This document discusses treatment and supportive care for a patient with acute myeloid leukemia (AML) that developed after myelodysplastic syndrome (MDS). It provides details on the patient's history, diagnostic testing results showing the presence of AML, and an overview of AML including typical treatment approaches. The document outlines the patient's induction therapy of 7+3 chemotherapy and supportive medications. It also reviews guidelines for post-remission treatment and monitoring, as well as approaches for relapse.

1. Treatment of Acute Myeloid
Leukemia that develops after
Myelodysplastic Syndrome &
Supportive Care
Joseph Helms
Wingate University School of Pharmacy
Oncology Rotation
Novant Health Presbyterian Medical Center

2. Objectives
1. List pertinent patient information
2. Describe the definition, clinical presentation, pathophysiology, risk
factors, and staging/diagnosis of Acute Myeloid Leukemia
3. Discuss most recent guidelines and primary literature relating to
Acute Myeloid Leukemia
4. Discuss supportive care and treatment of Acute Myeloid Leukemia

3. What is Acute Myeloid Leukemia?
• Acute form of Myeloid Leukemia
• Can occur as a result of Myelodysplastic Syndrome (MDS may develop into AML)
• Uncontrolled growth of blasts in the bone; “crowds” the bone marrow
• In general, treatment based on if < or > 60 years of age
• Diagnosed usually in the elderly
• Classic treatment: “7+3”
• Cytarabine + anthracycline (often daunorubicin)
• HiDAC is the high dose form
• Elderly patients may have trouble tolerating regimen
• Difference between AML and MDS? Hypercellular vs. Hypocellular
• Difference between AML and ALL? CD13, CD34, and CD117
• Difference between AML and APL? Subtype of AML and many pre-myelocytes

4. Patient Case
• CC: Was diagnosed with AML after admission; Neutropenia fever, Pancytopenia, Fatigue
• HPI: Nausea & Vomiting for 2 weeks, Weight loss
• Admit Date: 8/27/16
• PMH:
• Hypertension
• Dyslipidemia
• Hypercalciuria
• Allergies: losartan, lisinopril, cyclobenzaprine, pravastatin, simvastatin, ezitimibe
• Family History: Breast Cancer (Daughter)
• Social History: Former smoker (Quit 2007; pack years not listed)
• BMI: 19.61 kg/m^2
• No ECOG score or PPS2 recorded

5. Patient: Bone Marrow Aspirate and Biopsy
• Deletions at chromosomes 5 and 17 (5 and 7: not a favorable
outcome)
• CSF1R/RPS14 on Chromosome 5 (42%)
• Bone Marrow Aspirate: 30% blasts
• Bone Marrow Biopsy: Hypercellular (70%); higher number of blasts
• Know it’s Acute Myeloid Leukemia vs. Acute Lymphocytic Leukemia,
because tested positive for CD13, CD34, CD117, HLA-DR, CD-45,
CD71, CD38, and MPO
• No Auer Rods Were Noted

6. Patient Case: Home Medications
• Amlodipine besylate 5 mg tablet daily
• Aspirin 81 mg tablet daily
• Lovastatin 20 mg tablet daily
• Mometasone 0.1% ointment
• Vitamin D3 5000U tablets daily
• Zolpidem tartrate 10 mg tablet

7. Patient Case: Admission Vitals and Labs
_________________________ 102
4.3 25 1.1
146 104 14
Vital
Measured
Value
Temp 97.9-101
HR 82
RR 16
BP 100/60
SpO2 Sat % 96%

8. Definitions
• Induction therapy- first treatment in cancer therapy with goal of sending the patient into
remission
• Consolidation therapy- after induction therapy; agents may be different from those used in
induction therapy; goals: prevent disease from recurring
• Complete Remission:
• No Auer rods
• Bone Marrow blasts <5%
• ANC> 1,000/mcl
• Platelets > 100,000/mcl
• Partial Remission:
• 50% reduction in blasts to within the 5-25%
• ANC> 1000/mcl
• Platelets> 100,000/mcl
• Evidence of disease (residual) outside of the bone marrow
• Treatment Failure:
• Complete Response not achieved

9. Epidemiology of AML & MDS
• There has been an increase in MDS as the elderly population has
increased in number
• Incidence is 3.5 per 100,000 per year
• Incidence is higher in men than in women
• <65: incidence of 1.7
• >65: incidence of 15.9
Marcucci G, Bloomfield CD. Acute Myeloid Leukemia. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine [Internet]. 19 e New York (NY):
McGraw-Hill; c2015. Chapter 132. [cited 2016 September 13]. [Incidence]; AccessMedicine. Available from:
http://accessmedicine.mhmedical.com/content.aspx?sectionid=79731765&bookid=1130&Resultclick=2

10. Clinical Presentation of AML
Fatigue Headache
Anorexia Sweating
Weight Loss Bone Pain
Bleeding/Bruising Anemia (often normocytic); low RBCs, low
platelets (thrombocytopenia) ; platelets
adherence properties may change
Fever & Infection WBC:
25-40% < 5000/microliter,
20% >100,000/microliter
Median: 15,000/microliter
Lymphadenopathy Elevated Uric Acid
Cough
Marcucci G, Bloomfield CD. Acute Myeloid Leukemia. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine [Internet]. 19 e New York (NY): McGraw-Hill; c2015.
Chapter 132. [cited 2016 September 13]. [Hematologic Findings]. AccessMedicine. Available from: http://accessmedicine.mhmedical.com/content.aspx?sectionid=79731765&bookid=1130&Resultclick=2

11. Pathophysiology of AML
http://www.cancer.gov/images/cdr/live/CDR526538.jpg
National Cancer Institute. Cancer.gov [Internet]. National Cancer Institute (NIH); c.2015.
Cancer Types: Acute Myeloid Leukemia Treatment-Patient Version; 2016 [cited 2016
September 13]; [Leukemia May Affect Red Blood Cells, White Blood Cells and Platelets].
Available from: https://www.cancer.gov/images/cdr/live/CDR526219.jpg
• Mutations of cells cause
myeloblast to not mature
• Bone Marrow gets
“crowded” with blasts
• Begin to see immature blasts
in the cells

12. Risk Factors of AML
AML:
• Anticancer agents
• Alkylating Agents: 4-6 years after exposure; chromosomes 5 & 7
• Topoisomerase II Inhibitors: 1-3 years after exposure; chromosome 11q23
• Anthracyclines
• Others: Benzene, Chloramphenicol, phenylbutazone, chloroquine, and methoxypsoralen
• Age> 65: disease becomes more resistant as age
• Men>Female
• Previous Cancer History
• Down’s Syndrome
• Radiation (high dose or with use of alkylating agents), Chemicals (Ethylene),
Smoking

13. Diagnosis of AML
Tests: Bone Marrow Aspiration, Bone Marrow Biopsy, Peripheral Blood Smear for diagnosis, and to monitor response to
treatment
• Usually performed on the hip (pelvic bone)
• Not as Commonly Used: Lumbar puncture (if suspect spread to CNS)
• Peripheral Blood Smear tells you if blood cells changing in numbers or in profile
MDS:
• Low RBCs, <20% blasts, and may have low WBC and platelets; may have anemia
• May want to rule out Vitamin B12, Folate deficiency, or other causes of decreased blood cells
AML:
• Not listed in NCCN Guidelines
• Generally known to be the following:
• >20% blasts
• Auer Rods
• Cells turn black with AML
• Cytochemistry
American Cancer Society [Internet]. Atlanta Georgia: American Cancer Society/Cancer.org. c. 2016. How is Acute Myeloid Leukemia Diagnosed?; 2016 February 22 [cited 2016 September 13]; [Complete Blood Cell Count and Peripheral Blood
Smear; Cytochemistry]. Available from: http://www.cancer.org/cancer/leukemia-acutemyeloidaml/detailedguide/leukemia-acute-myeloid-myelogenous-diagnosed

14. Prognostic Factors of Remission for AML
• Chromosomes: Most Important Prognostic Factor:
• Good Impact on Prognosis: NPM1 mutations (5q35. 1), CEBPA mutations (19q13. 1),
and miR-181a overexpression (1q32. 1 and 9q33.3)
• Bad Impact on Prognosis: FLT3-ITD (13q12), KIT mutation (4q12), FLT3-TKD (13q12),
RUXN1 mutations (21q22. 12), WT1 mutations (11p13), ASXL1 mutations (20q11.
21), DNMT3A mutations (2p23. 3), IDH mutations (IDH 1 and IDH 2) (2q34 & 15q26.
1), MLL-PTD (11q23), TET2 mutations (4q24), BAALC overexpression (8q22. 3), ERG
overexpression (21q22. 3), MN1 overexpression (22q12. 1), EV1 overexpression
(3q26.2), miR-155 overexpression (21q21.3), and miR-3151 (8q22.3)
• If achieve Complete Remission after one cycle, the patient is more likely to
have a longer complete remission than a patient requiring multiple cycles
Marcucci G, Bloomfield CD. Acute Myeloid Leukemia. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine [Internet]. 19 e New York (N:
http://accessmedicine.mhmedical.com/ViewLarge.aspx?figid=98711279&gbosContainerID=0&gbosid=0Y): McGraw-Hill; c2015. Chapter 132. [cited 2016 September 13]. [Table 132-3: Molecular Prognostic Markers in AML]. AccessMedicine. Available
from: http://accessmedicine.mhmedical.com/ViewLarge.aspx?figid=98711279&gbosContainerID=0&gbosid=0

15. Prognostic Factors (con’t)
• Poor performance status
• High leukocyte count
• If obtain Complete Remission after first induction cycle, more likely to
have longer duration of Complete Remission

16. Treatment Induction of AML: NCCN
Guidelines
O’Donnell MR, Tallman MS, Abboud CN, Altman JK, Appelbaum FR, Arber DA, Bixby D, Blum W, Borate U, Coutre SE, Lima MD, Fathi AT, Foran JM, Gore SD, Lancet J, Maness LJ, Maricucci G, Martin ME, Martin, MG, Moore JO, Olin R, Pollyea DA, Pratz K, Ravandi-
Kashani F, Shamji PJ, Stone RM, Strickland SA, Wang ES, Weiduwilt M. NCCN Clinical Practical Guidelines in Oncology: Acute Myeloid Leukdemia. NCCN Guidelines [Internet]. 2016. [cited 2016 September 13]: Title Page- MS-73, , Treatment Induction, AML mm,lllI
> 60, (AML-11). Available from: https://www.nccn.org/professionals/physician_gls/pdf/aml.pdf

17. Treatment Post-Remission
O’Donnell MR, Tallman MS, Abboud CN, Altman JK, Appelbaum FR, Arber DA, Bixby D, Blum W, Borate U, Coutre SE, Lima MD, Fathi AT, Foran JM, Gore SD, Lancet J, Maness LJ, Maricucci G, Martin ME, Martin, MG, Moore JO, Olin R, Pollyea DA, Pratz K, Ravandi-
Kashani F, Shamji PJ, Stone RM, Strickland SA, Wang ES, Weiduwilt M. NCCN Clinical Practical Guidelines in Oncology: Acute Myeloid Leukdemia. NCCN Guidelines [Internet]. 2016. [cited 2016 September 13]: Title Page- MS-73, AML Post-Remission Therapy: Age >
60 y: (AML-13). Available from: https://www.nccn.org/professionals/physician_gls/pdf/aml.pdf

18. Relapse Treatment/Monitoring (In General)
Relapse Treatment: If had remission
1. Clinical Trial
2. Chemotherapy----- RIC
(Reduced Intensity
Conditioning) allogeneic HCT
(only if in remission)
3. If initial induction regimen was
effective for patient for a
prolonged initial remission (>12
months), then can re-try the
regimen
4. Supportive Care
5. Lower dose of cytarabine
Monitoring: In General
• CBC with platelets 1-3 months for 2
years, then 3-6 months up to 5 years
• Will be at least 12 weeks before get a
bone marrow with decitabine; for
surveillance guidelines recommend
bone marrow biopsy/aspirate if
peripheral smeer is abnormal or
cytopenias develop
• Bone marrow donor search
O’Donnell MR, Tallman MS, Abboud CN, Altman JK, Appelbaum FR, Arber DA, Bixby D, Blum W, Borate U, Coutre SE, Lima MD, Fathi AT, Foran JM, Gore SD, Lancet J, Maness LJ, Maricucci G, Martin ME, Martin, MG, Moore JO, Olin
R, Pollyea DA, Pratz K, Ravandi-Kashani F, Shamji PJ, Stone RM, Strickland SA, Wang ES, Weiduwilt M. NCCN Clinical Practical Guidelines in Oncology: Acute Myeloid Leukdemia. NCCN Guidelines [Internet]. 2016. [cited 2016
September 13]: Title Page- MS-73, Surveillance vvv (After Completion of Consolidation): (AML-14). Available from: https://www.nccn.org/professionals/physician_gls/pdf/aml.pdf

19. Supportive Care
• Bacterial Prophlyaxis: Fluoroquinolone
• Fungal Prophylaxis: Posaconazole
• Voriconazole better if used for treatment, though guidelines say equivalent
• Viral Prophylaxis: acyclovir (HSV, VZV), famciclovir (HSV, VZV),
ganciclovir (HSV, VZV, CMV, HHV-6)
• Hydration to prevent crystal nephropathy; has renal adjustments
• Famciclovir has no data for viral prophylaxis in oncology
• Ganciclovir may cause myelosuppression
Baden LR, Sankar S, Angarone M, Blouin G, Camins B, Casper C, Cooper B, Dubberke ER, Morris A, Freifeld AG, Greene JN, Ito JI, Kaul DR, Lustberg ME, Montoya JG, Rolston K, Satyanarayana G, Segal B, Seo S, Shoham S, Taplitz R, Topal J, Wilson JW. NCCN
Clinical Practice Guidelines in Oncology (NCCN Guidelines): Prevention and Treatment of Cancer-Related Infections. NCCN Guidelines [Internet]. 2016. [cited 2016 September 13]. Title page- MS 114, Prevention of Herpes Simplex Virus and Varicella Zoster
Virus (VZV) Reactivation or Disease, (INF-3). Available from: https://www.nccn.org/professionals/physician_gls/pdf/infections.pdf

20. Supportive Care (Con’t)
• Tumor Lysis Syndrome Prophylaxis: Not needed unless stronger
chemo agents
• Hydration
• Diuresis
• Rasburicase or Allopurinol
• Would Consider Rasburicase: Hyperuricemia, poor renal function, high percentage of
blasts
• Do not need to alkalinize urine (can cause Calcium Phosphate precipitation due to
hyperphosphatemia)
• Growth Factors:
• Do Not Use in AML

21. General Toxicities of All Chemotherapy
• Chemotherapies in general target the rapidly dividing
cells of the body which explain the following toxicities:
• Myelosuppression
• Nausea and Vomiting
• GI toxicity
• Diarrhea
• Alopecia
• Nails may fall off

22. Decitabine (Dacogen)
• Uses:
• FDA: Myelodysplastic Syndrome
• Off-Label: AML
• Renal Adjustments: No renal adjustments except during treatment
when SCr >2 mg/dL (hold until SCr resolves)
• Hepatic Adjustments: No hepatic adjustments except when ALT or
Bilirubin >2 ULN during treatment
• Blood: ANC < 1000/mm^3 and platelets <50,000, reduce or give dose
later

23. Decitabine (Dacogen) (con’t)
• Dosed off of Body Surface Area (BSA)
• 20 mg/m2/day days 1-5 for one hour infusion
• MOA: Hypomethylating agent
• Time to Effect: 3-4 cycles before see response
• Given Every 28 days
• Metabolism: cytidine deaminase (possibly)
• Half-life elimination: approximately 30 minutes
• Cost: ~$2,000 for 50 mg vial (IV)

24. Adverse Effects of Cytarabine + Anthracycline
(Daunorubin, Idarubicin) vs. Decitabine
• Cytarabine: Conjunctivitis, “hand-foot” syndrome, neurologic toxicity
• Anthracyclines:
• Cardiotoxicity: dose-related; becomes irreversible at 300-500 mg/m^2 (450
mg/m^2 is usually limit); monitor left ventricular ejection fraction with EKG;
permanent; usually takes 5-10 years to develop
• Vesicant
• Infertility
• Secondary AML and MDS

25. Bone Marrow Transplant
• HLA typing should be done at diagnosis
• Usually bone marrow transplants done in younger patients
• Donor needed; does not have to be a family member
• RIC (Reduced Intensity Conditioning) allogeneic for >60 years of age:
• Option especially for patients with first complete remission, and few other
disease states
• 1.) If in Complete Remission as post-remission therapy
• 2.) Failed induction: Only in clinical trials, and must not have a large quantity
of disease

26. Primary Literature
Kantarjan HM, Thomas XG, Dmoszynska A, Wierbowska A, Mazur G,
Mayer J, Gau J-P, Chou W-C, Buckstein R, Cermak J, Kuo C-Y, Oriol A,
Ravandi F, Faderl S, Delauny J, Lysak D, Minden M, Arthur A.
Multicenter, Randomized, Open-Label, Phase III trial of Decitabine
Versus Patient Choice, With Physician Advice, of Either Supportive Care
or Low-Dose Cytarabine for the Treatment of Older Patients with Newly
Diagnosed Acute Myeloid Leukemia. Journal of Clinical Oncology
[Internet]. 2012 July 20 [cited 2016 September 13]; 30(21): 2670-2677.
Available from: http://jco.ascopubs.org/content/30/21/2670.long

27. Primary Literature
• Multi-center, randomized, open label
• Phase III, Alpha 0.05, Power: 80%
• Enrollment: 485 patients > 65 were assigned in 1:1 ratio; 28 patients in supportive care
• Patients were intermediate or high risk
• Treatment groups: decitabine vs. (Treatment choice: cytarabine or supportive care)
• Primary Endpoint: Kaplan Meier Curve
• Overall Survival: decitabine 7.7 months vs. Treatment choice 5.0 months
• Non-significant difference in overall survival: P=0.108
• Secondary Endpoint: Logistic Regression
• Complete Remission plus Complete Remission without plate recovery (>100,000 platelets wasn’t
required): decitabine 17.8% vs. Treatment choice 7.8%
• Safety: Thrombocytopenia: decitabine 40% vs. cytarabine 35%, anemia: decitabine 34%
vs. cytarabine 27%, febrile neutropenia: decitabine 24% vs. cytarabine 16%
Kantarjan HM, Thomas XG, Dmoszynska A, Wierbowska A, Mazur G, Mayer J, Gau J-P, Chou W-C, Buckstein R, Cermak J, Kuo C-Y, Oriol A, Ravandi F, Faderl S, Delauny J, Lysak D, Minden M, Arthur A. Multicenter, Randomized, Open-Label, Phase III trial of
Decitabine Versus Patient Choice, With Physician Advice, of Either Supportive Care or Low-Dose Cytarabine for the Treatment of Older Patients with Newly Diagnosed Acute Myeloid Leukemia. Journal of Clinical Oncology [Internet]. 2012 July 20 [cited 2016
September 13]; 30(21): 2670-2677. Available from: http://jco.ascopubs.org/content/30/21/2670.long

28. Primary Literature: Baseline Characteristics
Categories Total Treatment Choice (n=243) Total Decitabine (n=242)
Median Age 73 73
Sex 37.9 Female, 62.1% Male 43.4% Female, 56.6% Male
Cytogenetics: Intermediate Risk 62.6% 63.6%
Cytogenetics: Poor Risk 36.9% 36%
ECOG Performance Status 0 or 1 76.3% 75.3%
ECOG Performance Status 2 23.7% 24.7%
Kantarjan HM, Thomas XG, Dmoszynska A, Wierbowska A, Mazur G, Mayer J, Gau J-P, Chou W-C, Buckstein R, Cermak J, Kuo C-Y, Oriol A, Ravandi F, Faderl S, Delauny J, Lysak D, Minden M, Arthur A. Multicenter, Randomized, Open-Label, Phase III
trial of Decitabine Versus Patient Choice, With Physician Advice, of Either Supportive Care or Low-Dose Cytarabine for the Treatment of Older Patients with Newly Diagnosed Acute Myeloid Leukemia. Journal of Clinical Oncology [Internet]. 2012 July
20 [cited 2016 September 13]; 30(21): 2670-2677, Table 1, Patient Demographics and Baseline Clinical Characteristics, (2672). Available from: http://jco.ascopubs.org/content/30/21/2670.full.pdf+html

29. Strengths and Weaknesses of Study
Strengths:
• Studied in correct patient
population
• Patients had a 2.7 month
longer survival with
decitabine than cytarabine,
but not statistically
significant
• More patients experienced
complete remission with
decitabine
• Showed good safety
Weaknesses:
• Very Low power of 80%
• Didn’t show any overall
survival benefit
• Grouped supportive care
patients with cytarabine
patients
• Showed to have CR in
patients without platelet
recovery

30. Patient’s Prognosis with AML
Patient Factors:
• Elderly patient
• Myelodysplastic Syndrome
Prognosis:
• Prognosis is not good for patient, because patient is elderly patient
who had Myelodysplastic Syndrome and developed AML; usually
these patients do not have a relatively good response to treatment
due to treatment resistance

31. Patient Assessment:
AML: The patient cannot tolerate the adverse effects of cytarabine and
an anthracycline, so patient taking decitabine. The patient should be
switched from piperacillin/tazobactam to ciprofloxacin and vancomycin
for “bug-bite” cellulitis treatment as most bug bite infections are
gram(+). Needs bacterial prophylaxis, fungal prophylaxis, and viral
prophylaxis because has AML and is neutropenic. Cannot take DVT
prophylaxis, because platelets <30,000. Does not require tumor lysis
prophylaxis, because does not have highest intensity chemotherapy
regimen. Should not take growth factors, because has Acute Myeloid
Leukemia and may perpetuate cell growth.

32. Patient’s Treatment Plan
• AML:
• Decitabine 20 mg/m^2 (32 mg) IV
• Repeat cycle in 28 days
• Bacterial Prophylaxis:
• Ciprofloxacin 500 mg tablet twice daily
• Bacterial Treatment (Skin Infection/Cellulitis):
• Piperacillin-tazobactram 3.375 g IV three times daily
• Fungal Prophylaxis:
• Posaconazole 300 mg delated release tablet daily (at bedtime)
• Nausea and Vomiting:
• Ondansetron 8mg IV three times daily, promethazine 12.5 mg IV q4h prn
• Viral Prophylaxis:
• Acyclovir 200 mg capsule twice daily

33. Patient’s Treatment Plan
• Tumor Lysis Syndrome:
• Doesn’t need prophylaxis, because usually used with cancer drugs that cause a higher load of tumor burden in
the blood
• Anemia:
• Transfused RBCs
• Thrombocytopenia
• Will give platelet transfusion if platelets fall below 10,000
• DVT Prophylaxis:
• Not getting due to thrombocytopenia (<30,000)
• Urinary Incontinence:
• Oxybutynin 5mg oral x 3 times daily
• Hypokalemia:
• Potassium of 20 mEq and 40 mEq on order
• Diarrhea:
• Loperamide 2 mg capsule every 4 hours as needed prn

34. Conclusions
• AML is a leukemia in which the bone is “filled” with immature blasts
and “crowds” the bone marrow; >20% blasts and Auer Rods
• Decitabine may have a better Complete Remission Profile than
cytarabine in older patients who do not have good prognostic factors
for MDS
• Do Not Give Growth Factors in AML
• Give patients best supportive care

35. References
Guidelines and Primary Literature:
O’Donnell MR, Tallman MS, Abboud CN, Altman JK, Appelbaum FR, Arber DA, Bixby D, Blum W, Borate U, Coutre SE, Lima MD, Fathi AT, Foran JM, Gore SD, Lancet J, Maness LJ, Maricucci G, Martin ME, Martin, MG, Moore JO, Olin R, Pollyea DA, Pratz K, Ravandi-Kashani F, Shamji PJ,
Stone RM, Strickland SA, Wang ES, Weiduwilt M. NCCN Clinical Practical Guidelines in Oncology: Acute Myeloid Leukdemia. NCCN Guidelines [Internet]. 2016. [cited 2016 September 13]: Title Page- MS-73. Available from: https://www.nccn.org/professionals/physician_gls/pdf/aml.pdf
Kantarjan HM, Thomas XG, Dmoszynska A, Wierbowska A, Mazur G, Mayer J, Gau J-P, Chou W-C, Buckstein R, Cermak J, Kuo C-Y, Oriol A, Ravandi F, Faderl S, Delauny J, Lysak D, Minden M, Arthur A. Multicenter, Randomized, Open-Label, Phase III trial of Decitabine Versus Patient
Choice, With Physician Advice, of Either Supportive Care or Low-Dose Cytarabine for the Treatment of Older Patients with Newly Diagnosed Acute Myeloid Leukemia. Journal of Clinical Oncology [Internet]. 2012 July 20 [cited 2016 September 13]; 30(21): 2670-2677. Available from:
http://jco.ascopubs.org/content/30/21/2670.long
Baden LR, Sankar S, Angarone M, Blouin G, Camins B, Casper C, Cooper B, Dubberke ER, Morris A, Freifeld AG, Greene JN, Ito JI, Kaul DR, Lustberg ME, Montoya JG, Rolston K, Satyanarayana G, Segal B, Seo S, Shoham S, Taplitz R, Topal J, Wilson JW. NCCN Clinical Practice Guidelines in
Oncology (NCCN Guidelines): Prevention and Treatment of Cancer-Related Infections. NCCN Guidelines [Internet]. 2016. [cited 2016 September 13]. Title page- MS 114. Available from: https://www.nccn.org/professionals/physician_gls/pdf/infections.pdf
Levy M, Smith T, Alvarez-Perez A, Back A, Baker JN, Beck AC, Block S, Dalai S, Bergman MA, Scavone J, Dans M, Fitch TR, Kapo J, Kutner JS, Kvale E, Misra S, Mitchell W, Portman DG, Sauer TM, Spiegel D, Sutton L, Szmullowicz E, Taylor RM, Temel J, Tickoo R, Urba SG, Weinstein E,
Zachariah F. NCCN Clinical Practical Guidelines in Oncology: Palliative Care. NCCN Guidelines [Internet]. 2016. [cited 2016 September 13]. Available from: https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
Others:
Marcucci G, Bloomfield CD. Acute Myeloid Leukemia. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine [Internet]. 19 e New York (NY): McGraw-Hill; c2015. Chapter 132. [cited 2016 September 13]. [Chapter 132];
AccessMedicine. Available from: http://accessmedicine.mhmedical.com/content.aspx?sectionid=79731765&bookid=1130&Resultclick=2
Mayoclinic Staff. Mayoclinic.org [Internet]. Rochester, Minnesota: Mayo Clinic; c1998-2016. Disease and Conditions: Acute Myelogenous Leukemia (AML); 2015 September 12 [cited 2016 September 13]; [Defintion, Symptoms, Causes, Risk Factors, Preparing for Your Appointment, Test
and diagnosis, Treatments and drugs, Alternative Medicine, Coping Skills]. Available from: http://www.mayoclinic.org/diseases-conditions/acute-myelogenous-leukemia/basics/risk-factors/con-20043431
National Cancer Institute. Cancer.gov [Internet]. National Cancer Institute (NIH); c.2015. Cancer Types: Acute Myeloid Leukemia Treatment-Patient Version; 2016 [cited 2016 September 13]; [Acute Myeloid Leukemia Treatment-Patient Version]. Available from:
https://www.cancer.gov/types/leukemia/patient/adult-aml-treatment-pdq
National Cancer Institute. Cancer.gov [Internet]. National Cancer Institute (NIH); c.2015. Cancer Types: Acute Myeloid Leukemia Treatment-Patient Version; 2016 [cited 2016 September 13]; [Leukemia May Affect Red Blood Cells, White Blood Cells and Platelets]. Available from:
https://www.cancer.gov/images/cdr/live/CDR526219.jpg
UpToDate [Internet]. UpToDate. c.2016. Patient Education: Acute Myeloid Leukemia in adults (Beyond the Basics); 2016 [cited 2016 September 13]; Acute Myeloid Leukemia in adults (Beyond the Basics). Available from: http://www.uptodate.com/contents/acute-myeloid-leukemia-
aml-treatment-in-adults-beyond-the-basics
American Cancer Society [Internet]. Atlanta Georgia: American Cancer Society/Cancer.org. c. 2016. How is Acute Myeloid Leukemia Diagnosed?; 2016 February 22 [cited 2016 September 13]; [Complete Blood Cell Count and Peripheral Blood Smear; Cytochemistry]. Available from:
http://www.cancer.org/cancer/leukemia-acutemyeloidaml/detailedguide/leukemia-acute-myeloid-myelogenous-diagnosed
Lexicomp [Internet]. Hudson, Ohio: Wolters Kluwer. 2016. Lexi-Drugs; [cited 2016 September 13]. Available from: https://online.lexi.com/lco/action/home

36. Questions