The Best Approach to AML Treatment, Maintenance

A panel discussed the optimal treatment for patients with acute myeloid leukemia (AML), as well as maintenance approaches. Their presentation was given at the 7th Annual Live Medical Crossfire®: Hematologic Malignancies.

When asked about optimizing AML treatment and how to improve hypomethylating agent (HMA)/venetoclax treatment in older patients specifically, lead presenter Tapan M. Kadia, MD, said, “There’s some data from the French showing that lower days may be better. HMA/[venetoclax], as we know, may not be optimal for all subgroups, including those patients who have receptor tyrosine kinase signaling mutations like RAS or FLT3, patients who have TP53 mutations. Can we use new backbone regimens like the [cladribine]/low-dose araC/[venetoclax] regimen that we’ve developed at MD Anderson? And if you need intensive chemotherapy to get your patient [who is] 60, 65, 68 years of age to allogeneic stem cell transplant, can you use low-intensity therapy to get them [to] the transplant?”

As for the efficacy of transplantation in this population of patients with AML, Dr. Kadia noted “we did a subsequent analysis [that demonstrated] that indeed you can get 35% to 40% of patients after induction into remission with an allogeneic stem cell transplant. A similar rate with 7 + 3 intensive chemotherapy in this older population. And if you look at survival, it’s actually fairly good, if not better, than intensive chemotherapy.”

The panel was presented with the case of a 62-year-old man with hyperlipidemia and hypertension who was otherwise healthy with respect to heart, kidney, and liver function. He presented with nonspecific fatigue and bone marrow that a pathologist determined to be consistent for AML. However, there was no molecular data. When the panelists were asked if they would immediately start treatment or wait, they agreed on the latter option. “He seems otherwise stable,” remarked Alice Mims, MD, MSCR. “No hyperleukocytosis, no sudden coagulopathy, [nothing] that would [make you] feel like you need to emergently start treatment. We would wait for mutational results for the whole panel to come back. Maybe they’re in the hospital, discharged, or [you] have them come back and then go look at the results and determine the next steps in treatment.”

Alexander Pearl, MD, MS, echoed those sentiments and stressed the importance of first obtaining mutational information. “We don’t have mutational data on TP53 for a few weeks. If somebody needs emergency therapy, we start it. If someone doesn’t need emergency therapy, we try to get a little bit more understanding of the genetics of the disease before we commit to a treatment approach.”