The prognostic effect of smoking status on intensively treated acute myeloid leukaemia - A Danish nationwide cohort study

Global, regional, and national burden of acute myeloid leukemia, 1990-2021: a systematic analysis for the global burden of disease study 2021

BACKGROUND

Acute myeloid leukemia (AML), as the most common subtype of leukemia in adults, is characterised by rapid progression and poor prognosis. In the context of the rapid development of medical technology and the complexity of social factors, a detailed report describing the latest epidemiological patterns of AML is important for decision makers to allocate healthcare resources effectively.

METHODS

Our research utilized the latest data sourced from the Global Burden of Disease (GBD) 2021. To delineate the burden of AML, we comprehensively described the incidence, deaths, disability-adjusted life years (DALYs), and the associated age-standardized rates per 100,000 persons (ASR) spanning from 1990 to 2021 stratifies according to age, sex, socio-demographic index (SDI), and nationality. Additionally, we extracted and analyzed data about the risk factors that contribute to AML-related deaths and DALYs.

RESULTS

According to our study, the incidence of AML has continued to rise globally from 79,372 in 1990 to 144,645 in 2021 and AML affected the male and the elderly populations disproportionately. Furthermore, there was a significant positive correlation between the burden of AML and the SDI value. Developed nations generally exhibited higher age-standardized incidence rate, age-standardized death rate, and age-standardized disability-adjusted life year rate than the developing nations. We also analyzed the prevalence of smoking, high body mass index, and occupational benzene and formaldehyde exposure in the AML population in different SDI regions. Moreover, smoking and high body mass index were more prevalent in developed countries, whereas occupational exposure to these chemicals was the predominant risk factor in developing countries.

CONCLUSION

The global burden of AML has increased over the past 32 years, with rising morbidity and mortality. The incidence of AML is differentially distributed across different SDI countries or regions. AML incidence is higher in the elderly and in men. The proportions of smoking, high body mass index, and occupational exposure to benzene and formaldehyde varied by region. The findings highlight the need for region-specific prevention and call for future research on preventive strategies and new treatments to lower AML incidence and improve patient outcomes.

Clinical outcomes of patients with acute myeloid leukemia and cardiovascular disease

Incidence of both acute myeloid leukemia (AML) and cardiovascular disease (CVD) increases with age. We evaluated whether pre-existing CVD impacts clinical outcomes in AML. We retrospectively evaluated 291 consecutive adult AML patients treated at our institution, 2014-2020. Pretreatment comorbidities were identified by chart review. Outcomes included complete remission (CR) and CR with incomplete count recovery (CRi) rates, disease-free survival (DFS), overall survival (OS) and incidence of cardiovascular adverse events. CVD was present in 34% of patients at AML diagnosis. CVD patients had worse performance status (p=0.03) and more commonly had secondary AML (p=0.03) and received hypomethylating (HMA) agent-based therapy (72% vs 38%, p< 0.001). CVD (0.45 vs 0.71, p<0.001) and diabetes mellitus (HR= 0.24, 95% CI: 0.08 - 0.8, p= 0.01) were associated with lower probability of achieving CR/CRi. Accounting for age, performance status (PS), complex karyotype, secondary disease and treatment, CVD patients had shorter OS (HR=1.5, 95% CI: 1.1-2.2, p=0.002), with 1- and 3-year OS 44% vs 67% and 25% vs 40%, respectively, but there was no difference in cumulative incidence of relapse between patients with vs without CVD. Thus, CVD is an independent risk factor for lower response rate and shorter survival in AML patients.

Smoking as a prognostic factor for survival in patients with disseminated germ cell cancer

We investigated the impact of smoking on overall survival (OS) in testicular germ cell cancer (TC) patients receiving first-line combination chemotherapy (bleomycin-etoposide-cisplatin [BEP]). Patients who received BEP for metastatic TC were identified in the Danish Testicular Cancer database. Information on smoking status at the time of diagnosis was obtained by medical record review. OS and cause of death were compared between current smokers and never-smokers. Of 1883 eligible patients, information on smoking status was available in 1156 patients, of whom 602 were current smokers. The 10-year OS was 92% in never-smokers compared with 83% in current smokers (P < .001) (hazard ratio for death = 1.85, 95% confidence interval = 1.29 to 2.66, P = .001). A higher proportion of current smokers died of TC compared with nonsmokers (P < .01). Smoking negatively affects survival after BEP in patients with disseminated TC. Vigorous smoking cessation programs are advocated in TC patients.

Smoking status in acute myeloid leukemia is associated with worse overall survival and independent of prior nonhematopoietic malignancies, cytogenetic abnormalities, and WHO category

Acute myeloid leukemia (AML) is an aggressive hematopoietic malignancy with several patient- and disease-associated variables known to impact prognosis. Tobacco smoking is an environmental factor associated with a greater incidence of AML, but there have been limited studies that evaluated smoking toward overall survival. We retrospectively searched for AML cases and collected clinical and diagnostic data for each case. We also used an independent next-generation sequencing (NGS) data set to assess for a distinct mutational signature associated with smoking. When stratified by smoking status, there was a greater number of males, patients aged ≥60 years, and patients with ≥2 comorbidities within the smoking category (P < .05). Survival analysis demonstrated decreased survival probability in the smokers, male smokers, smokers with 1 other comorbidity, and smokers without a prior history of nonhematopoietic malignancy (P < .05) as compared to nonsmokers. Smoking was associated with a decrease in survival within the World Health Organization categories of AML, not otherwise specified (AML NOS; P = .035) and AML with recurrent genetic abnormalities (AML RGA; P = .002). Multivariate analysis showed that patients who were smokers had a greater hazard ratio than nonsmokers after adjusting for the other covariates. Our findings demonstrated that smoking was independently associated with decreased overall survival after adjusting for other potentially confounding factors. In addition, our results suggest that a mutational signature can be recognized using NGS data in a subset of AML patients who smoke.

Effects of chemotherapy dose reductions in overweight patients with acute myeloid leukaemia: A Danish nationwide cohort study

Overweight patients with cancer are frequently reduced in chemotherapy dose due to toxicity concerns, although previous studies have indicated that dose reduction (DR) of overweight patients results in comparable toxicity but may compromise overall survival (OS). Current evidence regarding DR in patients with acute myeloid leukaemia (AML) is limited. To investigate the association between DR and outcome among overweight patients with AML we analysed a Danish nationwide cohort of overweight adult AML patients treated with remission induction chemotherapy. Among 536 patients identified, 10.1% were categorized as DR defined as 95% or less of full body surface area (BSA)-based dose. Risk factors for DR were high body mass index (BMI) and BSA, therapy-related AML and favourable cytogenetics. No significant differences were observed for rates of complete remission (CR), 30- and 90-day mortality between DR and non-DR patients. Furthermore, DR did not affect median relapse-free survival (RFS) [DR, 14.5 (95% confidence interval, 9.0-41.7) months; non-DR, 15.0 (12.3-19.3)] with an adjusted difference in five-year restricted mean survival time (Δ5y-RMST) of 0.2 (-8.4 to 8.8) months nor median OS (DR, 17.0 [11.9 to 45.5] months; non-DR, 17.5 [14.8 to 20.5]) with an adjusted Δ5y-RMST of 0.8 (-5.7 to 7.3) months. In conclusion, we found no statistically significant association between DR and outcomes among overweight patients with AML. However, we acknowledge the limited sample size and encourage further studies in this important subject.

The Global Burden of Leukemia and Its Attributable Factors in 204 Countries and Territories: Findings from the Global Burden of Disease 2019 Study and Projections to 2030

Background. Leukemia is a common malignancy that has four main subtypes and is a threat to human health. Understanding the epidemiological status of leukemia and its four main subtypes globally is important for allocating appropriate resources, guiding clinical practice, and furthering scientific research. Methods. Average annual percentage changes (AAPCs) were calculated to estimate the change trends of age-standardized rates (ASRs) from 1990 to 2019 in 204 countries and territories. The risk factors for leukemia death and disability-adjusted life-year (DALY) were also analyzed. In addition, the future trends in ASRs were projected through 2030. Results. The total number of incident cases, deaths, and DALYs from leukemia in 2019 was 0.64, 0.33, and 11.66 million, respectively. Decreasing trends in age-standardized incidence rate (ASIR), the age-standardized death rate (ASDR), and age-standardized DALY rate were detected on a global level while increasing trends in ASIR were detected in the high-sociodemographic index (SDI) regions. The leukemia burden was heavier in males than in females. By cause, acute myeloid leukemia (AML), chronic myeloid leukemia (CML), and chronic lymphocytic leukemia (CLL) were more likely to impose a burden on the elderly, while acute lymphoblastic leukemia (ALL) showed a greater impact in the younger population. A significant positive correlation was observed between SDI and AAPC in ASIR, while SDI was negatively correlated with AAPCs in both ASDR and age-standardized DALY rate. Smoking remained the most significant risk factor associated with leukemia-related death and DALY, especially in males. Similar deaths and DALYs were caused by smoking and high body mass index (BMI) in females. Future projections through 2030 estimated that ASIR and ASDR will continue to increase, while the DALY rate is predicted to decline. Conclusions. Patterns and trends of leukemia burden are correlated with SDI. The estimated contributions to leukemia deaths indicate that timely measures are needed to reduce smoking and obesity.

The prognostic impact of cigarette smoking on survival in acute myeloid leukemia with TP53 mutations and/or 17p deletions

Cigarette smoking has been associated with increased risk of developing acute myeloid leukemia (AML) in adults. There is limited data on the impact of smoking in AML patients with certain cytogenetic abnormalities. The aim of this study is to assess whether cigarette smoking affected the survival outcome of patients with newly diagnosed AML with TP53 alterations. We conducted a retrospective study of patients who were diagnosed with AML at the Thomas Jefferson Hospital with presence of TP53 mutations and/or 17p deletions. Patients' sex, age, race, smoking status (ever vs. never), cytogenetics, mutational profile, induction regimen, and induction response were analyzed. A total of 102 patients were included in the study with a median follow-up of 27.8 months. Among 100 patients who had documentation of smoking status, 59 patients (59%) were ever-smokers and 41 (41%) were never-smokers. Kaplan-Meier survival analysis showed that never-smokers did not differ in overall survival (OS) when compared to ever-smokers (P = 0.34). Univariate analysis revealed that age and cytogenetics had a statistically significant impact on survival. In multivariate analysis incorporating sex, age, race, smoking status, cytogenetics, and induction regimen as covariates, cytogenetics and induction regimen were independent prognostic factors for OS. In summary, no significant difference in OS was found between ever- and never-smokers in AML patients with TP53 alterations. Additional studies are needed to examine the prognostic impact of cigarette smoking in AML with specific cytogenetic abnormalities.

Acute myeloid leukaemia in patients we judge as being older and/or unfit

The definition of older age in AML is arbitrary. In the context of the clinical studies, it starts with age ≥60 or ≥65 years and in recent years ≥70 or 75, depending on the selection of the studied population. In clinical practice, with older age, we often mean that the patient is unfit for intensive chemotherapy. Higher age overlaps with categories such as worse performance status, unfitness, comorbidities, poor-risk cytogenetics, adverse mutation patterns, age-related clonal haematopoiesis and specific disease ontogeny. Intensive induction therapy can result in prolonged overall survival, at least in a subset of elderly patients aged up to 75 years despite the reluctance of some physicians and patients to use treatment regimens perceived as toxic. Venetoclax and azacitidine combination is the new standard of comparison for persons unfit for intensive therapy. New oral hypomethylating agent CC-486 as maintenance therapy led to a prolonged overall survival in a randomized trial of patients ≥55 years of age who were in first complete remission, but not eligible for allogeneic stem cell transplantation. Any therapy is better than no therapy, but a substantial proportion of older patients still receive only palliative care. Making a decision for AML diagnosed in older age should be individualized and shared through the dialog with the patient and relatives or cohabitants, considering medical issues and social factors including personal goals. Although we are witnesses of the advances in basic research and therapy, we are still a very long way from curing older patients with AML.

Correlation between tobacco control policies and mortality of haematological cancers across Europe: An ecological study

INTRODUCTION

To determine the correlation between tobacco control policies and mortality of haematological malignancies: leukemia, lymphoma and multiple myeloma (MM).

METHODS

Ecological study with the countries as the unit of analysis. Tobacco Control Scale (TCS) scores from 2010, 2013 and 2016 were used as measures for the level of tobacco control policy implementation in 27 European countries. Mortality rates for leukemia, lymphoma, and MM, were obtained from the WHO Mortality Database and the European Cancer Information System for each country for 2010, 2013, 2015 and 2018. Correlation between yearly TCS scores and mortality rates from the same and prospective years were calculated using Spearman's rank correlation coefficients (r_sp) and 95% confidence intervals (95% CI) (2010 TCS scores vs 2010, 2013, 2015, 2018 mortality rates; 2013 TCS scores vs 2013, 2015, 2018 mortality rates; and 2016 TCS scores vs 2018 mortality rates).

RESULTS

The 2010 TCS scores were significantly negatively associated with leukemia mortality rates in 2013 (r_sp=-0.58; 95% CI: -0.79, -0.24; p=0.002), 2015 (r_sp=-0.65; 95% CI: -0.85, -0.30; p=0.001) and 2018 (r_sp=-0.44; 95% CI: -0.71, -0.06; p=0.021). TCS scores from 2013 and 2016 had significant negative associations with leukemia mortality in all prospective years. TCS scores did not demonstrate consistent correlations with lymphoma and MM mortality.

CONCLUSIONS

The level of tobacco control policies in European countries correlates negatively with leukemia mortality at ecological level, with no correlation seen for lymphoma and MM. This study advocates that increased tobacco control implementation may improve leukemia mortality.