Treatment approaches in AML

Thursday, February 27, 2020

A diagnosis of acute myeloid leukemia (AML) was once an emergency, requiring immediate treatment. Today, the need to start treatment is still urgent, but many patients can benefit by waiting a few days for testing to reveal a fuller picture of the disease. That’s the advice of James M. Foran, MD, of the Mayo Clinic. He joins Blood & Cancer host David H. Henry, MD, of the Pennsylvania Hospital, Philadelphia, to walk through some patient scenarios and the newest treatment options.

In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about what patients do and do not remember from their visits.

Practice points:

  • Rapid testing results can drive important choices in the initial treatment of AML.
  • Adjunctive therapies may improve survival by 7%-20% in appropriate patients.

Although a total work-up may take up to 2 weeks, new research suggests it is feasible to get rapid sequencing/cytogenetic testing and assign treatment within 7 days.

Treatment varies:

Daunorubicin and cytarabine (Vyxeos) are still central treatment strategies, but there may be survival advantages (7%-20% improvement) by adding adjunctive therapies, if indicated. A few are listed below:

  • Liposomal formulations of daunorubicin-cytarabine (CPX351) can have survival advantages in therapy-related AML or AML with myelodysplastic syndrome (MDS)-related changes.
  • Gemtuzumab (Mylotarg) may be indicated for core binding factor (CBF) AML.
  • Midostaurin (Rydapt) may improve survival in patients with FMS-like tyrosine kinase (FLT) 3
  • Enasidenib (Idhifa) may be indicated in patients with IDH mutations.

Options for elderly patients:

In a recent study, CC 486 (oral azacitidine) showed a significant survival advantage and remission duration in elderly patients with AML. The drug is not yet available but could eventually be a maintenance therapy option for patients who do not go on to transplant.

Azacitidine, plus or minus an IDH2 inhibitor, showed much higher remission rates in elderly patients, but did not translate into a survival advantage.

AML in the outpatient setting:

Many patients with AML are being increasingly managed as outpatients, which ultimately will require a different kind of support infrastructure in our hospitals and clinics.

Show notes by Debika Biswal Shinohara, MD, PhD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.

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Podcast Participants

David Henry, MD
David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd.
Ilana Yurkiewicz, MD
Ilana Yurkiewicz, MD, is a fellow in hematology and oncology at Stanford University, where she also completed her internal medicine residency. Dr. Yurkiewicz holds an MD from Harvard Medical School and a BS from Yale University. She went into hematology and oncology because of the high-stakes decision-making, meaningful relationships with patients, and opportunity to help people through some of the toughest challenges of their lives. Dr. Yurkiewicz is also a medical journalist. She is a former AAAS Mass Media Fellow and Scientific American blog columnist, and her writing has appeared in numerous media outlets including Hematology News, where she writes the monthly column Hard Questions. Dr. Yurkiewicz is on Twitter: @ilanayurkiewicz.