The first 60 days: Acute myeloid leukaemia in older or unfit patients
Most people with acute myeloid leukaemia are over 65, and many cannot take intensive chemotherapy. Venetoclax with azacitidine, two gentler drugs, doubled remission rates and lengthened life in this group, replacing the old choice between supportive care and low-dose chemotherapy. Below, week by week, is what OnCo's record of Acute myeloid leukaemia in older or unfit patients says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Venetoclax plus azacitidine (VIALE-A) or venetoclax plus decitabine; ivosidenib plus azacitidine for IDH1-mutated disease; targeted triplets in trials.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- Medical oncologistNamed in the standard of care for: Newly diagnosed, unfit for intensive chemotherapy, Fit older patients, 60 to 75, Not a candidate for any leukaemia-directed therapy, Relapse after venetoclax-azacitidine.
- Transplant and cell therapy teamNamed in the standard of care for: Fit older patients, 60 to 75, Relapse after venetoclax-azacitidine.
- Palliative and supportive care teamNamed in the standard of care for: Not a candidate for any leukaemia-directed therapy.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
7+3 or CPX-351 for secondary disease, with a FLT3 inhibitor where indicated, and reduced-intensity allogeneic transplant in remission.
Hydroxyurea for count control, transfusion support and palliative care; low-dose cytarabine or glasdegib combinations where tolerated.
Genotype-directed drugs (gilteritinib, IDH inhibitors, menin inhibitors) or trials; transplant for the few who respond.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Performance status and geriatric assessment, Comorbidity index and organ function, ELN 2022 risk group, IDH1/2, NPM1, FLT3 and TP53 mutations, Measurable residual disease by flow cytometry), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Newly diagnosed AML unfit for intensive chemotherapy, AML in fit older patientseligible for intensive therapy or CPX-351, IDH- or NPM1-mutated AML in unfit patients.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Newly diagnosed, unfit for intensive chemotherapy
- For my situation (newly diagnosed, unfit for intensive chemotherapy), which of the standard options do you recommend and why?Guideline options include: Venetoclax plus azacitidine (VIALE-A) or venetoclax plus decitabine; ivosidenib plus azacitidine for IDH1-mutated disease; targeted triplets in trials.
- Am I a candidate for Venetoclax, Azacitidine, Decitabine or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of VIALE-A and AGILE apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Fit older patients, 60 to 75
- For my situation (fit older patients, 60 to 75), which of the standard options do you recommend and why?Guideline options include: 7+3 or CPX-351 for secondary disease, with a FLT3 inhibitor where indicated, and reduced-intensity allogeneic transplant in remission.
- Am I a candidate for Cytarabine + anthracycline ('7+3'), CPX-351 (liposomal daunorubicin-cytarabine), Midostaurin or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Not a candidate for any leukaemia-directed therapy
- For my situation (not a candidate for any leukaemia-directed therapy), which of the standard options do you recommend and why?Guideline options include: Hydroxyurea for count control, transfusion support and palliative care; low-dose cytarabine or glasdegib combinations where tolerated.
- Am I a candidate for Hydroxyurea (hydroxycarbamide), Glasdegib, Cytarabine, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Relapse after venetoclax-azacitidine
- For my situation (relapse after venetoclax-azacitidine), which of the standard options do you recommend and why?Guideline options include: Genotype-directed drugs (gilteritinib, IDH inhibitors, menin inhibitors) or trials; transplant for the few who respond.
- Am I a candidate for Gilteritinib, Ivosidenib, Revumenib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Venetoclax, Shorter venetoclax courses in unfit AML, myeloMATCH, G8 geriatric screening tool?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “How long venetoclax needs to be given, and whether MRD-negative patients can stop”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Whether fit older patients do better with venetoclax-azacitidine than with intensive chemotherapy”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Acute myeloid leukaemia in older or unfit patients: the full pageMost people with acute myeloid leukaemia are over 65, and many cannot take intensive chemotherapy. Venetoclax with azacitidine, two gentler drugs, doubled remission rates and lengthened life in this group, replacing the old choice between supportive care and low-dose chemotherapy.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Hypomethylating agents (azacitidine, decitabine): Low-intensity chemotherapy that strips chemical 'off' switches (methyl groups) from DNA so silenced genes can be read again.
- Tumour lysis syndrome (TLS): When a treatment kills cancer cells faster than the body can clear their contents, flooding the blood with potassium, phosphate and uric acid and injuring the kidneys and heart.
- ELN 2022 risk classification: The three-tier system (favourable, intermediate, adverse) that decides how aggressively an adult with AML is treated and whether a transplant is recommended.
Every term links to the glossary.