Journal of Leukemia

ISSN: 2329-6917

Journal of Leukemia
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on Medical, Pharma, Engineering, Science, Technology and Business

Approach to AML Treatment. Survey Results from the 6th International Hematologic Malignancies Conference: Bridging the gap 2015,Beijing,China

Kaiyan Liu1, Pankaj Malhotra2, Simrit Parmar3*, Raymond Wong4, Steve Kornblau3, Vikram Mathews5, David Ritchie6, Jiong Hu7, Suraopl Issaragrisil8, Borje Andersson3, Elizabeth J Shpall3, Richard Champlin3 and Xiao Jun Huang1

1Peking University, Beijing, China

2Post Graduate Institute of Medical Education and Research, Chandigarh, India

3MD Anderson Cancer Center, USA

4Chinese University of Hong Kong, China

5Christian Medical College and Hospital, Vellore, India

6Royal Melbourne Hospital, Australia

7Ruijin Hospital, Shanghai, China

8Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

*Corresponding Author:
Simrit Parmar
Department of Stem Cell Transplantation and Cellular Therapy
The University of Texas M. D. Anderson Cancer Center
Houston, TX, 77030, USA
Tel: 713-745-5592
Fax: 713-792-3459

Received date: May 28, 2015; Accepted date: June 05, 2015; Published date: June 15, 2015

Citation: Liu K, Malhotra P, Parmar S, Wong R, Kornblau S, et al. (2015) Approach to AML Treatment. Survey Results from the 6th International Hematologic Malignancies Conference: Bridging the gap 2015, Beijing, China. J Leuk 3:186. doi: 10.4172/2329-6917.1000186

Copyright: © 2015 Liu K, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Leukemia

For the past six years, the Asia-Pacific Hematology Consortium (APHCON), through its Bridging the Gap (BTG) conference series has convened Asia’s top hematologists and oncologists to share their practical knowledge and experiences. In addition to the high informational value of panelist and speaker presentations, we wish to learn directly from conference participants. This year in Beijing, we deployed a survey in hopes of discovering answers to the following questions: What are the common standards of care in Asia’s hematology oncology community? Which of these are best practices? In which scenarios are the treatment strategies controversial or in disagreement? What educational or material needs remain to be met? This letter represents the first in a series of survey summaries that detail the state of the art in hematology oncology in the Asia-Pacific sphere. Our aim is to spark a conversation that addresses areas of opportunity for improving patient care and physician support.

In this letter we present the results of the first survey, focused on Acute Myeloid Leukemia (AML) (Table 1). We asked 16 questions regarding treatment preferences among 86 physicians from China and 27 physicians from other countries including Australia, India, Japan, Nepal, Thailand and the United States of America. The per-question response rate was 87% for Chinese physicians and 67% for the others. Unless we state otherwise, we report survey results as the percentage of respondents, excluding those who did not provide an answer to a particular question.

Question a,bResponses No Response
1. What is your induction regimen of choice for newly Diagnosed AML? Standard 7+3 Induction Clofarabine Based Therapy High Dose Cytarabine Clinical Trial  
China 91%; Other 78% 4, 17% 2, 4% 2, 0% 4, 15%
2. What is your ideal induction regimen for adolescent AML? Standard 7+3 Induction Cytarabine/dauno-rubicin/etoposide Clinical Trial Clofarabine/Cytarabine  
68, 60% 12, 20% 10, 15% 10, 5% 9, 26%
3. What is your induction regimen for elderly (>60 yrs) AML? Hypomethylating agents Standard 7+3 Induction Clinical Trial Intermediate dose Cytarabine  
49, 44% 24, 22% 21, 17% 6, 17% 12, 33%
4. Which hypomethylating agent do you prefer to use for AML induction? Decitabine Azacytidine      
77, 33% 23, 67%     14, 33%
5. Based on recent data, would you use Sorafenib as part of AML induction regimen? I need more data FLT3 positive AML All AML patients No  
44, 45% 43, 50% 10, 5% 2, 0% 6, 8%
6. In the era of Sorafenib, do you recommend allogeneic stem cell transplant for FLT3+ve AML? Yes No      
91, 86% 9, 14%     10, 22%
7. Would you recommend Sorafenib maintenance in post-allogenic transplant setting? Yes, only if FLT3 remains positive Yes, in all patients No    
10, 15% 15, 22% 74, 55%   9, 26%
8. Do you recommend allogeneic stem cell transplant in CR1 AML? Only in High Risk AML MRD positive AML FLT3 AML All of the above  
25, 12% 4, 6% 0, 6% 71, 75% 12, 41%
9. Would you recommend allogeneic stem cell transplant in CR1 AML with diploid cytogenetics? Yes Yes, only if MRD positive No    
43, 53% 51, 27% 5, 20%   14, 44%
10. Do you recommend allogeneic stem cell transplant in CR1 Secondary AML? Yes No      
95, 94% 5, 6%     13, 41%
11. Based on recent data, would you use Gemtuzuman ozogamicin (e.g. Mylotarg) in AML induction? Yes No      
38, 53% 62, 47%     14, 30%
12. Do you use NK Cell Therapy in treatment of AML? Yes No      
28, 12% 72, 88%     21, 41%
13. Do you routinely offer intrathecal therapy to AML patients with CNS involvement? Yes No Only if CSF < 5 Blasts    
91, 76% 2, 24% 7, 0%   19, 37%
14. What is your induction regimen for APL? ATRA/Arsenic Daunorubicin/ATRA Clinical Trial    
78, 29% 19, 59% 3, 12%   14, 37%
15. If available, would you use Oral versus Intravenous Arsenic? Oral Arsenic Intravenous Arsenic      
74, 75% 26, 25%     15, 40%
16. Are you concerned about cardiac side effects of Arsenic Trioxide? Yes, in all patients Yes, only in older patients No    
60, 63% 33, 31% 7, 6%   16, 41%

Table 1: AML survey questions and response rates.

In cases of newly diagnosed AML, a wide margin of all survey respondents (91% China, 78% other) chose the Standard 7+3 induction regimen. A minority of non-Chinese respondents (17%) indicated a preference for high dose cytarabine from the outset. When asked specifically about AML induction in adolescents, again a majority of physicians in our survey (68% China, 60% other) recommended Standard 7+3. The remaining responses were split among clinical trials, cytarabine + daunorubicin + etoposide, and clofarabine + cytarabine. The less common implementation of these induction regimens may be due to several factors. First, a smaller amount of data supports alternative approaches versus decades of experience implementing the Standard protocol [1]. However, recent and ongoing clinical studies are adding to the body of evidence. A European trial (EORTC-GIMEMA AML-12), for example, found improved outcomes for patients under 46 years of age for higher dosages of cytarabine in conjunction with daunorubicin and etoposide [2]. This more aggressive induction raises the concern of availability of chemotherapy agents for higher doses or longer dosage periods. While Standard 7+3 remains the most common induction regimen, further studies, the availability of biosimilars, and ongoing education and knowledge dissemination may shift the paradigm for AML induction in younger patients.

For older (>60 yrs) patients, a plurality of physicians (~48% of all respondents) would recommend hypomethylating agents (HMAs) for AML induction. Evidence is mounting that HMAs provide better outcomes for this age demographic in terms of increased survival and quality of life, with less treatment-re

lated death, than do traditional chemotherapies [3]. Nevertheless, the remainder of physicians split their response between Standard 7+3, clinical trials, and intermediate doses of cytarabine. Decitabine is the most recommended HMA in China (77%), while respondents from other countries prefer Azacytidine (67%). This difference likely reflects regional variations in drug availability and physician training. Observations from both preclinical and phase II studies indicate these chemicals possess different activities and are not biologically equivalent. Yet, neither has shown a major efficacy advantage [3].

Targeted therapies using kinase inhibitors are beginning to show more promise in clinical settings, and are gaining ground in the West. Sorafenib is one such compound with activity against mutant FMS-like tyrosine kinase 3 (FLT3). The bulk of our survey respondents were split between those who recommend Sorafenib for FLT3+ AML and those who require more information on the drug before they add it to their treatment regimen, with about 44% of all respondents in each camp. Recent phase II trials incorporating Sorafenib report some efficacy in achieving complete remission (CR) in younger patients, and warrant further trials [4]. The drug has a propensity, however, to select for resistant mutants. Taking a cautious “wait-and-see” stance is consistent with the call for more clinical evidence from the United States’ National Comprehensive Cancer Network (NCCN) [1].

A large majority of survey respondents (~90%) recommend Allogeneic Stem Cell Transplantation (SCT) for FLT3+ve AML. Several studies demonstrate a potential benefit of STC in patients with poor prognoses due to FLT3 mutations [5]. Nevertheless, relapse was common in these patients. A majority of our respondents (74% China, 55% other) would recommend Sorafenib after SCT only if the FLT3 positive diagnosis persists, with a smaller group (10%, 15%) favoring Sorafenib after SCT in all cases. Nearly three quarters (~72%) of all respondents recommend SCT in all cases of CR1 AML, while most of the remaining physicians reserve this treatment for high-risk patients. For instance, among the physicians we surveyed, many would recommend SCT in CR1 AML with diploid cytogenetics (43% China, 53% other), especially in patients showing minimal residual disease (MRD, 51% China, 27% other). For CR1 secondary AML, the opinion in favor of SCT is nearly unanimous (95%).

Less popular treatments for AML included Gemtuzuman ozogamicin (GO, e.g., Mylotarg) or NK cell therapy. In both cases, over 50% of physicians would not recommend these options. Still, over a third of survey respondents would use GO. This drug has been voluntarily removed from the U.S. market following reports of some harmful side effects. But physicians in the West and in Asia see a utility for the treatment, especially in older patients who cannot tolerate the toxicity of aggressive chemotherapy regimen [6,7]. Only about one quarter of all survey respondents were inclined to use Natural killer (NK) cell therapy in treating AML. NK cell therapies must overcome numerous limitations, such as in vivo survival and target specificity, before becoming a more widely used and viable treatment for AML [8].

CNS involvement in AML is rare, but we lack sufficient data to know just how infrequent or possibly overlooked this condition actually is. Most survey respondents routinely offer intrathecal therapy for AML patients with CNS involvement, especially physicians from China. Intrathecal induction is highly recommended by the NCCN guidelines [1]. Meanwhile, the results of a recent retrospective, single-institution study challenge the necessity of targeted CNS therapy versus modern approaches such as SCT [9]. Given the rarity of these cases, additional retroactive data analyses that consider past and modern treatments will be vital to clarifying the best approach.

We also asked physicians about their induction regimen for Acute Promyelocytic Leukemia (APL). Ninety-five percent of all respondents recommended a course that explicitly includes all-trans retinoic acid (ATRA). This group was split between ATRA+arsenic trioxide (ATO, 78% China, 29% other) versus ATRA+daunorubicin (19% China, 59% other). Both are valid alternatives under varying circumstances, supported by considerable clinical data and recommended by the NCCN [1,10,11]. Recent non inferiority studies have shown that ATRA+ATO may offer advantages such as decreased adverse events and hematologic toxicity in low- to intermediate-risk APL patients [12].

In administering ATO, 75% of all survey respondents say they prefer oral to intravenous arsenic. Over 60% of physicians are concerned about cardiac side effects of ATO irrespective of patients’ age, and another 33% of respondents are concerned in older patients. Thus over 93% of all survey respondents expressed some concern over this widely employed and efficacious treatment. These trends were nearly identical between respondents from China and other nations, and underscore a desire among physicians for an ATO-based treatment with less potential for deleterious side effects.

Overall, the trends in treatment preference were quite similar among physicians regardless of nationality (Figure 1). Few questions showed a marked difference based on nationality: whether to use GO; which HMA to administer; what conditions warrant SCT in CR1-AML; and the use of ATO or chemotherapeutic in conjunction with ATRA to treat APL. The high level of global accord in the survey reflects successful communication of standards of care and the willingness of physicians of various backgrounds to integrate new ideas into their thinking. The high level of agreement allows us to readily identify questions of diagnosis and treatment that lack consensus, and to highlight areas that need more research, more clinical data, and better communication among our colleagues.


Figure 1: Physicians from China and other represented countries responded similarly to survey questions about AML treatment. The data points (open circles) correspond to all possible answers to the 16 AML survey questions. The axes represent the percentage of respondents from China (vertical) and all other included countries (horizontal) who selected a given answer. The dotted line is a best-fit regression with an r2 value = 0.72.

Patient care in burgeoning populations improves dramatically when more physicians are represented in the global knowledge base. We believe our survey takes a giant step toward giving underrepresented physicians a greater voice in the worldwide conversation.


Select your language of interest to view the total content in your interested language
Post your comment
Share This Article
Relevant Topics
Disc Acute Lymphoblastic Leukemia
Disc Acute Megakaryocytic Leukemia
Disc Acute Myelomonocytic Leukemia
Disc Acute Myleoid Leukemia
Disc Advances in Alternative Lung Cancer Treatment
Disc Aleukemic Leukemia
Disc Anaemia Symptoms
Disc Anemia Causes
Disc Anti-Cancer Drug
Disc Antiphospholide Antibody Syndrome
Disc Autoimmune Disorder
Disc Autoimmune Haemolytic Anaemia
Disc Blood
Disc Blood Cancer
Disc Blood Cancer Symptoms
Disc Blood Clot in Brain
Disc Blood Clots
Disc Blood Group
Disc Blood Lymphocytes
Disc Bone Cancer Stages
Disc Bone Marrow Cancer Survival
Disc Brain Tumor Treatment
Disc Cancer Science
Disc Cancer Therapies
Disc Cancer therapy
Disc Cellular Oncology
Disc Chemo Resistance
Disc Chronic Lymphocytic Leukemia
Disc Chronic Myleloid Leukemia
Disc Clinical Oncology
Disc Comparative Oncology
Disc Dental Oncology
Disc Electro Chemotherapy
Disc Eosinophilia
Disc Esophageal Cancer
Disc Factor XIII
Disc Feline Leukemia Complex
Disc Genitourinary Oncology
Disc Gynecological Cancers
Disc Haematologist
Disc Haemolytic Anaemia
Disc Haemolytic Disease of the Newborn
Disc Haemophilia
Disc Haemostasis
Disc Hairy Cell Leukemia
Disc Interventional Oncology
Disc Iron Test
Disc Juvenile Myelomonocytic Leukaemia
Disc Kidney Cancer Prognosis
Disc Large Cell Lymphoma
Disc Leukemia
Disc Leukemia Drugs
Disc Leukemia Symptoms
Disc Leukopenia
Disc Lung Tumor
Disc Lungs Cancer Cure
Disc Lupus
Disc Lymph Node Cancer
Disc Lymphocytosis
Disc Lymphoma Cancer
Disc Lymphoma Symptoms
Disc Lymphosarcoma
Disc Mast Cell Leukemia
Disc Molecular Oncology
Disc Morbus Hodgkin
Disc Multiple Myeloma
Disc Musculoskeletal Oncology
Disc Myeloma
Disc Neutropenia
Disc Neutrophilic Leukocytosis
Disc Oncology Analytics
Disc Oncology Emergency
Disc Oncology Esthetics
Disc Oncology Nutrition
Disc Oseophagus Cancer
Disc Ovarian Cancer and Prognosis
Disc Pancreatic Cancer
Disc Pediatric Leukemia
Disc Plasma Cell Disorder
Disc Plasma Cell Leukemia
Disc Radio Oncology
Disc Radiotherapy
Disc Red Blood Cells
Disc Sarcoma Cancer
Disc Sickle Cell Disease
Disc Sickle Cell Trait
Disc Spleen Cancer
Disc Squamous Cell Carcinoma
Disc Systematic Lupus Erythematous
Disc T-cell Lymphomas
Disc Thoracic Oncology
Disc Tumorigenesis
Disc Veterinary Oncology
Disc White Blood Cell
Recommended Journals
Disc Blood Disorders Journal
Disc Integrative Oncology Journal
Disc Blood Journal
Disc Chemotherapy Journal
Disc Cancer Science Journal
  View More»
Recommended Conferences
Disc Leukemia and Bone Marrow Transplantation Conference
Nov 10-12, 2016, Istanbul, Turkey
Disc 6th Hematology and Lymph Conference
Nov 14-16, 2016 San Francisco, USA
Article Tools
Disc Export citation
Disc Share/Blog this article
Article usage
  Total views: 11615
  [From(publication date):
June-2015 - Oct 25, 2016]
  Breakdown by view type
  HTML page views : 7841
  PDF downloads :3774

Post your comment

captcha    Reload  Can't read the image? click here to refresh

OMICS International Journals
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
OMICS International Conferences 2016-17
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri, Food, Aqua and Veterinary Science Journals

Dr. Krish

1-702-714-7001 Extn: 9040

Clinical and Biochemistry Journals

Datta A

1-702-714-7001Extn: 9037

Business & Management Journals


1-702-714-7001Extn: 9042

Chemical Engineering and Chemistry Journals

Gabriel Shaw

1-702-714-7001 Extn: 9040

Earth & Environmental Sciences

Katie Wilson

1-702-714-7001Extn: 9042

Engineering Journals

James Franklin

1-702-714-7001Extn: 9042

General Science and Health care Journals

Andrea Jason

1-702-714-7001Extn: 9043

Genetics and Molecular Biology Journals

Anna Melissa

1-702-714-7001 Extn: 9006

Immunology & Microbiology Journals

David Gorantl

1-702-714-7001Extn: 9014

Informatics Journals

Stephanie Skinner

1-702-714-7001Extn: 9039

Material Sciences Journals

Rachle Green

1-702-714-7001Extn: 9039

Mathematics and Physics Journals

Jim Willison

1-702-714-7001 Extn: 9042

Medical Journals

Nimmi Anna

1-702-714-7001 Extn: 9038

Neuroscience & Psychology Journals

Nathan T

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

John Behannon

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

1-702-714-7001 Extn: 9042

© 2008-2016 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version