AML treatment evolves constantly. This serves to document our latest FHCC local consensus practice. Individual treatments decisions will be a product of discussions between providers and patients.
This site is not meant to substitute for clinical judgement, but rather outlines the considerations providers will make, and pulls data that maybe useful in deciding treatment of AML patients. By making these considerations explicit, treatment hopefully will be more uniform and consistent across providers.
Initial evaluation is detailed here.
FHCC adopts the European Leukemia Net (ELN) approach to risk stratification with closely mirrors the world health organization international consensus classification of myeloid malignancies. ELN was recently updated here
The number of first degree relatives should be documented - siblings, children, parents, and their vital status and general health should be noted, as a preliminary to consideration of future transplant. The presence or absence of a caregiver is especially important to note.
In general, every effort should be made to enroll patients on an appropriate clinical trial if available.
It should be stressed that clinical trials should not be offered to patients unless patient participation is appropriate. Patient participation is only appropriate if (a) in the context of randomized trials, any arm to which the patient maybe randomized would be considered an optimal or appropriate treatment, or if (b) in the context of non-randomized trials, the treatment on the trial would be expected to be as good as any 'standard' treatment the patient could receive in the context of usual (i.e. non-trial) care.
In all cases assessing whether clinical trial participation is appropriate requires shared decision making with the treating physician. The value of standard treatment depends on the expected risks and benefits. Use of intensive therapy as salvage among patients who relapse within 6 months after transplant is associated with poor response rates (~25%) and a median overall survival of only ~6 months. Whether this benefit is worth the toxicity should be the subject of a discussion between physicians and their patients.
In some cases, randomized trials have demonstrated that superior outcomes when compared to control treatments. Such findings do not preclude the ethical enrollment of a patient on a clinical trial. As an example, among patients with relapsed AML w/ FLT3-ITD mutations, targeted therapy with gilteritinib resulted in survival that was longer than with intensive chemotherapy; https://www.nejm.org/doi/full/10.1056/nejmoa1902688. Nevertheless the median event-free survival of patients treated with gilteritinib was only 2.7 months. Some patients may decide that the magnitude of benefit from standard therapies (i.e. gilteritinib) was so small as to be inconsequential, and as a result that consideration of trial therapy is reasonable. While, as a result of these data, especially strong pre-clinical data may be needed to justify treating patients with relapsed AML w/ FLT3-ITD on a trial rather than with gilteritinib, such a patient may understandably consider the benefit of participating in clinical research and developing new knowledge as a balance to the uncertain efficacy of a novel therapeutic approach.
Our current portfolio of clinical trials is available here.
- Characterization of disease risk and treatment
- Disease identity and prognosis
- Risk stratification
- Consideration of fitness for intensive chemotherapy
- Initial treatment of fit patients
- Initial treatment of unfit patients
- Treatment of fit relapsed patients
- Treatment of unfit relapsed patients
- Transplantation
- Management of Relapses after Transplantation
- Infection prophylaxis
- Management of Febrile Neutropenia
- Management of Antiplatelet Agents in Patients with Coronary Artery Disease
- Supportive Transfusion of Blood Products
- Pain Management in Patients with Liquid Tumors
- Psychosocial Supports and Cancer-Related Distress
- End of Life Care & Hospice