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Acute Myelogenous Leukemia (AML)  Other genetic abnormalities, e.g.

, FLT3 mutation, N-
RAS.
Acute myelogenous leukemia (AML) is a fast-growing cancer of
the blood and bone marrow. In AML, the bone marrow makes Doctors also examine the patient to find out if leukemia cells have
many unformed cells called blasts. Blasts normally develop into spread outside the blood and bone marrow. Doctors may use a
white blood cells that fight infection. However, the blasts are chest X-ray and an ultrasound of the abdomen to look at the organs
abnormal in AML. They do not develop and cannot fight and tissues inside. They may also use a test called a lumbar
infections. The bone marrow may also make abnormal red blood puncture (spinal tap) to find out whether there are leukemia cells in
cells and platelets. The number of abnormal cells (or leukemia the fluid around the brain and spinal cord.
cells) grows quickly. They crowd out the normal red blood cells,
white blood cells and platelets the body needs.
Treatment options for acute myelogenous leukemia

AML can get worse quickly, so doctors usually begin treatment


On this page:
right away. To plan treatment, doctors look at a patient's risk
factors (also called prognostic factors). Risk factors are patient and
 Acute myelogenous leukemia symptoms and diagnosis disease traits that clinical studies have linked to better or worse
 Treatment options for acute myelogenous leukemia outcomes from treatment. Examples of risk factors are a patient's
 Chemotherapy for AML age and subtype of AML. To learn more about AML risk factors as
well as how treatment options may differ for children or for adults
 Bone marrow or cord blood transplant for AML
older than age 60, see Risk Factors for Planning Treatment of
 Making treatment decisions AML.

For a patient with AML, the treatment plan may include:


 Chemotherapy — drugs that destroy cancer cells or stop
Acute myelogenous leukemia symptoms and diagnosis them from growing (described below).
 A bone marrow or cord blood transplant (described
AML is the most common type of acute leukemia. More than below).
11,900 new cases occur in the United States each year, mostly in  All-trans retinoic acid (ATRA) if he or she has the
older adults. The average age of a person with AML is 65 years. subtype of AML known as promyelocytic leukemia.
Fewer than 10% of people with AML are children. Acute  Other newer treatments that were recently developed or
myelogenous leukemia is also called acute myeloblastic leukemia, are still being studied in clinical trials — you can ask
acute myeloid leukemia, acute granulocytic leukemia or acute your doctor whether any newer treatments may be
nonlymphocytic leukemia. options for you.

Symptoms Whichever treatment you and your doctor choose, you may be
asked to be part of a clinical trial. Even standard treatments
The symptoms of AML are caused by low numbers of healthy continue to be studied in clinical trials. These studies help doctors
blood cells and high numbers of leukemia cells. learn more about which treatments work best for which patients.
 White blood cells fight infection. Low numbers can lead
to fever and frequent infections. Chemotherapy for AML
 Red blood cells carry oxygen throughout the body. Low
numbers can lead to anemia — feeling tired or weak,
being short of breath and looking pale. Induction chemotherapy
 Platelets control bleeding. Low numbers can lead to easy
bleeding or bruising and tiny red spots under the skin For most patients, the standard first phase of AML treatment is
(petechiae). induction chemotherapy. The goal of induction chemotherapy is to
 High numbers of leukemia cells may cause pain in the bring the disease into remission. Remission is when the patient's
bones or joints. blood counts return to normal and bone marrow samples show no
sign of disease (less than 5% of cells are leukemia cells).
A person with AML may feel generally unwell and run-down. He
Induction chemotherapy is very intense. It usually lasts one week,
or she may also have other, less common symptoms.
followed by three or more weeks for the patient to recover from the
treatment. Often two drugs are used:
Diagnosis  Cytarabine (ara-C)
 An anthracycline drug such as daunorubicin
AML is diagnosed when blood and bone marrow samples show a (Daunomycin) or idarubicin (Idamycin)
large number of leukemia cells. AML has eight subtypes, labeled
M0 through M7. The subtypes are based on the type of blood cells
affected. To find out the sub type and how well the leukemia might Some patients may also be given additional drugs or different
respond to treatment, the samples are looked at to find: drugs. Patients who have the AML subtype promyelocytic
leukemia also are given all-trans retinoic acid (ATRA).
 The number of healthy blood cells.
 The size and number of leukemia cells.
If one week of treatment does not bring a remission, treatment may
 The changes that appear in the chromosomes of the be repeated once or twice. Induction brings a complete remission
leukemia cells. This is called cytogenetics.
in: If an allogeneic transplant may be an option for you, your doctor
will do a test to find out your HLA tissue type. Your doctor will
also test possible donors in your family to find out if they are a
 About 70% to 80% of adults under age 60.
suitable match for you.
 About 50% of adults over age 60.
 More than 90% of children.
In adults in good health with standard AML and a matched sibling,
and allogeneic transplant may be considered after remission with
Successful induction chemotherapy destroys most of the leukemia induction therapy.
cells, but a few will be left in the body. If these cells are not
destroyed, they can cause a relapse of the disease. More treatment
If you do not have a suitable donor in your family, your doctor can
is needed to destroy the remaining leukemia cells. The next step
search the Be The MatchSM Registry for an unrelated donor or cord
may be consolidation chemotherapy or a transplant, depending on
blood unit. To save time, your doctor may check for potential
the treatment plan.
donors on the registry at the same time he or she is testing for
donors in your family.
Consolidation chemotherapy
The closeness of the donor match can affect a patient's chances of a
The second phase of chemotherapy is often called consolidation good transplant outcome. In general, transplants using matched
chemotherapy. The goal of consolidation chemotherapy is to sibling donors have had the best results. However, outcomes for
destroy any remaining leukemia cells. A common treatment is high unrelated donor transplants have improved in the last decade. For
doses of cytarabine (ara-C) given in three or more cycles. Doctors some groups of patients, outcomes for sibling donor and unrelated
may also use different drugs and schedules. donor transplants are similar.

Consolidation chemotherapy is used to treat many patients with Reduced-intensity and non-myeloablative transplants
AML. It is the standard treatment at first remission for adults with
low-risk cytogenetic factors (changes in the chromosomes of
For some people with AML, an allogeneic transplant may offer the
leukemia cells), especially adults younger than age 60.
best chance for a long-term remission. However, more than half of
people with AML are over age 60. Many people older than age 60
Bone marrow or cord blood transplant for AML are unable to tolerate the intense treatment of a standard transplant.
People with other health problems, such as heart disease or organ
For some patients, a bone marrow or cord blood transplant may damage from previous chemotherapy, may also be unable to
offer the best chance for a long-term remission. A transplant is a tolerate a standard transplant. An allogeneic transplant using less
strong treatment with risks of serious side effects, so it is not used intense treatment may be an option for some of these patients. This
for all patients with AML. A transplant is used when chemotherapy type of transplant is called a reduced-intensity transplant or non-
alone is unlikely to provide a long-term remission. myeloablative transplant.

Autologous transplant Transplant success rates

An autologous transplant uses blood-forming cells collected from Transplants have risks of serious complications, but a transplant
the patient. If an autologous transplant is a treatment option for offers some patients the best chance for a long-term remission. If
you, you will have blood-forming cells collected from your blood transplant is an option for you, your doctor can talk with you about
stream. The cells are usually collected after one or two cycles of the possible risks and benefits of a transplant. For statistics
consolidation treatment. The cells are frozen until you are ready for showing patients' results after transplant, see AML Transplant
transplant. You may receive an autologous transplant soon after Outcomes.
your induction therapy is completed, or your cells may be saved as
a backup option in case you relapse after receiving consolidation Making treatment decisions
chemotherapy.
AML is an acute disease that can get worse quickly. Most patients
Autologous transplants have risks of serious side effects, but these begin treatment with induction chemotherapy soon after diagnosis.
risks are lower than for allogeneic transplants. However, a patient Many patients reach remission, but relapse of AML is common. All
has higher risks of a leukemia relapse after an autologous patients need a second phase of treatment to try to prevent relapse.
transplant. This is because leukemia cells may be returned to the The second phase of treatment is based on a patient's risk factors.
patient along with his or her blood-forming cells. (For more information, see Risk Factors for Planning Treatment of
AML.) It is important to discuss your risk factors and your
Allogeneic transplant treatment options with a doctor who is experienced in treating
AML.
An allogeneic transplant replaces the abnormal cells in a patient's
bone marrow with healthy blood-forming cells from a family
member or unrelated donor or cord blood unit. An allogeneic
transplant has a higher risk of serious side effects than
consolidation chemotherapy or an autologous transplant. However,
the risk of relapse is lower after an allogeneic transplant.

Choosing a donor or cord blood unit


Planning for a possible transplant Blood cell development. A blood stem cell goes through several steps to become a red blood cell, pla

All patients with AML may want to talk with their doctors about
including the possibility of a transplant in their treatment plan. A
transplant may be the first choice or it may be a backup plan. When
transplant is not the first treatment, early planning may allow for
more flexibility in treatment options and a quicker transplant later,
if it is needed. In general, to prepare for the possibility of
transplant:
 Patients with AML should be HLA tissue typed at
diagnosis.
 Patients should be referred to a transplant doctor for
consultation at an appropriate time based on risk factors.
 Family members who might be suitable donors should be
tested at the same time as the patient or soon after.
 Doctors can take an early look at potential unrelated
donors and cord blood units on the Be The
Match Registry as soon as they know the patient's HLA
tissue type. This first look is free of charge. In CML, too many blood stem cells develop into a type of white
 Patients who have no suitable related donor and few blood cell called granulocytes. These granulocytes are abnormal
potential unrelated donors may want to discuss storing and do not become healthy white blood cells. They may also be
their own blood-forming cells for a possible autologous called leukemic cells. The leukemic cells can build up in the blood
transplant. and bone marrow so there is less room for healthy white blood
cells, red blood cells, and platelets. When this happens, infection,
The only patients who may not benefit from this planning are those anemia, or easy bleeding may occur.
who would clearly be unable to tolerate even a reduced-intensity
transplant. Some older patients and patients who have organ This summary is about chronic myelogenous leukemia. See the
damage or other health problems may be unable to tolerate a following PDQ summaries for more information about leukemia:
transplant. If you want to consider a transplant, a transplant doctor
can examine you to see whether a transplant is a good option.
 Adult Acute Lymphoblastic Leukemia Treatment
It is important to talk about your treatment options with a doctor
 Childhood Acute Lymphoblastic Leukemia Treatment
who is experienced in treating AML. Your doctor can discuss your  Adult Acute Myeloid Leukemia Treatment
specific risk factors and treatment options with you. For more  Childhood Acute Myeloid Leukemia/Other Myeloid
information to help you talk to your doctor about whether a Malignancies Treatment
transplant is an option for you, you can share the referral  Chronic Lymphocytic Leukemia Treatment
guidelines (PDF) from the Physician Resources section of this Web  Hairy Cell Leukemia Treatment
site with your doctor.
Possible signs of chronic myelogenous leukemia include tiredness,
Chronic myelogenous leukemia is a disease in which the bone night sweats, and fever.
marrow makes too many white blood cells.
These and other symptoms may be caused by CML. Other
Chronic myelogenous leukemia (also called CML or chronic conditions may cause the same symptoms. A doctor should be
granulocytic leukemia) is a slowly progressing blood and bone consulted if any of the following problems occur:
marrow disease that usually occurs during or after middle age, and
rarely occurs in children.
 Feeling very tired.
Normally, the bone marrow makes blood stem cells (immature  Weight loss for no known reason.
cells) that develop into mature blood cells over time. A blood stem  Night sweats.
cell may become a myeloid stem cell or a lymphoid stem cell. The  Fever.
lymphoid stem cell develops into a white blood cell. The myeloid  Pain or a feeling of fullness below the ribs on the left
stem cell develops into one of three types of mature blood cells: side.

 Red blood cells that carry oxygen and other materials to Sometimes CML does not cause any symptoms at all.
all tissues of the body.
 Platelets that help prevent bleeding by causing blood Most people with CML have a gene mutation (change) called the
clots to form. Philadelphia chromosome.
 Granulocytes (white blood cells) that fight infection and
disease Every cell in the body contains DNA (genetic material) that
determines how the cell looks and acts. DNA is contained inside
chromosomes. In CML, part of the DNA from one chromosome
moves to another chromosome. This change is called the “
Philadelphia chromosome.” It results in the bone marrow making
an enzyme, called tyrosine kinase, that causes too many stem cells flow into a tube. The blood sample is sent to the laboratory
to develop into white blood cells (granulocytes or blasts). and the red blood cells, white blood cells, and platelets are
counted. The CBC is used to test for, diagnose, and
monitor many different conditions.
The Philadelphia chromosome is not passed from  Blood chemistry studies: A procedure in which a blood
parent to child. sample is checked to measure the amounts of certain
substances released into the blood by organs and tissues
in the body. An unusual (higher or lower than normal)
amount of a substance can be a sign of disease in the
organ or tissue that makes it.
 Cytogenetic analysis: A test in which cells in a sample of
hromosome. A piece of chromosome 9 and a piece of chromosome 22 break off and trade places.blood
The or bone marrow are viewed under a microscope to
formed on chromosome 22 where the piece of chromosome 9 attaches. The changed chromosomelook
22 isfor certain changes in the chromosomes, such as the
delphia chromosome. Philadelphia chromosome.
 Bone marrow aspiration and biopsy: The removal of
bone marrow, blood, and a small piece of bone by
inserting a needle into the hipbone or breastbone. A
pathologist views the bone marrow, blood, and bone
under a microscope to look for abnormal cells.

Enlarge

Tests that examine the blood and bone marrow are used to detect
(find) and diagnose chronic myelogenous leukemia.

The following tests and procedures may be used:

 Physical exam and history: An exam of the body to


check general signs of health, including checking for
signs of disease such as an enlarged spleen. A history of
the patient’s health habits and past illnesses and
treatments will also be taken.
Bone marrow aspiration and biopsy. After a small area of
 Complete blood count (CBC): A procedure in which a skin is numbed, a Jamshidi needle (a long, hollow needle)
sample of blood is drawn and checked for the following: is inserted into the patient’s hip bone. Samples of blood,
o The number of red blood cells, white blood bone, and bone marrow are removed for examination
cells, and platelets. under a microscope.
o The amount of hemoglobin (the protein that
carries oxygen) in the red blood cells.
Certain factors affect prognosis (chance of recovery) and treatment
o The portion of the sample made up options.
of red blood cells.
Enlarge The prognosis (chance of recovery) and treatment options depend
on the following:

 The patient’s age.


 The phase of CML.
 The amount of blasts in the blood or bone marrow.
 The size of the spleen at diagnosis.
 The patient’s general health.

After chronic myelogenous leukemia has been diagnosed, tests are


done to find out if the cancer has spread.

Staging is the process used to find out how far the cancer has
spread. There is no standard staging system for chronic
myelogenous leukemia (CML). Instead, the disease is classified by
Complete blood count (CBC). Blood is collected by phase: chronic phase, accelerated phase, or blastic phase. It is
inserting a needle into a vein and allowing the blood to
important to know the phase in order to plan treatment. The In relapsed CML, the number of blast cells increases after a
following tests and procedures may be used to find out the phase: remission.

 Cytogenetic analysis: A test in which cells in a sample of There are different types of treatment for patients with chronic
blood or bone marrow are viewed under a microscope to myelogenous leukemia.
look for certain changes in the chromosomes, such as the
Philadelphia chromosome. Different types of treatment are available for patients with chronic
 Bone marrow aspiration and biopsy: The removal of myelogenous leukemia (CML). Some treatments are standard (the
bone marrow, blood, and a small piece of bone by currently used treatment), and some are being tested in clinical
inserting a needle into the hipbone or breastbone. A trials. A treatment clinical trial is a research study meant to help
pathologist views the bone marrow, blood, and bone improve current treatments or obtain information on new
under a microscope to look for abnormal cells. treatments for patients with cancer. When clinical trials show that a
new treatment is better than the standard treatment, the new
There are three ways that cancer spreads in the body. treatment may become the standard treatment. Patients may want
to think about taking part in a clinical trial. Some clinical trials are
open only to patients who have not started treatment.
When cancer cells spread outside the blood, a solid tumor may
form. This process is called metastasis. The three ways that cancer
cells spread in the body are: Six types of standard treatment are used:

Targeted therapy
 Through the blood. Cancer cells travel through the blood,
invade solid tissues in the body, such as the brain or
heart, and form a solid tumor. Targeted therapy is a type of treatment that uses drugs or other
 Through the lymph system. Cancer cells invade the substances to identify and attack specific cancer cells without
lymph system, travel through the lymph vessels, and harming normal cells. Tyrosine kinase inhibitors are targeted
form a solid tumor in other parts of the body. therapy drugs used to treat chronic myelogenous leukemia.
 Through solid tissue. Cancer cells that have formed a
solid tumor spread to tissues in the surrounding area. A tyrosine kinase inhibitor called imatinib mesylate is used as
initial treatment for certain types of chronic myelogenous leukemia
in newly diagnosed patients. It blocks an enzyme called tyrosine
The new (metastatic) tumor is the same type of cancer as the kinase that causes stem cells to develop into more white blood cells
primary cancer. For example, if leukemia cells spread to the brain, (granulocytes or blasts) than the body needs. Another tyrosine
the cancer cells in the brain are actually leukemia cells. The disease kinase inhibitor called dasatinib is used to treat patients with
is metastatic leukemia, not brain cancer. certain types of CML that have progressed, and is being studied as
an initial treatment.
Chronic myelogenous leukemia has 3 phases.
Chemotherapy
As the amount of blast cells increases in the blood and bone
marrow, there is less room for healthy white blood cells, red blood Chemotherapy is a cancer treatment that uses drugs to stop the
cells, and platelets. This may result in infections, anemia, and easy growth of cancer cells, either by killing the cells or by stopping
bleeding, as well as bone pain and pain or a feeling of fullness them from dividing. When chemotherapy is taken by mouth or
below the ribs on the left side. The number of blast cells in the injected into a vein or muscle, the drugs enter the bloodstream and
blood and bone marrow and the severity of symptoms determine can reach cancer cells throughout the body (systemic
the phase of the disease. chemotherapy). When chemotherapy is placed directly into the
spinal column, an organ, or a body cavity such as the abdomen, the
Chronic phase drugs mainly affect cancer cells in those areas (regional
chemotherapy). The way the chemotherapy is given depends on the
In chronic phase CML, fewer than 10% of the cells in the blood type and stage of the cancer being treated.
and bone marrow are blast cells.
Biologic therapy
Accelerated phase
Biologic therapy is a treatment that uses the patient’s immune
In accelerated phase CML, 10% to 19% of the cells in the blood system to fight cancer. Substances made by the body or made in a
and bone marrow are blast cells. laboratory are used to boost, direct, or restore the body’s natural
defenses against cancer. This type of cancer treatment is also called
biotherapy or immunotherapy.
Blastic phase
High-dose chemotherapy with stem cell transplant
In blastic phase CML, 20% or more of the cells in the blood or
bone marrow are blast cells. When tiredness, fever, and an enlarged
spleen occur during the blastic phase, it is called blast crisis. High-dose chemotherapy with stem cell transplant is a method of
giving high doses of chemotherapy and replacing blood-forming
cells destroyed by the cancer treatment. Stem cells (immature
Relapsed Chronic Myelogenous Leukemia blood cells) are removed from the blood or bone marrow of the
patient or a donor and are frozen and stored. After the
chemotherapy is completed, the stored stem cells are thawed and
given back to the patient through an infusion. These reinfused stem Some of the tests will continue to be done from time to time after
cells grow into (and restore) the body’s blood cells. treatment has ended. The results of these tests can show if your
condition has changed or if the cancer has recurred (come back).
Donor lymphocyte infusion (DLI) These tests are sometimes called follow-up tests or check-ups.

Donor lymphocyte infusion (DLI) is a cancer treatment that may Treatment Options for Chronic Myelogenous Leukemia
be used after stem cell transplant. Lymphocytes (a type of white
blood cell) from the stem cell transplant donor are removed from Chronic Phase Chronic Myelogenous Leukemia
the donor’s blood and may be frozen for storage. The donor’s Accelerated Phase Chronic Myelogenous Leukemia
lymphocytes are thawed if they were frozen and then given to the Blastic Phase Chronic Myelogenous Leukemia
patient through one or more infusions. The lymphocytes see the Relapsed Chronic Myelogenous Leukemia
patient’s cancer cells as not belonging to the body and attack them.
A link to a list of current clinical trials is included for each
Surgery treatment section. For some types or stages of cancer, there may
not be any trials listed. Check with your doctor for clinical trials
Splenectomy is surgery to remove the spleen. that are not listed here but may be right for you.

New types of treatment are being tested in clinical trials. Chronic Phase Chronic Myelogenous Leukemia

Information about clinical trials is available from the NCI Web site. Treatment of chronic phase chronic myelogenous leukemia may
include the following:
Patients may want to think about taking part in a clinical trial.
 Targeted therapy with a tyrosine kinase inhibitor.
For some patients, taking part in a clinical trial may be the best  High-dose chemotherapy with donor stem cell transplant.
treatment choice. Clinical trials are part of the cancer research  Biologic therapy (interferon) with or without
process. Clinical trials are done to find out if new cancer chemotherapy.
treatments are safe and effective or better than the standard  Chemotherapy.
treatment.  Splenectomy.
 A clinical trial of lower- dose chemotherapy with donor
Many of today's standard treatments for cancer are based on earlier stem cell transplant.
clinical trials. Patients who take part in a clinical trial may receive  A clinical trial of a new treatment.
the standard treatment or be among the first to receive a new
treatment.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical
Trials Registry that are now accepting patients with chronic phase
Patients who take part in clinical trials also help improve the way chronic myelogenous leukemia. For more specific results, refine
cancer will be treated in the future. Even when clinical trials do not the search by using other search features, such as the location of
lead to effective new treatments, they often answer important the trial, the type of treatment, or the name of the drug. General
questions and help move research forward. information about clinical trials is available from the NCI Web site.

Patients can enter clinical trials before, during, or after starting Accelerated Phase Chronic Myelogenous Leukemia
their cancer treatment.
Treatment of accelerated phase chronic myelogenous leukemia
Some clinical trials only include patients who have not yet may include the following:
received treatment. Other trials test treatments for patients whose
cancer has not gotten better. There are also clinical trials that test
new ways to stop cancer from recurring (coming back) or reduce  Stem cell transplant.
the side effects of cancer treatment.  Targeted therapy with a tyrosine kinase inhibitor.
 Biologic therapy (interferon) with or without
Clinical trials are taking place in many parts of the country. See the chemotherapy.
Treatment Options section that follows for links to current  High-dose chemotherapy.
treatment clinical trials. These have been retrieved from NCI's  Chemotherapy.
clinical trials database.  Transfusion therapy to replace red blood cells, platelets,
and sometimes white blood cells, to relieve symptoms
Follow-up tests may be needed. and improve quality of life.
 A clinical trial of a new treatment.
Some of the tests that were done to diagnose the cancer or to find
out the stage of the cancer may be repeated. Some tests will be Check for U.S. clinical trials from NCI's PDQ Cancer Clinical
repeated in order to see how well the treatment is working. Trials Registry that are now accepting patients with accelerated
Decisions about whether to continue, change, or stop treatment phase chronic myelogenous leukemia. For more specific results,
may be based on the results of these tests. This is sometimes called refine the search by using other search features, such as the
re-staging. location of the trial, the type of treatment, or the name of the drug.
General information about clinical trials is available from the NCI
Web site.
Blastic Phase Chronic Myelogenous Leukemia

Treatment of blastic phase chronic myelogenous leukemia may


include the following:

 Targeted therapy with a tyrosine kinase inhibitor.


 Chemotherapy using one or more drugs.
 High-dose chemotherapy.
 Donor stem cell transplant.
 Chemotherapy as palliative therapy to relieve symptoms
and improve quality of life.
 A clinical trial of a new treatment.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical
Trials Registry that are now accepting patients with blastic phase
chronic myelogenous leukemia. For more specific results, refine
the search by using other search features, such as the location of
the trial, the type of treatment, or the name of the drug. General
information about clinical trials is available from the NCI Web site.

Relapsed Chronic Myelogenous Leukemia

Treatment of relapsed chronic myelogenous leukemia may include


the following:

 Targeted therapy with a tyrosine kinase inhibitor.


 Donor stem cell transplant.
 Donor lymphocyte infusion.
 Biologic therapy (interferon).
 A clinical trial of new types or higher doses of targeted
therapy and donor stem cell transplant.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical
Trials Registry that are now accepting patients with relapsing
chronic myelogenous leukemia. For more specific results, refine
the search by using other search features, such as the location of
the trial, the type of treatment, or the name of the drug. General
information about clinical trials is available from the NCI Web site.