Practice Pearl 1: Categorizing Patients for Treatment in AML

Experts in the area of acute myeloid leukemia discuss categorizing patients for treatment based on molecular testing results.

Katie Culos, PharmD, BCOP: Amanda, give us the insight from your perspective as the pharmacist. We know that we are collecting as much information as we can, and Yehuda talked about a lot of very important biomarkers that we need to make our best treatment options. How does this information affect your recommendation for treatment?

Amanda Brahim, PharmD, BCOP, BCPS, BCACP: Up until 2 years ago, probably not much. Luckily, in the last couple of years we’ve had a number of new targeted agents that have been approved. It is something that now not only have we recognized as prognostic factors, but targeted molecular entities to target these aberrations. As pharmacists, we have so many more drugs in our armamentarium. When we get the results back of cytogenetics and specific mutations, we do use those, prior to rounds, to come up with a more appropriate treatment recommendation to bring to the physicians.

Katie Culos, PharmD, BCOP: Are there certain patients for whom you will wait to get all of the information before treating?

Amanda Brahim, PharmD, BCOP, BCPS, BCACP: The ones where we’re talking about intensive induction chemotherapy, we do want to know if it is secondary AML or myelodysplasia-related changes, so we’ll typically wait for those, because that’s an important decision point on whether or not we’re going to use our traditional 7+3 intensive chemotherapy induction or if we would use the newer liposomal variant with daunorubicin and cytarabine in a 5:1 molar ratio, which we refer to as CPX351. That is one example of an important decision point where we do need to have that information before initiating therapy.

Katie Culos, PharmD, BCOP: Thank you. Yehuda, outside of all of this diagnostic information that we receive, what are some additional factors that you take into account when you’re deciding the optimal treatment regimen for your patients?

Yehuda Deutsch, MD: As you mentioned, we have to take into account a lot of factors. Those factors include patient-related factors, as well as the disease-related factors, you mentioned the cytogenetic and molecular features. 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.

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.