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Defining the optimal total number of chemotherapy courses in younger patients with acute myeloid leukemia: a comparison of three versus four courses

Burnett, Alan K., Russell, Nigel H., Hills, Robert K., Knapper, Stephen ORCID:, Freeman, Sylvie, Huntly, Brian, Clark, Richard E., Thomas, Ian F., Kjeldsen, Lars, McMullin, Mary Frances, Drummond, Mark, Kell, Jonathan and Spearing, Ruth 2021. Defining the optimal total number of chemotherapy courses in younger patients with acute myeloid leukemia: a comparison of three versus four courses. Journal of Clinical Oncology 39 (8) , pp. 890-901. 10.1200/JCO.20.01170

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PURPOSE The optimum number of treatment courses for younger patients with acute myeloid leukemia (AML) is uncertain. The United Kingdom National Cancer Research Institute AML17 trial randomly assigned patients who were not high risk to a total of three versus four courses. PATIENTS AND METHODS Patients received two induction courses based on daunorubicin and cytarabine (Ara-C), usually with gemtuzumab ozogamicin. Following remission, 1,017 patients were randomly assigned to a third course, MACE (amsacrine, Ara-C, and etoposide), plus a fourth course of MidAc (mitoxantrone and Ara-C) and following an amendment to one or two courses of high-dose Ara-C. Primary end points were cumulative incidence of relapse (CIR), relapse-free survival (RFS), and overall survival (OS). Outcomes were correlated with patient characteristics, mutations, cytogenetics, induction treatments, and measurable residual disease (MRD) postinduction. RESULTS In logrank analyses, CIR and RFS at 5 years were improved in recipients of four courses (50% v 58%: hazard ratio [HR] 0.81 [0.69-0.97], P = .02 and 43% v 36%: HR 0.83 [0.71-0.98], P = .03, respectively). While OS was not significantly better (63% v 57%: HR 0.84 [0.69-1.03], P = .09), the noninferiority of three courses to four courses was not established. The impact on relapse was only significant when the fourth course was Ara-C. In exploratory analyses, although MRD impacted survival, a fourth course had no effect in either MRD-positive or MRD-negative patients. A fourth course was beneficial in patients who lacked a mutation of FLT3 or NPM1, had < 3 mutations in other genes, or had a presenting WBC of < 10 × 109 L−1. CONCLUSION Although a fourth course of high-dose Ara-C reduced CIR and improved RFS, it did not result in a significant OS benefit. Subsets including those with favorable cytogenetics, those lacking a mutation of FLT3 or NPM1, or those with < 3 other mutations may derive survival benefit.

Item Type: Article
Date Type: Publication
Status: Published
Schools: Medicine
Centre for Trials Research (CNTRR)
Additional Information: Licensed under the Creative Commons Attribution 4.0 License:
Publisher: American Society of Clinical Oncology
ISSN: 0732-183X
Funders: Cancer Research UK
Date of First Compliant Deposit: 8 May 2021
Date of Acceptance: 7 October 2020
Last Modified: 08 May 2023 00:12

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