Acute Myeloid Leukemia Practice Pearls: Key Points in Pathway Identification

Acute myeloid leukemia (AML) is the most frequently occurring cause of acute leukemia in adults. This aggressive form of cancer is diagnosed in approximately 21,000 individuals annually in the United States and slightly more than half will die each year. In a Pharmacy Times® Practice Pearls video series, experts discussed best practices in the management of AML, including patient identification, formulary decisions, and providing therapy from an outpatient setting for optimal patient care.

The panelists—Katie Culos, PharmD, BCOP, a hematology/oncology clinical pharmacist at Vanderbilt University Medical Center in Nashville, Tennessee; Amanda Brahim, PharmD, BCOP, BCPS, BCACP, a hematology/oncology clinical pharmacist at Memorial Cancer Institute in Pembroke Pines, Florida; and Yehuda Deutsch, MD, a hematologist/oncologist in the Department of Malignant Hematology and Cellular Therapy at Memorial Cancer Institute—noted that myriad factors are involved in determining the appropriate care pathway for patients with AML.

Practice Pearl 1: Pathway Identification

The panelists noted that the first types of tests for patients are generally a complete blood count, blood smear, a bone marrow aspiration, and biopsy.

“Then we could do some additional imaging tests. Just for the sake of completeness, we get a comprehensive metabolic panel and then we’ll do some more specific molecular tests as well,” Brahim said.

Deutsch added that cytogenetic and molecular testing are vital in AML, both for prognostic information, or outcomes, and for deciding on treatment.

“There are times when patients are referred to us when there are certain tests that either have not been done or not resulted, and sometimes we will repeat these tests in order to make sure we have the correct information to make the right decision for treatment,” he said.

The panel emphasized the importance of cytogenetic and molecular results in the diagnosis, treatment, and outcomes in AML, which is why it’s important to have test results before starting treatment. The cytogenetic and molecular tests are typically collected with the bone marrow biopsy and aspiration.

“The tests that we need to do are cytogenetic analysis, which includes chromosome analysis or karyotype; FISH [fluorescence in situ hybridization] testing; as well as molecular testing, either with NGS (next-generation sequencing) or PCR. There are panels that can be performed, that include an AML-type of FISH panel or MDS-FISH panel,” he said. “In terms of molecular testing, there also are single mutations that can be looked for or a full panel, a full myeloid panel. We typically collect these specimens. In terms of the molecular testing, it’s important to have testing for those mutations that are prognostic, that are predictive, that are biomarkers, and that can be targeted. So, these include, but they’re really not limited to, FLT-3 mutations, including the ITD and TKD, IDH1, IDH2 mutations, TP-53, ASXL1, RUNX1, as well as many other mutations.”

Beyond the diagnostic information, there are several other factors that must be taken into account when deciding the optimal treatment regimen for patients, according to the panel.

“In terms of the patient characteristics, this is important, we do take into account age. However, age is sometimes just a number, and there are plenty of older patients who are very well fit. It’s a matter of fitness and comorbidities, as well as supportive care and people that they have around them to help take care of them,” Deutsch said. “Patients that are typically over the age of 75, who likely are less fit and likely with more comorbidities, they’re patients that probably will not be candidates for intensive induction chemotherapy. However, that does not absolutely exclude them from that. Patients that are in their 60s and 70s, they sometimes are more in a grey zone, where we have to really take into account their comorbidities to determine if they are candidates for therapy, for intensive chemotherapy.”

Click here for the full Pharmacy Times® Practice Pearls video series on AML.