Acute Myelogenous Leukemia (AML) Treatment in India

Acute Myelogenous Leukemia (AML) is a rapidly progressing cancer of the bone marrow and blood that affects the production of normal white blood cells. It requires prompt, aggressive treatment through chemotherapy, targeted therapy, and in some cases, bone marrow transplantation. India has emerged as a leading destination for AML care due to its advanced hematology centers, expert oncologists, and cost-effectiveness.

The total cost of AML treatment in India typically ranges from $8,000 to $40,000, making it up to 80–90% more affordable compared to the USA and Europe, without compromising on quality.

What is Acute Myelogenous Leukemia?

Acute Myelogenous Leukemia (AML) is a fast-growing cancer of the bone marrow and blood, where abnormal myeloid cells multiply rapidly and interfere with the production of normal blood cells. AML progresses quickly and requires immediate treatment.

Causes of AML

The exact cause of AML is not always clear, but several risk factors and genetic mutations have been identified that can increase the likelihood of developing this disease:

• Genetic Mutations: Specific mutations in genes such as FLT3, NPM1, and IDH1/2 can lead to the development of AML. These mutations affect the regulation and proliferation of blood cells.
• Previous Cancer Treatments: Chemotherapy and radiation therapy for other cancers can increase the risk of developing therapy-related AML.
• Exposure to Chemicals: Long-term exposure to certain chemicals, such as benzene, can increase the risk.
• Genetic Disorders: Conditions like Down syndrome, Bloom syndrome, and Fanconi anemia are associated with a higher risk of AML.
• Myelodysplastic Syndromes: These are a group of disorders caused by poorly formed or dysfunctional blood cells, which can sometimes progress to AML.

What are the Types of AML?

There are several subtypes of AML, each with distinct characteristics and treatment implications:

What is the Diagnosis of AML?

Blood Tests:

• Complete Blood Count (CBC): To check for abnormal white blood cell counts, hemoglobin, and platelets.
• Peripheral Blood Smear: Examines the shape and size of blood cells, looking for myeloblasts.
• Bone Marrow Biopsy: To confirm the diagnosis and determine the level of bone marrow involvement.
• Cytogenetic Testing: Identifies specific genetic mutations or abnormalities that can affect treatment plans (e.g., FLT3, CEBPA, IDH1, IDH2, and others).
• Flow Cytometry and Molecular Testing: To identify the types of leukemia cells and further refine the diagnosis.

Treatment Goals:

• Induction Therapy: Achieve remission by reducing leukemia cells to undetectable levels.
• Consolidation Therapy: To eliminate remaining leukemia cells and reduce the risk of relapse.
• Maintenance Therapy: Prevent relapse by eradicating minimal residual disease (MRD).

Induction Therapy (First-Line Treatment):

The primary goal of induction therapy is to achieve complete remission (CR). It typically consists of a combination of chemotherapy agents:

• Standard Chemotherapy Regimen:
  • 7 + 3 Protocol:
    • Cytarabine (Ara-C): Administered intravenously for 7 days.
    • Anthracyclines (e.g., Daunorubicin or Idarubicin): Administered for the first 3 days.
  • Alternatives for high-risk subtypes (e.g., FLT3 mutations): May involve adding targeted therapies, such as Midostaurin or Gilteritinib, for FLT3 mutations.
• Targeted Therapy: For patients with specific genetic mutations, additional targeted therapy may be added (e.g., IDH inhibitors like Enasidenib or Ivosidenib for IDH1 or IDH2 mutations).
• Aims: To induce remission by eliminating the leukemia blasts in the bone marrow.

Consolidation Therapy:

After achieving remission with induction therapy, consolidation therapy is used to solidify the remission and reduce the chance of relapse.

• Chemotherapy: High-dose chemotherapy with cytarabine (HiDAC) is the standard consolidation therapy after remission is achieved.
  • Cytarabine (HiDAC): 3-4 courses are usually given, with doses ranging from 1-3 grams/m².
• Stem Cell/Bone Marrow Transplant (SCT): In high-risk or relapsed cases, an allogeneic stem cell transplant may be considered to prevent relapse, especially for patients with poor prognostic factors.
  • Allogeneic Stem Cell Transplant: Considered if there is a high risk of relapse, such as in patients with certain genetic mutations (e.g., FLT3-ITD, complex karyotype).
  • Autologous Stem Cell Transplant: Less commonly used but may be an option in specific cases.

Maintenance Therapy:

• Low-Dose Chemotherapy: In some cases, low-dose chemotherapy may be used as maintenance therapy, though this is not always part of the standard protocol for AML.
• Targeted Therapy: For patients with specific mutations, maintenance therapy with targeted agents may be continued.
  • IDH Inhibitors (Enasidenib or Ivosidenib): For patients with IDH mutations.
  • FLT3 Inhibitors (Midostaurin, Gilteritinib): For FLT3-mutated AML.

Supportive Care:

• Blood Transfusions: Red blood cell and platelet transfusions to manage anemia and thrombocytopenia.
• Antibiotics and Antifungals: To prevent or treat infections, as patients with AML have low immunity.
• Growth Factors (e.g., G-CSF): May be used to stimulate the bone marrow to produce white blood cells and reduce the risk of infection during treatment.
• Hydration: For patients receiving high-dose chemotherapy or cytarabine, to prevent kidney damage.

Targeted and Novel Therapies:

For patients with specific genetic mutations, newer therapies may be utilized to improve outcomes:

• FLT3 Inhibitors:
  • Midostaurin: Approved for newly diagnosed AML with FLT3 mutations.
  • Gilteritinib: Used for relapsed or refractory AML with FLT3 mutations.
• IDH Inhibitors:
  • Enasidenib (IDH2 inhibitor): For patients with IDH2 mutations.
  • Ivosidenib (IDH1 inhibitor): For patients with IDH1 mutations.
• BCL2 Inhibitors: Venetoclax is used in combination with other agents (e.g., hypomethylating agents) for older patients or those unfit for intensive chemotherapy.

Stem Cell Transplantation:

For patients with high-risk disease or relapsed AML:

• Indications: High-risk genetic mutations (e.g., FLT3-ITD), poor response to chemotherapy, or secondary AML.
• Types of Transplant:
  • Allogeneic Stem Cell Transplant: Preferred for patients with high-risk features or relapse.
  • Autologous Stem Cell Transplant: Considered in specific scenarios.
• Risks: Graft-versus-host disease (GVHD), infection, and relapse post-transplant.

Relapse Treatment:

If AML relapses after initial therapy, the treatment approach involves:

• Salvage Chemotherapy: Using different combinations of chemotherapy drugs to induce remission again.
• Stem Cell Transplant: A second transplant may be considered if the patient relapses after a previous transplant.

Symptoms of AML

The symptoms of AML are often nonspecific and can be mistaken for other common illnesses. They include:

• Easy Bruising or Bleeding: Due to a low platelet count.
• Fever: Often a sign of infection.
• Shortness of Breath: Caused by anemia or an enlarged spleen.
• Pale Skin: Resulting from anemia.
• Unexplained Weight Loss: Often associated with cancer.
• Bone or Joint Pain: Caused by the buildup of abnormal cells in the bone marrow.

Acute Myelogenous Leukemia (AML) Treatment Cost Comparison

The total cost of Acute Myelogenous Leukemia (AML) treatment in India ranges from $8,000 to $40,000, depending on factors like chemotherapy intensity, targeted therapy, and whether a bone marrow transplant is required.

Recovery Period After AML Treatment

The recovery timeline for AML varies depending on the treatment phase and whether a bone marrow transplant (BMT) is involved. Here's a structured breakdown:

Summary:

• Short-term recovery (blood counts, fatigue): 1–3 months
• Long-term recovery (immune system, full strength): 6–12 months
• Frequent follow-ups (bone marrow tests, MRD testing): Ongoing for 1–3 years