Traditionally, treatment stratification for acute myeloid leukemia (AML) has been based on age. In general, once a patient reaches the age of 75 years, their ability to safely receive intensive chemotherapy with a reasonable chance of response declines, says Jeffrey Lancet, MD. However, treatment biology is now recognized as playing a major role in prognosis.

Individuals with complex cytogenetics, adverse karyotypes, and specific mutational abnormalities will fare poorly with chemotherapy and should be stratified toward a clinical trial, notes Lancet. Several factors should be considered when assessing a patient with AML, including the chances of cure with chemotherapy alone and whether the individual is eligible for transplant, Raoul Tibes, MD, adds.

In general, patients up to 60 years of age with intermediate or high-risk cytogenetic disease are thought to benefit from transplant. Overall, patients with intermediate or high-risk disease with a sibling donor younger than 60 years should be considered for transplant in first remission, Lancet notes. Current data suggests that patients with AML will benefit the most from a sibling allogeneic transplant. At this time, the role of unrelated or alternative donor transplants is still uncertain.

Conducting minimal residual disease testing prior to transplant may have potential prognostic value for outcomes in AML, Mark R. Litzow, MD, suggests. Lancet adds that molecular genetic risk stratification systems are also starting to affect transplant decisions.