yet understand. Here are some tips for coping:

• Learn enough to make decisions about your care. The term “leukemia” can be confusing because it refers to a group of cancers that aren’t all that similar except for the fact that they affect the bone marrow and blood. You can waste a lot of time researching information that doesn’t apply to your kind of leukemia. To avoid that, ask your doctor to write down as much information about your specific disease as possible. Then narrow your search for information accordingly.
• Write down questions for your doctor before each appointment, and look for information in your local library and on the internet. Good sources include the National Cancer Institute (https://www.cancer.gov), the American Cancer Society (https://www.cancer.org/) and the Leukemia & Lymphoma Society (https://www.lls.org/).
• Lean on family and friends. It can be difficult to talk about your diagnosis, and you’ll likely get a range of reactions when you share the news. But talking about your diagnosis can be helpful. So can the outpouring of practical help that often results.
• Take care of yourself. It’s easy to get caught up in the tests, treatments and procedures of therapy. But it’s important to take care of yourself, not just the cancer. Try to make time for yoga, cooking or other favorite diversions.