6.2 Managing relapsed or refractory disease
Molecular monitoring for MRD is recommended for patients with APL, CBF leukaemia and NPM1 mutant AML (Döhner et al. 2010, 2017; Sanz et al. 2019). Comprehensive guidelines about the performance, monitoring frequency and interpretation of MRD technologies (flow cytometry and molecular) are available (Schuurhuis et al. 2018).
In general, bone marrow sampling is more sensitive than peripheral blood monitoring. The optimal frequency and duration of testing continues to be refined, with current guidelines provided by Schuurhuis et al. (2018).
If relapse is suspected, investigations should include:
- full blood count with blood film examination
- bone marrow aspiration and trephine, including flow cytometry, cytogenetic analysis and molecular testing (depending on clinical context).
Managing relapsed or refractory disease is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate. From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A and B, and in the special population groups section should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.
Access to the best available therapies, including clinical trials are crucial to achieving the best outcomes for anyone with relapsed or refractory disease. Novel therapies are becoming available for patients with relapsing and refractory disease. Identification of relevant targets may require repeat molecular assessment to identify lesions newly emergent at the time of treatment failure.
Survivorship care should be considered and offered at an early stage. Many people live with advanced cancer for many months or years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.