Overview

Leukaemia is cancer of the white blood cells. Acute leukaemia means it progresses quickly and aggressively, and usually requires immediate treatment.

Acute leukaemia is classified according to the type of white blood cells affected.

The 2 main types of white blood cells are:

• monocytes and granulocytes, which come from myeloid stem cells
• lymphocytes, which come from lymphoid stem cells

This topic focuses on acute myeloid leukaemia (AML), which is an aggressive cancer of the monocyte or granulocyte cells.

The following types of leukaemia are covered separately:

• acute lymphoblastic leukaemia
• chronic myeloid leukaemia
• chronic lymphocytic leukaemia

Symptoms of AML

The symptoms of AML usually develop over a few weeks and become worse over time.

Symptoms can include:

• looking pale or "washed out"
• feeling tired or weak
• breathlessness
• frequent infections
• unusual and frequent bruising or bleeding, such as bleeding gums or nosebleeds
• losing weight without trying to

Seeking medical advice

Speak to a GP if you or your child have possible symptoms of AML.

Although it's highly unlikely that leukaemia is the cause, these symptoms should be investigated.

If your GP thinks you may have leukaemia, they'll arrange blood tests to check your blood cell production.

If the tests suggest there's a problem, you'll be urgently referred to a specialist in treating blood conditions (haematologist) for further tests and treatment.

What causes AML?

It's not clear exactly what causes AML and, in most cases, there's no identifiable cause.

But some things can increase your risk of getting AML, including:

• previous chemotherapy or radiotherapy
• exposure to very high levels of radiation (including previous radiotherapy treatment)
• smoking and other exposure to benzene, a chemical used in manufacturing that's also found in cigarette smoke
• having a blood disorder or some genetic conditions, such as Down's syndrome

Who's affected

AML is a rare type of cancer, with around 3,100 people diagnosed with it each year in the UK.

The risk of developing AML increases with age. It's most common in people over 75.

How AML is treated

Treatment for AML needs to begin as soon as possible, as it can develop quickly.

Chemotherapy is the main treatment for AML. It's used to kill as many leukaemia cells in your body as possible and reduce the risk of the condition coming back (relapsing).

In some cases, intensive chemotherapy and radiotherapy may be needed, in combination with a bone marrow or stem cell transplant.

Help and support

There are organisations that offer information, advice and support if you or a family member has been diagnosed with AML.

These include:

• Leukaemia Care – you can also call their freephone helpline on 08088 010 444, or email support@leukaemiacare.org.uk
• Cancer Research UK
• Macmillan Cancer Support

Symptoms

The symptoms of acute myeloid leukaemia (AML) usually develop over a few weeks, becoming more severe as the number of immature white blood cells increases.

Symptoms of AML can include:

• skin looking pale or "washed out"
• tiredness
• breathlessness
• losing weight without trying
• frequent infections
• having a high temperature, and feeling hot or shivery (fever)
• night sweats
• unusual and frequent bleeding, such as bleeding gums or nosebleeds
• easily bruised skin
• flat red or purple spots on the skin
• bone and joint pain
• a feeling of fullness or discomfort in your tummy
• swollen glands in your neck, armpit or groin that may be sore when you touch them

When to seek medical advice

See a GP if you or your child have the symptoms of AML.

Although it's highly unlikely that AML is the cause, these symptoms need to be investigated and treated promptly.

Who can get it

It's not clear what causes acute myeloid leukaemia (AML), but the myeloid stem cells produce more white blood cells than are needed.

The white blood cells produced are still immature, so they do not have the infection-fighting properties of fully developed white blood cells.

As the number of immature cells increases, the amount of healthy red blood cells and platelets decrease, and it's this fall that causes many of the symptoms of leukaemia.

Increased risk

It's not known what triggers the genetic mutation in AML, although a number of different things can increase your risk of developing the condition.

Radiation exposure

Being exposed to a significant level of radiation can increase your chances of developing AML, although this usually requires exposure at very high levels.

In the UK, most people are unlikely to be exposed to levels of radiation high enough to cause AML. 

But some people who have had radiotherapy as part of a previous cancer treatment may have a bigger chance of getting AML.

Benzene and smoking

Exposure to the chemical benzene is a known risk factor for AML in adults.

Benzene is found in petrol, and it's also used in the rubber industry, although there are strict controls to protect people from prolonged exposure.

Benzene is also found in cigarette smoke, which could explain why people who smoke have an increased risk of developing AML.

Previous cancer treatment

Treatment with radiotherapy and certain chemotherapy medicines for an earlier, unrelated cancer can increase your risk of developing AML many years later.

Blood disorders

People with certain blood disorders, such as myelodysplasia, myelofibrosis or polycythaemia vera, have an increased risk of developing AML.

Genetic disorders

People with certain genetic conditions, including Down's syndrome and Fanconi's anaemia, have an increased risk of developing leukaemia.

Diagnosis

In the initial stages of diagnosing acute myeloid leukaemia (AML), your GP will check for physical signs of the condition and arrange for you to have blood tests.

A high number of abnormal white blood cells, or a very low blood count in the test sample, could indicate leukaemia.

If this is the case, you'll be urgently referred to a a specialist in treating blood conditions (haematologist).

A haematologist may carry out further tests.

Bone marrow biopsy

To confirm a diagnosis of AML, a small sample of your bone marrow will be taken to examine under a microscope. This procedure is known as a bone marrow biopsy. 

The doctor or nurse will numb an area of skin at the back of your hip bone, before using a thin needle to remove a sample of liquid bone marrow.

In some cases, they'll remove some liquid bone marrow and a thin piece of bone marrow together.

You will not feel any pain during the procedure, but it can feel uncomfortable when the sample is being taken.

You may also have bruising and discomfort for a few days afterwards.

The procedure takes around 20 to 30 minutes.

The bone marrow sample will be checked for cancerous cells. If cancerous cells are present, the biopsy can also be used to determine the type of leukaemia you have.

Further tests

Other tests can be used to get more information about the progress and extent of your AML. They can also help decide how it should be treated.

Genetic testing

Genetic tests can be carried out on blood and bone marrow samples to find out what type of AML you have. This can help doctors make decisions about the most appropriate treatment.

Chest X-ray

If you have AML, a chest  X-ray may be used to check that your heart and lungs, are healthy.

These tests help doctors assess your general health before they decide on the most appropriate treatment for you.

Lumbar puncture

In rare situations where it's thought there's a risk that AML has spread to your nervous system, a lumbar puncture may be carried out.

In this procedure, a needle is used to extract a sample of the fluid that surrounds and protects your spine (cerebrospinal fluid) so it can be checked for cancerous cells.

If cancerous cells are found in your nervous system, it may affect your treatment.

Coping with your diagnosis

Being diagnosed with AML can be particularly difficult, as the condition usually comes on suddenly and treatment has to be started quickly.

This can be upsetting and confusing. But finding out what type of leukaemia you have, what treatment you need and how treatment will affect you can help you cope better and feel more in control.

There is more information and advice about coping with AML on Cancer Research UK.

Treatment

Acute myeloid leukaemia (AML) is an aggressive cancer that grows quickly, so treatment will usually begin a few days after a diagnosis has been confirmed.

As AML is a complex condition, it's usually treated by a group of different specialists working together called a multidisciplinary team (MDT).

Your treatment plan

Treatment for AML is often carried out in 2 stages:

• induction – this first stage of treatment aims to kill as many leukaemia cells in your blood and bone marrow as possible and treat any symptoms you may have
• consolidation – this stage aims to prevent the cancer coming back (relapsing) by killing any remaining leukaemia cells in your body

The induction stage of treatment is not always successful and sometimes needs to be repeated before consolidation can begin.

If you're thought to have a high risk of experiencing complications of AML treatment (for example, if you're over 75 or have another underlying health condition), less intensive chemotherapy treatment may be carried out.

Your doctors will watch you carefully and suggest other treatments if needed.

Induction

The initial treatment you have for AML 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 be given chemotherapy medication at a high dose to kill the cancerous cells in your blood and bone marrow.

You'll usually be given a combination of 2 or more chemotherapy medicines.

Most people have 2 rounds of induction chemotherapy.

The treatment will be carried out in hospital or in a specialist centre, as you'll need very close medical and nursing supervision.

You may be able to go home between treatment rounds.

You'll have regular blood transfusions because your blood will not 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 treated quickly.

You may also be prescribed antibiotics to help prevent infections.

For intensive treatment, the chemotherapy medications will be injected into a thin tube that's inserted either into a blood vessel near your heart or into your arm.

Side effects of intensive chemotherapy for AML are common.

They can include: 

• feeling or being sick
• bruising or bleeding easily
• diarrhoea
• loss of appetite
• sore mouth and mouth ulcers (mucositis)
• tiredness
• skin rashes
• hair loss
• infertility – this may be temporary or permanent

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 do not 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.

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.

Other drugs

If you have the type of AML known as acute promyelocytic leukaemia, you'll usually be given other drugs as well as having chemotherapy.

The 2 drugs most commonly used are:

• all tans retinoic acid (ATRA) – usually given during and after induction chemotherapy, it changes immature white blood cells into healthy mature cells, and can reduce symptoms quickly
• arsenic trioxide – usually given if the AML has come back, it speeds up the death of leukaemia cells and changes the immature blood cells into healthy mature cells

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

Consolidation

If there's no AML left after induction chemotherapy, the next stage of treatment is consolidation.

This often involves receiving regular injections of chemotherapy medication that are usually given in hospital.

The consolidation phase of treatment lasts several months.

Other treatments

Radiotherapy

Radiotherapy involves using high doses of controlled radiation to kill cancerous cells.

It's used to:

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

Side effects of radiotherapy can include hair loss, nausea and fatigue.

Most of the side effects should pass once your course of radiotherapy has been completed.

Bone marrow and stem cell transplants

If the treatment is not working or there's a high chance of your leukaemia coming back, you may be offered a bone marrow or stem cell transplant.

Before transplantation can take place, the person receiving the transplant will need intensive high-dose chemotherapy, and possibly radiotherapy, to destroy the cells in their bone marrow.

You may be given donated stem cells or you may have a transplant of your own stem cells. The stem cells are given through a tube into a blood vessel (a drip) in a similar way to chemotherapy medicine.

You'll need to stay in hospital for a few weeks after the transplant, usually in a room on your own, because you'll have a high chance of getting infections.

Your friends and family should be able to visit you, but they'll need to wear protective clothing.

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.

Targeted medicines

You may be offered targeted medicines if you have certain types of AML. Targeted medicines affect the way cancer cells grow.

Some targeted medicines come as tablets and others are given through a drip into your vein.

Adults recently diagnosed with AML may be offered a combination of venetoclax and low-dose cytarabine, if intensive chemotherapy is not suitable.

Your specialist can discuss with you whether targeted treatment is suitable for you.

Clinical trials and newer unlicensed treatments

In the UK, a number of clinical trials are currently underway that aim to find the best way of treating AML.

Clinical trials are studies that use new and experimental techniques to see how well they work in treating, and possibly curing, AML.

As part of your treatment, your care team may suggest taking part in a clinical trial to help researchers learn more about the best way to treat your AML, and AML in general.

Find a clinical trial for acute myeloid leukaemia on Cancer Research UK

If you take part in a clinical trial, you may be offered medicine that's not licensed for use in the UK and is not normally available.

But there's no guarantee that the techniques being studied in the clinical trial will work better than current treatments.

Your care team can tell you whether there are any clinical trials available in your area, and can explain the benefits and risks involved.

A treatment team for AML may include a:

• haematologist (blood cancer specialist)
• haemato-pathologist (specialist in the study of cancerous blood cells)
• paediatrician (specialist in treating children)
• cancer nurse specialist (sometimes called a CNS), who will be the first point of contact between you and the members of your care team
• radiologist (specialist in X-rays and scans)
• pharmacist
• social worker
• psychologist
• counsellor

Complications

If you have acute myeloid leukaemia (AML), you may experience 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 is a common complication of AML.

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

This means you're more vulnerable to developing an infection, and any infection could be more serious than usual.

Complications arising from infection are very common in people with AML. But if treated early, nearly all infections respond to appropriate treatment.

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 GP to ensure that your vaccinations are up to date - you will not be able to have any vaccine containing "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, as prompt treatment may be required to prevent complications.

Symptoms of an infection can include:

• a sore throat
• a high temperature, and feeling hot or shivery (fever)
• flu-like symptoms, such as headaches, aching muscles and tiredness
• breathlessness or a cough
• pain when peeing

Bleeding

If you have AML, you might bleed and bruise more easily because of the low levels of platelets (clot-forming cells) in your blood. Bleeding may also be excessive.

People with advanced AML are more vulnerable to excessive bleeding inside their body.

Serious bleeding can occur:

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

All these types of haemorrhage should be regarded as a medical emergency.

Dial 999 immediately and ask for an ambulance if you think a haemorrhage is occurring.

Infertility

Most treatments used to treat AML 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 talk to you about the risk of infertility in your specific circumstances and discuss any fertility options before you begin your treatment.