High-dose cytosine arabinoside and daunorubicin postremission therapy in adults with de novo acute myeloid leukemia. Long-term follow-up of a prospective multicenter trial

Prior hypomethylating agent use lacks impact on clinical outcome in patients with secondary acute myeloid leukemia arising from myelodysplastic syndromes treated with standard induction chemotherapy

Patients with secondary acute myeloid leukemia (sAML) arising from prior myelodysplastic syndromes have poor prognosis. Anthracycline plus cytarabine (7 + 3) is a standard treatment option for patients who are fit for intensive therapy. In the present study, 22 of 96 sAML patients (23 %) were treated with 7 + 3 and achieved median overall survival (OS) of 9.8 months. Hypomethylating agents (HMA) were given for MDS in 6/22 (28 %) of the patients. When evaluating the prior HMA group, CR/CRi was 50 % for those with prior HMA exposure and 63 % for those without HMA exposure (P = 0.6). Median OS was 14 months for prior HMA exposure vs 10 months for no prior HMA (P = 0.9). The outcome of sAML patients who were treated with 7 + 3 continues to be poor. No statistical significant difference was found between response rates and mOS between prior HMA exposure or not. Additional larger studies are needed to confirm our results.

Treatment of de novo acute myeloid leukaemia in Hong Kong: a twenty-year experience (1975 to 1996)

BACKGROUND

Small patient numbers and short follow-up are common in some acute myeloid leukaemia (AML) studies and data on secondary malignancies after treatment of AML are rare.

AIMS

To determine the prognostic factors and long-term treatment results.

METHODS

A retrospective study of patients with de novo AML under the age of 60 over a 20-year period in which two induction therapy regimens: 7:3 (1975-1983) and 7:3:7 (1984-1996) and three consolidation chemotherapy regimens: 5:2 (1975-1983), 5:2:5 (1984-1990) and Ara-C/mitoxantrone (1991-1996) were used. Disease-free (DFS), overall survivals (OS) and prognostic factors were analysed.

RESULTS

Two-hundred and two of 276 (73%) patients attained complete remission (CR). The CR rates of 7:3 and 7:3:7 regimens were 70.5% and 74.5% respectively (p=0.92). The median DFS was 12 months and the projected DFS at 10- and 20-years were 23% and 21% respectively. For patients consolidated with 5:2, 5:2:5 and Ara-C/mitoxantrone, the median DFS was 15 m, 12 m and 11 m respectively and the projected ten-year DFS were 27%, 21% and 18% respectively (p=0.2). Ninety per cent of relapses occurred within two years from remission but there were two late relapses at 109 m and 120 m respectively. Young age and FAB M3 subtype were favourable prognostic factors to OS (p=0.04) and DFS (p=0.006) respectively. There was no secondary solid tumour in the long-term survivors.

CONCLUSION

Our experience confirmed the efficacy of standard-dose Ara-C/daunorubicin and the prognostic value of age and FAB subtype. Median and projected DFS were similar to western studies.

A phase III comparison of high dose ARA-C (HIDAC) versus HIDAC plus mitoxantrone in the treatment of first relapsed or refractory acute myeloid leukemia Southwest Oncology Group Study

The aim of this study is to determine whether the addition of mitoxantrone to high dose cytarabine improves the outcome of treatment in patients with relapsed or refractory acute myeloid leukemia (AML). One hundred and sixty-two eligible patients, 14-76 years of age, with AML either in first relapse or that failed to respond to initial remission induction therapy, with no CNS involvement were randomized to receive therapy with cytarabine 3 gm/M2 i.v. over 2 h every 12 h for 12 doses on days 1-6 (Arm I) (HIDAC); or HIDAC plus mitoxantrone 10 mg/M2 i.v. daily on days 7 9 (Arm II) (HIDAC + M). Patients achieving complete remission were treated with three courses of consolidation including HIDAC (Ara-C 3 gm/M2 i.v. 12 h days 1 3; 2 gm/M2 over age 50) alone (ARM I) or with mitoxantrone (10 mg/M2 i.v. day 1) (ARM II). Among 162 patients (81 HIDAC, 81 HIDAC + M) evaluated for induction toxicity, there were 10 (12%) induction deaths with HIDAC and 13 (17%) with HIDAC + M (2-tailed P = 0.65). Most early deaths were due to infection and/or hemorrhage. Among 162 patients evaluated for responses to induction therapy, 26/81 (32%) HIDAC and 36/81 (44%) HIDAC + M patients achieved complete remission (two-tailed P = 0.15). Although this difference was not statistically significant in univariate analysis, it was after adjusting for the effects of WBC and PMN percentage in multivariate analysis (P=0.013). Median survivals from study entry were 8 months (HIDAC) and 6 months (HIDAC + M); 2-tailed logrank P = 0.58. Among 48 patients registered for consolidation, the median disease-free survivals from that registration were 8 months with HIDAC and 11 months with HIDAC + M (P = 0.60). There were three treatment-related deaths during consolidation (1 HIDAC, 2 HIDAC + M), all due to infections. In this randomized trial, the addition of mitoxantrone to high-dose cytarabine was associated with a trend toward a higher CR rate. There was less evidence for an advantage in disease-free or overall survival, although any such conclusion is limited by the size of the study.

Pharmacoeconomic considerations in treating patients with acute leukaemia

Whereas individual cost-effectiveness analyses of new agents for acute leukaemia should be performed in target populations, any meaningful pharmacoeconomic evaluation of treatment options for this condition should include the many types of costs and outcomes in unselected, representative groups of patients. Both direct costs (e.g. costs for medication and hospitalisation) and indirect costs (e.g. lost productivity costs and reduced quality of life) are important parameters to assess, as are the costs of chronic adverse effects, research and development costs for new agents, and costs of procedure-related deaths. Complete remission, cure and survival are the 'success' response criteria for acute leukaemia treatments, in addition to prolonged life with acceptable quality of life for patients with incurable acute leukaemia. Death is 'failure', caused either by resistant disease (relapse and progressive disease) inspite of optimal chemotherapy or, sometimes, by insufficient treatment. All of these parameters should be taken into account when a pharmacoeconomic evaluation is performed (either for administrative or scientific purposes) in order to ensure a comprehensive and reliable background for the evaluation in question. Treatment of acute leukaemia is expensive with a total cost of about $US3000 per patient per day during the induction. Although 80% of children with acute leukaemia are cured, only less than 50% of adults are cured. Thus, a great cost is associated with death during treatment and only optimal medical treatment with full-scale combination chemotherapy and full supportive treatment can keep the number of deaths to a minimum.

Long term follow-up of patients with acute myelogenous leukemia who received the daunorubicin, vincristine, and cytosine arabinoside regimen

BACKGROUND

In 1985, the authors published a study of acute myelogenous leukemia (AML) patients treated with a chemotherapeutic regimen that was then considered intensive. Ten years later, the authors reanalyzed the same cohort to determine whether the very promising actuarial results observed at 5 years held after longer follow-up.

METHODS

Between 1977 and 1982, 61 patients with AML were treated with a protocol consisting of daunorubicin, vincristine, and cytosine arabinoside induction followed by consolidation and maintenance for a total of 2 years. The complete remission (CR) rate was 66%, 84% in males versus 47% in females (P < 0.005). At the time of the first analysis in 1984, the overall survival (OS) was 17%, the projected 5-year continuous CR rate (CCR) 32%, and the disease free survival (DFS) rate 29%, with the best results observed for males and for patients ages 40-60 years (P < 0.05).

RESULTS

When the data were reanalyzed 11 years later in 1995, the results were 14% OS, 23% CCR, and 16% DFS at 5 years. However, these figures dropped to 8%, 18%, and 11% at 10 years and to 8%, 12%, and 7% at 15 years, respectively. Among the 40 CR patients, 31 relapsed (up to 13 years after CR), and all died within 1.6 years after relapse. Nine patients were in CCR: 4 died of unrelated causes (suicide, alcoholic cirrhosis, acute peritonitis, or bladder carcinoma), 1 was lost to follow-up after 11 years, 2 were alive and well at 17 years at last follow-up, and 2 were transplanted in first CR and were doing well at 13 and 14 years at last follow-up. The survival advantage for males over females persisted (P = 0.0197), but the advantage for patients age 40-60 years did not hold.

CONCLUSIONS

These long term data indicate that actuarial analysis at 5 years may overestimate the cure rate of AML patients because a number of late relapses do occur. However, the picture is blurred by the incidence of death not related to leukemia or its treatment; and when these patients were censored at the time of death, 17% of CR patients were still projected to be alive and free of leukemia after 17 years.