Considerations regarding maintenance therapy for acute myeloid leukemia in remission

ABSTRACT

Introduction

For most adult patients with acute myeloid leukemia, relapse is characteristic of the disease. When allotransplant in first complete remission is administered as consolidative therapy, relapse is still common, affecting 20–40% of recipients. Maintenance of remission with low-dose treatments may hold promise in preventing relapse.

Areas Covered

Improvements in the detection of clinical and biological variants of disease allow the practitioner to identify which patients, based on disease features, may benefit from therapy directed at residual clonal elements that might contribute to relapse. Along with improvements in methods of detecting residual disease, novel agents are under investigation as a platform in order to maintain remission and may contribute to prolonged survival. In this manuscript, we review literature available through PubMed regarding the use of maintenance therapy, described as post-remission or post-transplant treatment intended to delay or prevent relapse.

Expert Opinion

Although results of randomized studies are limited, a role for maintenance therapy, particularly directed at molecular targets, in distinct settings of post-remission management is recommended. We also advise that randomized studies of immune therapy along with opportunities for further evaluation of risk-agnostic interventions be a focus of cooperative groups.

KEYWORDS:

• AML
• maintenance
• remission
• targets
• therapy
• allogeneic
• transplantation

Article highlights

• The role of maintenance therapy for Acute Myeloid Leukemia in remission requires discrete targets.

• The distinction of maintenance therapy in the post-allogeneic transplant setting follows the model of dose-intensive chemotherapy and adoptive immunotherapy.

• What can we learn from the introduction of oral azacytidine as an approved maintenance therapy in patients with AML in first remission ineligible for dose-intensive management and allogeneic transplantation is that prolonged, low-dose medication may delay or prevent disease relapse for a subset of patients.

• Potential maintenance strategies directed against leukemia-specific mutations after allogeneic transplantation have demonstrated the feasibility, and likely the efficacy of post-transplant maintenance.

• Immunotherapy as a risk-agnostic approach to maintenance after allogeneic transplantation may be the only option available to the majority of patients whose disease is not characterized by unique disease targets.

Declaration of interest

GJ Schiller has received grants or contracts from; AbbVie, Actinium, Actuate, Agios, Arog, Astellas, Amgen Aptevo, AltruBio, AVM Bio, Bristol Myers Squibb/Celgene, Biopath, BioMea, Biosight, Cellularity, Celator, Constellation, Cogent, Cellectis, Daiichi-Sankyo, Deciphera, Delta-Fly, Fate, Forma, FujiFilm, Gamida, Genentech-Roche, Glycomimetics, Geron, Gilead, Incyte, Karyopharm, Kiadis, Kite/Gilead, Kronos Bio, Kura, Janssen, Immunogene, Loxo, Marker, Mateon, Onconova, Pfizer, PrECOG, Regimmune, Samus, Sangamo, Sellas, Stemline, Syros, Takeda, Tolero, Trovagene, Agios, Amgen, Jazz, Orca, Ono-UK, Novartis. GJ Schiller has also received consulting fees from; Bristol Myers Squibb, Curios, and Daiichi, has received honoraria and is on the speakers’ bureau for Agios, Gamida, Gilead, Incyte, Amgen, Bristol Myers Squibb, Novartis, Ono Pharma, AVM Biotech, and GSK, is on the speakers’ bureau for AbbVie, Astellas, Celgene, Karyopharm, and Stemline and has received honoraria from AZ. GJ Schiller serves on the board/advisory committee member for Agios, Gamida, Gilead, Incyte, Amgen, Bristol Myers Squibb, Novartis, Ono Pharma, AVM Biotech, GSK and AZ and holds stock in Amgen, Bristol Myers Squibb, and Janssen/J&J. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.