Newly-diagnosed Acute Myeloid Leukemia Research Articles

Increased Th17 and Treg levels in peripheral blood positively correlate with minimal residual disease in acute myeloid leukaemia.

Immune dysregulation plays a key role in acute myeloid leukemia (AML). We aimed to explore the correlation between T helper cell 17 (Th17) and the regulatory cells (Tregs) in the peripheral blood of patients with newly diagnosed (ND) AML and bone marrow blast cells, as well as minimal residual disease (MRD) before and after treatment. Changes in Th17 and Treg cells in the peripheral blood of 32 patients with ND AML were observed before and after induction chemotherapy with cytarabine for seven days and anthracycline for three days. The levels of inflammatory cytokines were measured using an enzyme-linked immunosorbent assay. Correlation analysis between bone marrow blast cells and Th17 and Treg cell frequencies was performed using the Pearson's correlation test. Frequencies of Th17 and Treg cells and MRD were assessed using flow cytometry. IL-6, IL-10, IL-17A, and GM-CSF levels gradually increased in patients with ND AML and CR and NR patients. The percentages of Th17 and Treg cells positively correlated with those of blast cells. In addition, the frequencies of Th17 and Treg cells in MRD-positive patients were higher than those in MRD-negative patients at the initial induction and after three months of chemotherapy. The frequencies of Tregs and Th17 cells positively correlated with MRD onset. Increased Th17 and Treg cell levels were positively correlated with onset of AML, poor remission, and MRD.

Abstract 3821: Real world outcomes among patients with newly diagnosed acute myeloid leukemia

Abstract Introduction: Treatment options for patients with acute myeloid leukemia (AML) have expanded in recent years. Although new treatments have demonstrated efficacy in clinical trials, less is known about their effect on outcomes in routine clinical practice. We examined outcomes for patients with newly-diagnosed AML (ND-AML) using real world data (RWD). Methods: This retrospective observational study was conducted using the COTA real-world (rw) database, a de-identified source of longitudinal electronic health record data pertaining to the diagnosis, management, and outcomes of patients with cancer. Adult patients with ND-AML, diagnosed January 1, 2013 to March 20, 2023 were included. First-line treatment regimens were grouped into therapeutic categories and outcomes were summarized. The index date was defined as date of initiation of first-line therapy. Results: Among 2516 patients with ND-AML included (Table), the most common regimens used were intensive chemotherapy with cytarabine (IC w/ara-C), hypomethylating agents with venetoclax (HMA+ven), and HMA alone. Complete response rate was highest in patients treated with IC w/ara-C or investigational regimen(s). Median overall survival (OS) was 16 mo overall, with highest median OS seen in patients treated with IC w/ara-C and investigational regimen(s). Median OS for patients treated with HMA+ven was 13.5 mo. Thirty-day mortality was lowest in patients treated with IC w/ara-C, CPX-351 (liposomal daunorubicin + cytarabine), and HMA+ven. Conclusions: Results suggest that IC w/ara-C remains the standard of care for most patients with ND-AML and this regimen has a higher CR rate and median OS. Variation of patient demographics and clinical characteristics across treatment groups did not permit cross-treatment comparisons, though future analyses evaluating these subgroups may provide further insight into effectiveness and safety of AML regimens in routine care for populations underrepresented in clinical trials. rwCR rate Median rwOS 30-day mortality N % (95% CI) Months (95% CI) % (95% CI) Overall 2516 45.3 (43.2, 47.3) 16.0 (14.9, 17.3) 5.9 (5.0, 6.8) IC w/ara-C 1171 60.6 (57.8, 63.4) 36.4 (31.0, 46.0) 1.6 (0.9, 2.3) HMA+ ven 300 33.7 (28.3, 39.3) 13.5 (11.4, 15.5) 3 (1.1, 4.9) Decitabine 242 12.8 (8.9, 17.7) 8.4 (6.7, 9.9) 10.4 (6.5, 14.2) Azacitidine 206 7.8 (4.5, 12.3) 7.2 (5.3, 9.6) 10.7 (6.4, 14.8) Investigational 206 61.6 (54.6, 68.3) 21.3 (15.2, 27.8) 3.4 (0.9, 5.9) Lower dose cytarabine 62 12.9 (5.7, 23.9) 8.7 (5.4, 16.1) 14.9 (5.4, 23.4) CPX-351 based 61 55.7 (42.4, 68.5) 9.3 (7.3, 15.1) 0.0 No treatment 188 NA 1.9 (1.5, 2.8) 30 (22.7, 36.6) Citation Format: Elizabeth D. Pulte, Laura L. Fernandes, Joseph Wynne, Eric Hansen, Andrew J. Belli, Anna Barcellos, Christina M. Zettler, Rebecca Bystrom, Jonathon Vallejo, Wenjuan Gu, Catherine Lerro, Kelly Norsworthy, Angelo DeClaro, Marc R. Theoret, Donna Rivera, Ching-Kun Wang. Real world outcomes among patients with newly diagnosed acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3821.

Work absenteeism, disability, and lost wages among patients with acute myeloid leukemia and their caregivers: a cohort study using US administrative claims and productivity data

ABSTRACT Objective We describe the impact of acute myeloid leukemia (AML) diagnosis on workplace absenteeism and disability days among patients and their caregivers. Methods This retrospective study included adults with newly diagnosed AML (2009–2019) and adult caregivers of patients with newly diagnosed AML, identified from the US Merative™ MarketScan® Commercial Database. The Merative MarketScan Health and Productivity Management Database provided linked patient-level records of workplace absence and short-term (STD) and long-term disability (LTD) data. Endpoints included workplace absence, STD and LTD for patients and caregivers during 12 months pre-AML (baseline) and ≤3 years’ follow-up, and corresponding cost of work loss. Results Patient workplace absence decreased in the months post-AML diagnosis, but the number of STD and LTD leave days claimed increased significantly by sixfold and fourfold, respectively. The proportion of patients making STD leave claims increased within 4–5 months of diagnosis, while the proportion making LTD leave claims increased significantly starting from month 5. Caregiver workplace absence peaked in the first 2 months post-diagnosis and remained elevated versus baseline throughout the study. Conclusion AML diagnosis leads to workplace absenteeism and increased economic burden for patients with AML and their caregivers.

Myelomonocytic and monocytic acute myeloid leukemia demonstrate comparable poor outcomes with venetoclax-based treatment: a monocentric real-world study.

Venetoclax (VEN), a BCL-2 inhibitor, has transformed treatment strategies for elderly and unfit acute myeloid leukemia (AML) patients by significantly improving response rates and survival. However, the predictive factors for VEN efficacy differ from traditional chemotherapy. The clinical relevance of the FAB (French-American-British) monocytic subtype, including M4 and M5, has been debated as a marker for VEN resistance. This real-world study examined 162 newly diagnosed (ND) and 85 relapsed/refractory (R/R) AML patients who received VEN-based therapy at West China Hospital, Sichuan University, from January 2019 to January 2023. We retrospectively collected clinical and treatment data from electronic medical records. The median age of the cohort was 55.5years (range: 16.5-83.5). The composite complete remission (cCR) rate in the entire cohort was 60.7%. Specifically, among newly diagnosed (ND) patients, FAB monocytic subtypes exhibited lower cCR compared to non-monocytic subtypes (55.1% vs. 76.3%, P = 0.007). Additionally, there were no significant differences observed between M4 and M5 subtypes, both in the ND group (61.7% vs. 40.9%, p = 0.17) and the R/R group (38.2% vs. 40%, p > 0.9). Furthermore, the median follow-up was 238 (range: 7-1120) days. ND patients with monocytic subtypes had shorter overall survival compared to non-monocytic subtypes (295days vs. not reached, p = 0.0017). Conversely, R/R patients showed no such difference (204 vs. 266days, p = 0.72). In summary, our study suggests that the FAB monocytic subtype can predict VEN resistance and shorter survival in ND AML patients. Moreover, there is no significant distinction between M4 and M5 subtypes.

Clinical features and outcomes of patients with acute myeloid leukemia: the single-center experience of 668 patients in China

ABSTRACT Objective To investigate efficacy and prognostic factors in the treatment of adult newly-diagnosed acute myeloid leukemia (AML) with or without allogeneic hematopoietic stem cell transplantation (Allo-HSCT). Methods We retrospectively analyzed 668 patients with newly-diagnosed AML (non-M3 type) in the Department of Hematology at Shanghai Changhai Hospital from January 2012 to December 2021. Based on different induction chemotherapy regimens, patients were categorized into an IA (idarubicin, IDA + cytarabine, Ara-C) (3 + 7, regimen) group (n = 303) and a DA (daunorubicin, DNR + cytarabine, Ara-C) (3 + 7, regimen) group (n = 365) with or without allo-HSCT. Minimal residual disease (MRD), complete response (CR), overall response rate (ORR), progression-free survival (PFS), overall survival (OS), and adverse effects (AE) were analyzed and compared. Characteristics significantly associated with overall or progression-free survival (OS or PFS) upon univariate analysis were subsequently included in a Cox proportional hazard model. Results This study used data from 668 AML patients. After induction therapy, the CR rate in the IA group was 70.63% and ORR was 79.87%, which were significantly higher than those in the DA group (with a CR rate of 56.99% and an ORR of 70.14%) (P = 0.0002 and P = 0.0035, respectively). There were no significant differences in drug safety between the two chemotherapy regimens used in IA and DA (P > 0.05). The recurrence rate was lower in patients with an MRD < 0.001 than in patients with an MRD ≥ 0.001. A continuous negative MRD during the period is significant because it is associated with prolonged OS and PFS of AML patients. Data from 100 patients in the two groups who underwent allo-HSCT were analyzed using univariate analysis and the Cox proportional hazards model. From the multivariate analysis, MRD was found to be the only independent predictor of OS (P = 0.042; HR 1; 95%CI 0.00–0.76). Conclusion In the treatment of adult AML patients, IA regimen is associated with a high CR rate and ORR rate and does not increase treatment-related toxicity. IA regimen prolongs OS and PFS in AML patients and reduces the likelihood of leukemia cells’ subsequent infiltration into the central nervous system. There is a high correlation between the level of MRD after treatment and the patient's bone marrow recurrence. To obtain superior treatment effects for patients undergoing allo-HSCT, the MRD should be reduced to less than 0.001 before pretreatment. A negative MRD before allo-HSCT can prolong OS in patients with AML. We examined the clinical characteristics and outcomes of AML patients in China, finding novel information on prognostic factors and primary treatment of AML that may be applicable in routine clinical practice.

Venetoclax and hypomethylating agent combination therapy in newly diagnosed acute myeloid leukemia: Genotype signatures for response and survival among 301 consecutive patients.

Venetoclax + hypomethylating agent (Ven-HMA) is currently the standard frontline therapy for older/unfit patients with newly diagnosed acute myeloid leukemia (ND-AML). Our objective in the current retrospective study of 301 adult patients (median age 73 years; 62% de novo) with ND-AML was to identify molecular predictors of treatment response to Ven-HMA and survival; European LeukemiaNet (ELN) genetic risk assignment was favorable 15%, intermediate 16%, and adverse 69%. Complete remission, with (CR) or without (CRi), count recovery, was documented in 182 (60%) patients. In multivariable analysis, inclusive of mutations only, "favorable" predictors of CR/CRi were NPM1 (86% vs. 56%), IDH2 (80% vs. 58%), and DDX41 (100% vs. 58%) and "unfavorable" TP53 (40% vs. 67%), FLT3-ITD (36% vs. 63%), and RUNX1 (44% vs. 64%) mutations; significance was sustained for each mutation after adjustment for age, karyotype, and therapy-related qualification. CR/CRi rates ranged from 36%, in the presence of unfavorable and absence of favorable mutation, to 91%, in the presence of favorable and absence of unfavorable mutation. At median follow-up of 8.5 months, 174 deaths and 41 allogeneic stem cell transplants (ASCT) were recorded. In multivariable analysis, risk factors for inferior survival included failure to achieve CR/CRi (HR 3.4, 95% CI 2.5-4.8), adverse karyotype (1.6, 1.1-2.6), TP53 mutation (1.6, 1.0-2.4), and absence of IDH2 mutation (2.2, 1.0-4.7); these risk factors were subsequently applied to construct an HR-weighted risk model that performed better than the ELN genetic risk model (AIC 1661 vs. 1750): low (n = 130; median survival 28.9 months), intermediate (n = 105; median 9.6 months), and high (n = 66; median 3.1 months; p < .001); survival in each risk category was significantly upgraded by ASCT. The current study identifies genotype signatures for predicting response and proposes a 3-tiered, CR/CRi-based, and genetics-enhanced survival model for AML patients receiving upfront therapy with Ven-HMA.

Unmet Medical Needs Amongst Older Patients Aged ≥60 Years with Newly Diagnosed Acute Myeloid Leukemia Receiving Intensive Chemotherapy: Experience from a Predominately United States Community Setting

Background: Venetoclax (Ven) in combination with hypomethylating agents is approved for treatment in patients (pts) with newly diagnosed (ND) acute myeloid leukemia (AML) who are ≥75 years old or unfit for intensive chemotherapy (IC), based on the longer median overall survival (OS) with Ven+azacitidine (Aza) compared with Aza in combination with placebo in the Phase III VIALE-A study (NCT02993523). Several studies are now evaluating Ven-based regimens in pts eligible for IC, for example Ven+Aza compared with IC (NCT04801797). Additionally, Ven in combination with cladribine (CLAD) and low-dose cytarabine (LDAC) is currently under investigation in a Phase II single-arm study (NCT03586609) amongst older pts (aged ≥60 years) with ND AML. An interim analysis of this trial evaluated 60 pts where complete remission (CR) and CR with incomplete count recovery (CRi) was observed in 93% of pts, and the median OS, overall and by transplant status, was not reached; 1-year OS was 72.9% and 2-year OS was 63.5% (Kadia et al. J Clin Oncol 2022). The aim of this study is to better understand treatment outcomes amongst older pts (aged ≥60 years) with ND AML receiving IC in a routine clinical care setting in the United States (US). Methods: This was a retrospective cohort study using the Flatiron Health electronic health record-derived, US nationwide, de-identified database. Pts aged ≥60 years with ND AML who initiated IC within 60 days of AML diagnosis (Dx) between January 1, 2014, and November 30, 2022, with ≥2 visits recorded within 3 months of AML Dx, and ≥3 months of follow-up before study end date (February 28, 2023) were included. Clinical trial participants and pts with acute promyelocytic leukemia or core binding factor were excluded. Descriptive analysis on patient characteristics was conducted. The proportion of pts who achieved real-world response (defined as &amp;lt;5% bone marrow [BM] blasts), real-world CR/CRi (defined as &amp;lt;5% BM blast with either platelet count &amp;lt;100 x 10 9/L or absolute neutrophil count &amp;lt;1000 x 10 9/L) and received a stem cell transplant (SCT) post-remission were reported. Thirty-day mortality, 60-day mortality, 1-year real-world OS (rwOS), and 2-year rwOS were evaluated using Kaplan-Meier (KM) analyses. The starting points for KM analyses were IC treatment initiation (all pts), SCT (pts who underwent SCT post-remission), and remission (pts who did not undergo SCT post-remission). Pts were censored at the last activity date or SCT date (whichever occurred earliest) for the overall patient cohort, and the last activity date for pts with or without SCT post-remission. Results: A total of 1105 pts met the study criteria. The median (IQR) age was 67 (64-71) years, 57% were male, 27% had secondary AML, 48% had BM blast &amp;gt;50% at Dx, and 66% were treated in the community setting. Excluding 340 pts with unknown cytogenetic and molecular data, 19%, 32%, and 48% of pts had European LeukemiaNet 2017 favorable, intermediate, and adverse risk, respectively. At a median (IQR) follow-up of 13 (6-28) months from AML Dx, 74% (n=821) of pts achieved real-world response, including 66% (n=724) who achieved real-world CR/CRi. For all pts, the 30-day mortality was 3%, 60-day mortality was 6%, 1-year rwOS was 58%, 2-year OS was 34%, and the median rwOS was 14.3 months ( Figure A). A total of 37% (n=306/821) of pts underwent SCT post-remission; 98% (n=300/306) underwent allogeneic-SCT and 2% (n=6/306) underwent autologous-SCT. The median rwOS was 40.4 months for pts undergoing SCT post-remission, and 13.8 months for pts without SCT post-remission ( Figure B). Conclusions: In this large real-world data study, we observed older pts (aged ≥60 years) with ND AML receiving IC treatment had a median OS of &amp;lt;14 months and &amp;lt;35% of pts remained alive 2 years after IC initiation. Findings from this study suggest the need for other novel treatment options, including Ven based regimens, to improve OS in older pts (aged ≥60 years) with ND AML who are eligible for IC. Future studies are warranted to conduct randomized controlled trials to comparatively evaluate IC vs other novel treatment options in older pts (aged ≥60 years) with ND AML, or conduct the appropriate statistical adjustment to minimize confounding in indirect treatment comparisons from different studies.

Treatment Outcomes of Stem Cell Transplant in Patients with Acute Myeloid Leukemia Treated with Venetoclax in Combination with Hypomethylating Agents: Experience from Routine Clinical Practices in the United States

Background: Venetoclax (Ven) in combination with hypomethylating agents (HMAs) is approved in the United States (US) for treatment in patients (pts) with newly diagnosed (ND) acute myeloid leukemia (AML) who are ≥75 years old or unfit for intensive chemotherapy. In a Phase Ib open-label trial (NCT02203773) and the Phase III VIALE-A trial (NCT02993523), a total of 33 pts with ND AML who were treated with Ven+HMAs underwent a stem cell transplant (SCT). The observed 12-month overall survival (OS) was 74.3% post-SCT, and the median OS was 29.9 months for pts who were in remission at the time of SCT (Pratz et al. EHA 2023). This study aims to evaluate the treatment patterns and outcomes of pts with ND AML treated with Ven+HMAs who underwent SCT post-remission from routine clinical practices in the US. Methods: This was a retrospective cohort study using the Flatiron Health electronic health record-derived, US nationwide, de-identified database. Pts aged ≥18 years with ND AML who initiated first-line Ven+HMAs treatment within 30 days from AML diagnosis (Dx) between July 1, 2018, and November 30, 2022, with ≥2 visits recorded within 3 months of AML Dx, and ≥3 months of potential data available before the study end date (February 28, 2023) were included. Pts with acute promyelocytic leukemia, t(9;22), treated with HMAs before AML Dx and pts who received Ven treatment more than 14 days prior to AML Dx were excluded. Descriptive analysis on patient characteristics was conducted. The proportion of pts who achieved real-world response (defined as &amp;lt;5% bone marrow [BM] blast), median time from Ven+HMAs treatment initiation to last administration (TTLA), and median time from Ven+HMAs initiation to SCT were reported. For pts who received SCT post-remission, 100-day real-world OS (rwOS), 12-month rwOS, and 15-month rwOS were evaluated using Kaplan-Meier analyses. The starting point of Kaplan-Meier analyses was SCT, and pts were censored at the last activity date. Results: Overall, 988 pts with ND AML treated with Ven+HMAs met the study criteria. A total of 51% (n=503/988) of pts achieved real-world response, of which 11% (n=57/503) subsequently underwent SCT post-remission. In pts with SCT post-remission (n=57) vs pts without SCT post-remission (n=446), the median age was 67 years vs 76 years, 30% (n=17/57) vs 30% (n=134/446) had secondary AML, and 60% (n=34/57) vs 24% (n=107/446) were treated at academic centers, respectively. Excluding pts with unknown cytogenetic and molecular data, the European LeukemiaNet (ELN) 2017 risk in pts with vs without SCT post-remission was favorable for 16% (n=7/43) vs 21% (n=76/355), intermediate for 33% (n=14/43) vs 26% (n=93/355), and adverse for 51% (n=22/43) vs 52% (n=186/355), respectively. Among pts with available molecular testing, FLT3 mutation in pts with SCT vs pts without SCT post-remission was 19% (n=5/26) vs 20% (n=48/245); IDH1/2 mutation was 33% (n=9/27) vs 35% (n=95/275); and TP53 mutation was 47% (n=9/19) vs 28% (n=54/192), respectively. Of the 57 pts who underwent SCT post-remission, the median (interquartile range [IQR]) TTLA on Ven+HMAs was 4.0 (3.0-5.3) months and the median (IQR) time from Ven+HMAs initiation to SCT was 5.4 (4.4-6.8) months. At a median follow-up of 8 months from SCT post-remission, the 100-day rwOS was 92%, 12-month rwOS was 52%, 15-month rwOS was 49%, and the median rwOS was 13.0 (95% confidence interval: 8.2-not reached) months ( Figure). Conclusions: In this study, similar to findings from clinical trials, we observed a subset of pts with ND AML treated with Ven+HMAs underwent SCT post-remission in routine clinical setting. Compared with pts who did not undergo SCT post-remission, pts who underwent SCT post-remission were younger, and more of these pts received care in academic centers. Of the Ven+HMAs-treated pts who underwent SCT post-remission, more pts treated in the routine clinical setting had the poor prognostic TP53 mutation than pts enrolled in the aforementioned clinical trials. In this study, most pts remained alive 100 days after SCT. The rwOS results observed in this study suggest that Ven+HMAs post-remission is a potential bridge to SCT in pts who are ineligible for intensive chemotherapy.

Comparative Analysis of Clinical Outcomes and Healthcare Resource Utilization (HRU) in Patients (Pts) with Newly Diagnosed (ND) Acute Myeloid Leukemia (AML) Unfit for High-Intensity Chemotherapy Treated with Venetoclax (VEN) Vs Other Therapies: Results from the AML Real World Evidence (ARC) Initiative

Introduction: The BCL-2 inhibitor VEN is approved in combination with hypomethylating agents or low-dose cytarabine for adults with ND AML. The ARC Initiative is a multicenter chart review study of adult pts with AML. This abstract presents real-world clinical outcomes and hospitalizations among ND AML VEN treated pts ineligible for intensive chemotherapy (IC) and their matched controls. Methods: This multicenter chart review study included adult pts (≥18 years) with ND AML who received VEN in combination with HMA on or after April 2016, or non-VEN regimens on or after May 2015, from 15 international academic sites (US: 11; Israel: 4). Pts ineligible for IC (i.e., ≥75 years or ≥1 comorbidity based on the Ferrara criteria) and treated with VEN (VEN cohort) were matched 1:1 to control pts who received non-VEN-based regimens (CON cohort). Pts were matched based on age (&amp;lt;60, 60-74, ≥75 years) and European LeukemiaNet (ELN 2017) risk. All analyses are based on the May 2023 data cutoff; data collection is ongoing. Clinical outcomes include composite complete remission (CRc; i.e., CR, CR with partial hematologic recovery [CRh], or CR with incomplete marrow recovery [CRi]) and overall survival (OS; assessed using Kaplan-Meier analysis). Hospitalizations were assessed overall and among pts who achieved CRc. Results were separately reported overall and among the respective subsets of VEN pts matched to CON pts treated with high-intensity regimens (CON-H) or low-intensity regimens (CON-L). Results: A total of 142 IC-ineligible VEN pts and 142 matched CON pts were included in the analysis, including 80 VEN pts matched to CON-H pts (56.3%) and 62 VEN pts matched to CON-L pts (43.7%) ( Table 1). Overall, VEN pts received VEN-azacitidine (75.4%) or VEN-decitabine (24.6%). A total of 68.3% of all pts were classified as ELN adverse risk, and 24.6% of VEN pts and 20.4% of CON pts were classified as Eastern Cooperative Oncology Group (ECOG) Grade ³2. Among pts with genetic mutations tested (96.5% of VEN pts and 94.4% of CON pts), 22.6% of VEN pts and 14.2% of CON pts had TP53 mutations and 21.9% and 19.4%, respectively, had IDH1/2 mutations. VEN pts had a mean of 11.6 months of follow-up, and CON pts had a mean of 15.0 months of follow-up. VEN pts were significantly more likely to achieve CRc than CON pts (64.7% vs 44.3%, p=0.001). This difference was more pronounced for VEN pts matched to CON-L pts (62.1% vs 18.0%, p&amp;lt;0.001). The 6-month OS rates were not statistically different between VEN pts and matched CON pts (74.7% vs 67.6%; p=0.20), despite the majority of CON pts receiving high-intensity regimens, but improved among VEN pts matched to CON-L pts (73.5% vs 55.3%; p&amp;lt;0.05). VEN pts had fewer days of hospitalization per pt per month (PPPM; mean 6.3 days vs 8.9 days, p=0.045) and shorter mean duration of hospitalization (13.7 days vs 18.2 days, p&amp;lt;0.001) compared with CON pts. A larger difference was seen in the amount of time (days) (6.5 vs 10.5 PPPM, p=0.006) and mean length of hospital stay (13.9 vs 22.4 days, p&amp;lt;0.001) for VEN pts matched to CON-H pts. Among pts with ≥1 all-cause hospitalization, 69.2% of VEN pts and 74.8% of CON pts were hospitalized for treatment administration (p=0.42). Among pts who achieved CRc, VEN pts had fewer days of hospitalization PPPM than CON pts (mean 4.3 days vs 6.8 days, p=0.002). This difference was more pronounced for VEN pts compared to CON-H pts (4.3 days vs 7.7 days, p=0.001). Mean duration of hospitalization was also shorter for VEN vs CON pts (13.6 days vs 20.4 days, p&amp;lt;0.001). Both VEN and CON pts experienced more hospitalizations before CRc was achieved, with statistically fewer hospitalizations for VEN pts compared with CON pts (days of hospitalization PPPM: 10.1 vs 17.4, p=0.001; duration of hospitalization: 16.4 vs 28.2, p&amp;lt;0.001). In the 60 days after CRc was achieved, VEN pts still had fewer days of hospitalization PPPM than CON pts (1.4 vs 5.2, p&amp;lt;0.001). Conclusions: Pts with ND AML who were ineligible for IC and received VEN had significantly higher rates of CRc than matched pts who received non-VEN-based regimens. Although pts treated with VEN-based regimens achieved similar rates of CRc compared to matched control pts treated with high-intensity therapy, pts treated with VEN-based regimens required a significantly lower burden of hospitalizations compared with matched pts on non-VEN-based regimens.

Poor Prognosis of SRSF2 Gene Mutations in Patients Treated with Venetoclax-Azacitidine (VEN-AZA) for Newly Diagnosed Acute Myeloid Leukemia. a Multicentric Real-Life Study of 117 Patients

Introduction Spliceosomes are complexes composed of small nuclear RNA that remove introns in protein-encoding genes. Spliceosome mutations ( SRSF2, SF3B1, U2AF1, ZRSR2), are encountered in ∼50% of secondary AML cases. Splicing mutations (splice-mut), in particular SRSF2, correlate with inferior outcomes to standard induction therapy. A recent report in a cohort of 119 patients, of whom 33 had splice mutations and 24 were SRSF2 mutated, reported the lack of impact of splice-mut on prognosis of AML patients treated upfront with Hypomethylating agents (HMA) + VEN in clinical trials (Lachowiez, C. A. et al Blood Adv. 2021). Aims We aimed to assess the impact of splice-mut in a population of patients with newly diagnosed acute myeloid leukemia (ND-AML), treated with VEN-AZA. Methods We performed a retrospective multicentric study including patients treated in three French centers in Marseille (Institut Paoli-Calmettes, CHU La Conception) and Nice (Hôpital L'Archet). Inclusion criterias were ND AML adult patients treated with VEN (7 to 28 days per cycle) and AZA at conventional doses. Next Generation Sequencing (NGS) was performed at diagnosis and was available for all patients. Data were collected from patients' electronic medical records. Statistical analyses were performed using GraphPad Prism v9.5.1 Results We included 117 ND-AML patients (median age = 75 yo; range, 32-89) treated with VEN-AZA between October 2019 and March 2023. The five most frequently mutated genes in the whole cohort were TET2, ASXL1, TP53 and RUNX1in thirty-seven (32%), 36 (31%), 32 (27%) and 31 (26%) patients, respectively. Thirty-four patients (29%) had a mutation in at least one of the spliceosome genes (=Splice-mut), including 20 (17%), 11 (9%), 4 (3%) and 1 (1%) mutations in SRSF2, U2AF1, SF3B1 and ZRSR2, respectively (Fig.1). Median variant allele frequency (VAF) was 42%, 43% and 26% for SRFS2, U2AF1 and SF3B1 respectively. Secondary AML was found in 18 (53%) of the splice-mut AML and 21 (25.3%) of the splice-wt AML groups of patients. Prior HMA was given in seven (20.6%) patients in the splice-mut versus 6 (7.2%) in the splice-wt cohort. Complex cytogenetics was identified in 7 (20.6%) patients in the splice-mut cohort and 28 (33.7%) in the splice-wt cohort. We found a TP53 mutation in 17.6% and 31.3% of splice-mut and wt cohorts, respectively. Best overall response rate (= CR, CRi and MLFS) was 72.6%; with CR, CRi and MLFS observed in 63 (54%), 16 (14%) and 6 (5%) patients, respectively. We did not find any difference in response rate between the splice-mut (=73.5%) and splice-wt (72.3%) AML. Prior treatment with hypomethylating agents and TET2 mutation were the only factors significantly associated with lower response rates (42% vs 82%, p=0.004, and 64% vs 85%, p=0.025, respectively), while IDH2 mutation was predictive of a better response (100%vs 75%, p=0.037, OR: 9.9 [CI 95% 0.57-173]). Median overall survival (OS) and leukemia-free survival (LFS) for the whole cohort was 10.8 and 7.1 months, respectively. In multivariate analysis taking into account TP53 and/or del17p, NRASmut and/or FLT3-ITD, IDH2mut, complex karyotype, and SRSF2, the only factors predicting OS and LFS were mutations in TP53 and SRSF2 genes. Patients mutated for SRSF2 had a 4.8 months OS and a 5 months LFS compared to 11.3 and 8 months, respectively (p=0.034 and p=0.037), comparable with TP53mut AML patients ( Fig.2). Conclusions SRSF2mut seems to be predictive of a worse survival in ND AML treated with VEN-AZA. This finding warrants further exploration in larger cohorts.

Prognostic Significance of NCAM1 (CD56) Expression in AML Patients Treated with HMA+Venetoclax

Introduction : NCAM1 (CD56) is a cellular adhesion molecule highly expressed on natural killer (NK) cells and other immune cells. NCAM1 is aberrantly expressed in 20% of patients with acute myeloid leukemia (AML) and is associated with resistance to chemotherapy, upregulation of the MAPK pathway, and poor prognosis. The significance of NCAM1 in the setting of venetoclax (VEN) therapy has not been explored. We set out to determine the functional and prognostic role of CD56 in vitro and in newly diagnosed (ND) patients receiving VEN-based therapy. Methods : OCI-AML2, KG-1, and MOLM-14 cell lines were purchased from ATCC and maintained in RPMI, 10% or 20% FBS, L-Glutamine, and penicillin/streptomycin. Ex vivo drug testing on cell viability was performed using an MTS assay. Briefly, AML cells were plated for 72 hours in replicates of six at 1,250 cells/well in R20 and titrated using a log scale over 7 doses (0-1000 nM) of VEN. After 3 days of culture at 37 °C in 5% CO2, MTS reagent was added, optical density was measured at 490 nm, and raw absorbance values were adjusted to a positive control and (normalized to untreated wells to produce cell viability estimates). VEN-resistant (VR) OCI-AML2 cells were generated by continuous incubation with escalating doses of VEN. Viability was monitored by Guava EasyCyte. Cells maintained resistant by co-culture with 1 µM of VEN twice weekly. Flow for NCAM1 was performed with commercially available antibodies on parental and VR cells. NCAM1 expression on parental vs. VR OCI-AML2 cells was compared with student's T test. Inactivation of NCAM1 in OCI-AML2 cells was carried out by CRISPR/Cas9 using sgRNAs cloned into plentiCRISPRv2 (Addgene, #52961). AUC was derived from 4-parameter logistic regression curves fit to normalized cell viability values for the 7 tested drug doses. Clinical outcomes including overall survival (OS) were assessed in a retrospective cohort of ND AML patients treated with a hypomethylating agent (HMA)+VEN at Oregon Health &amp; Science University (OHSU). CD56 positivity on AML blasts was based on surface immunophenotype determined by multiparameter flow cytometry. OS was measured from AML diagnosis (with time from diagnosis to VEN start as left-truncation), estimated by Kaplan-Meier, compared with the log-rank test, and modeled with Cox regression to estimate unadjusted and adjusted hazard ratios (HRs) for CD56. Results : Across the 3 AML cell lines evaluated, higher baseline NCAM1 expression levels correlated with increased ex vivo resistance to VEN. The MOLM14 cell line was most resistant with highest median NCAM1 expression (90%), followed by OCI-AML2 with median NCAM1 expression (55%) and then KG-1 with lowest NCAM1 expression (3%). VR OCI-AML2 cells had higher expression of NCAM1 compared to parental OCI-AML2 cells (80% expression vs 55%; p=0.0003). CRISPR knockout of NCAM1 sensitized parental OCI-AML2 cells to VENcompared to cells containing a non-targeting control guide (Fig 1). To support our pre-clinical findings, we retrospectively identified N=98 ND AML patients treated with HMA+VEN at OHSU from 12/2018 to 12/2022. Median follow-up was 16 months and 60% of patients died. Median age at diagnosis was 73 (range=19-87), with 39% at least 75 years old. While 65% of patients were male, 63% had de novo AML and 23% had an antecedent hematologic disorder (AHD). By European LeukemiaNet (ELN) 2022 prognostic risk classification, 58% had adverse risk (14% unknown). The most common somatic mutations were IDH1/2 (27% of patients), NRAS/KRAS (26%), FLT3 ITD or TKD (19%), NPM1 (13%), and TP53 (13%). According to diagnostic flow, 30% of patients were CD56+, 22% CD11b+, 15% CD64+, and 85% HLA-DR+. Median (range) days between diagnosis and VEN start was 13 (1-285). NCAM1 positivity significantly correlated with shorter OS in the univariable (HR=1.80 [95% CI: 1.04-3.09], p=0.032; Fig 2) and multivariable settings (HR=2.10 [95% CI: 1.17-3.75], p=0.012, N=97), with the latter model controlling for age ≥75, AHD, and CD11b. Conclusion : NCAM1 expression is a marker of poor prognosis in ND AML patients treated with HMA+VEN. Knockout of NCAM1 in the OCI-AML2 cell line sensitized cells to VEN. Our data suggest that NCAM1 expression on AML blasts plays a biological role in promoting cellular resistance to VEN. Given emerging knowledge of VEN targeted downstream pathway associations, experiments are underway to explore the role of MAPK pathway and BCL2 family member dependence.

Intensive Chemotherapy (IC) Followed By Oral Azacitidine (AZA) Maintenance Versus Venetoclax (VEN) Plus AZA for Patients (pts) with Acute Myeloid Leukemia (AML): Retrospective Analysis of an Electronic Medical Record (EMR) Database in the United States

Introduction:Frontline therapy with IC is usually recommended for eligible pts with newly diagnosed (ND) AML. Pts who achieve remission with induction and are transplant-ineligible can receive oral AZA (Oral-AZA) maintenance. For pts ineligible for IC, VEN with injectable AZA (VEN-AZA) is the recommended treatment. Selection of frontline therapy can be challenging for pts considered reasonable candidates for either IC or VEN-AZA. A prior analysis suggested that survival outcomes may be comparable in matched pts with ND AML treated with either IC or VEN-AZA (Zeidan AM, et al, Annal Hematol 2023;102:749-754). However, the impact of Oral-AZA maintenance was not accounted for. In this analysis, we compare the survival outcomes of pts who received IC followed by Oral-AZA maintenance (IC-Oral-AZA) versus those who received frontline VEN-AZA and achieved remission, before and after matching for baseline and clinical characteristics Methods:In this retrospective, observational, study using Flatiron Health's database, de-identified data from adult pts with ND AML who received either frontline IC-Oral-AZA or frontline VEN-AZA and achieved remission were analyzed. Exclusion criteria included diagnosis of acute promyelocytic leukemia, treatment with arsenic trioxide/tretinoin, clinical trial participation, or prior hematopoietic stem cell transplant (HSCT). Treatment with Oral-AZA for IC-Oral-AZA pts had to commence prior to a 2nd line of therapy or disease relapse, and after Sept 1, 2020. Cohorts were matched 1:1 on baseline demographic and clinical characteristics using propensity scores to minimize differences. Matched characteristics included sex, age at diagnosis (18-64, 65-74, ≥ 75 years), race/ethnicity, region, ECOG performance status (PS), BMI, previous diagnosis of myelodysplastic syndromes or myeloproliferative neoplasm, cytogenetic risk category, whether AML is treatment-related or was diagnosed as mixed phenotype. Baseline molecular data were insufficient. Relapse-free survival (RFS) and overall survival (OS) were estimated for unmatched and matched cohorts using Kaplan-Meier analysis from date of remission, censoring pts at the time of HSCT/end of follow-up. Cox regression analyses were conducted for RFS and OS, both on an unadjusted basis and after adjusting for any remaining differences in age between the matched cohorts. Confirmatory landmark analysis is being conducted. Results:In total, 50 IC-Oral-AZA and 403 VEN-AZA pts met the selection criteria prior to matching. The matching process yielded 33 pts in each cohort, with median follow-up from start of therapy of 13.1 and 11.2 months for IC-Oral-AZA and VEN-AZA cohorts, respectively. The cohorts matched well on median age at diagnosis (63 years for both), sex (54.5%, 51.5% males), ECOG PS 2+ (18.2%, 21.2%), cytogenetic risk (46.7% poor, 26.7% intermediate, 26.7% favorable risk for both groups, among those with known risk status), whether AML was treatment-related (12.1%, 21.2%), race/ethnicity, region, and BMI. Three pts (9.1%) in the IC-Oral-AZA cohort and 8 (24.2%) in the VEN-AZA cohort received HSCT during follow-up. Median time from remission to start of Oral-AZA for the IC-Oral-AZA cohort was 128 days. For the unmatched cohorts, median RFS was significantly longer for IC-Oral-AZA (20.0 months [95% CI, 13.4-not reached (NR)]) than for VEN-AZA (9.3 months [8.3-10.7]; P&amp;lt;0.001) as was median OS (IC-Oral-AZA, NR [15.5-NR]) versus VEN-AZA (13.4 months [10.7-15.5]; P &amp;lt; 0.001). For the matched cohorts, median RFS was significantly longer for IC-Oral-AZA (20.0 months [95% CI, 9.9-NR]) than for VEN-AZA (8.7 months [4.1-15.5]; P = 0.002) as was median OS (IC-Oral-AZA, NR [14.6-NR] versus VEN-AZA, 15.2 months [7.4-19.7]; P = 0.002) (Figures A and B). The Cox analyses confirmed the superior outcomes of the IC-Oral-AZA cohort for both RFS (unadjusted HR, 0.33 [95% CI, 0.17-0.65]; P &amp;lt; 0.01, adjusted HR, 0.34 [0.17-0.70]; P &amp;lt; 0.01) and OS (unadjusted HR, 0.28 [0.11-0.68]; P &amp;lt; 0.01, adjusted HR, 0.29 [0.11-0.74]; P &amp;lt; 0.01). Conclusion:Pts treated with frontline IC followed by Oral-AZA as maintenance had significantly better survival outcomes than pts who were treated and achieved remission with frontline VEN-AZA. These results suggest that pts with ND AML eligible for frontline IC should receive this regimen followed by Oral-AZA maintenance, if they are not candidates for transplant at remission.

Ultra-Low-Dose of Decitabine with Venetoclax As Induction and Consolidation Therapy for Elderly or Frail Newly Diagnosed Acute Myeloid Leukemia and High Risk Myelodysplastic Syndrome Patients

Background: Venetoclax with hypomethylating agents is a new standard of care for newly diagnosed (ND) patients with acute myeloid leukemia (AML) who are 75 years or older, or unfit for intensive chemotherapy. Pharmacodynamic studies have suggested superiority of the longer 10-day regimen of decitabine which has shown promising results in high-risk AML in phase 2 trials. We hypothesized that venetoclax with 10-day decitabine may be effective in ND and secondly AML/MDS, particularly for high-risk subgroups. Methods: We retrospectively analyzed 45 patients with ND AML, secondary AML (sAML), or high-risk MDS who was older than 60 years or unfit for intensive chemotherapy due to frail / due to the COVID-19 pandemic. Patients were required adequate end-organ function. Patients received decitabine (6mg/m2 IV for 10-days) with oral venetoclax (400mg daily for 3 weeks (D10+VEN)) for induction, followed by the same chemo-free regimen for consolidation if patients responsed to induction therapy. The primary efficacy endpoint was overall response rate (ORR). The second endpoint was overall survival (OS) and progress free survival (PFS). Findings: Between January, 2020 and July , 2023, 45 patients were treated with this regimen, 31 (68.9%) had ND AML, 8 patients (17.8%) had untreated sAML, 6 patients (13.3%) had untreated high-risk MDS. The median age was 65 years (IQR, 59-69) and 26(57.8%) patients had ECOG performance status of 3 or higher. The ORR among all patients was 82.2% and in disease subgroups were: ND AML, 87.1% (27/31) (95% CI 79, 94); untreated sAML, 75% (6/8); untreated high-risk MDS, 66.7%(4/6). According 2022 ELN risk classification by genetics, the ORR in favorable risk patients was 87.5%(7/8), intermediate risk patients was 100%(12/12), adverse risk patients was 72%(18/25). The most common treatment-emergent adverse events included infections with grade 3/4 neutropenia (n=36, 80%) and febrile neutropenia (n=7, 15.6%). There were 2 grade 5 adverse events including one infections with Enterobacter cloacae Bacteremias combined with heart failure because of the shortage of Blood product transfusion during the COVID-19 pandemic, and one case of intracranial hemorrhage related to prolonged grade 3/4 thrombocytopenia. The one year OS of all patients was 71.9%(23/32), and in favorable risk patients was 83.3% (5/6), intermediate risk patients was 72.7%(8/11), adverse risk patients was 73.3%(11/15). The two-year OS of all patients was 58.3%(7/12). Conclusion: Ultra-low-dose of ten-day decitabine with venetoclax as induction and consolidation chemo-free therapy in elderly or frail newly diagnosed acute myeloid leukemia and high risk myelodysplastic syndrome result in high overall response rate and high 1-year overall survivial.

Phase 2 Study of CPX-351 in Combination with Venetoclax in Patients with Newly Diagnosed, High Risk Acute Myeloid Leukemia

Background CPX-351 is a nanoscale liposome of a fixed 5:1 molar ratio of cytarabine and daunorubicin which has improved survival of secondary acute myeloid leukemia (AML) 1. Venetoclax (ven) is a BCL2 inhibitor which, in combination with azacitidine or cytarabine, has become the standard of care for elderly AML. Ven has shown synergism with chemotherapy, with high complete remission (CR) rates in newly diagnosed (ND) and relapsed / refractory (RR) AML 2. In this study, we aim to assess the efficacy and safety of CPX-351 and ven (CPX-ven) in RR and ND AML. Methods This was a phase 2 study with a lead-in safety phase. Enrolment was allowed if the blasts were ≥10%. Patients (pts) age ≥18 with RR AML were eligible for the safety lead-in phase (LIP) or arm A. Arm B enrolled pts age 18 - 69 with ND AML. Other inclusion criteria included adequate liver, renal and cardiac function, and ECOG performance status ≤2. Pts with CNS involvement or prior CPX-351 were excluded. The recommend phase 2 dose was CPX-351 (daunorubicin 44 mg/m 2 and cytarabine 100 mg/m 2 IV on D1, 3 and 5 of induction, and daunorubicin 22 mg/m2 IV on D1 and 3 during consolidation) combined with ven on D2-8 of each cycle. Ven was dosed at 300mg daily and reduced to 150mg or 50mg daily for pts on a moderate or strong CYP3A inhibitors, respectively. The primary outcome measure was complete remission (CR) or CR with incomplete count recovery (CRi). Here, we report the outcomes of arm B including pts with ND AML. Results 14 pts were enrolled on arm B. One pt withdrew and one was too early in treatment, therefore 12 were evaluable. Baseline characteristics are shown in Table 1. The median age was 59.5 years (range, 44 - 69); Four (33.3%) were female. All 12 (100%) pts were classified as adverse risk per the 2017 European Leukemia Net Guidelines. Two (16.7%) pts had treatment for a prior non-myeloid malignancy (therapy-related AML). Eight (66.7%) had an antecedent haematological disorder (secondary AML), of whom seven had treatment (median 1 line, range 1 - 2). Four (33.3%) pts had a complex karyotype, of whom three harbored a TP53 mutation. Nine (75.0%) pts achieved a response, including four CR (33.3%), five CRi (41.6%), and one induction mortality (8.3%) prior to disease assessment. 3/4 (75.0%) pts with complex cytogenetics (including 2/3 (66.7%) with a TP53 mutation) achieved a CR/CRi. Of the secondary AML pts with an evaluable response, 5/7 (71.4%) achieved a CR/CRi. Of the nine pts achieving CR/CRi, five (55.5%) were negative for minimal residual disease (MRD) by flow cytometry. The median number of cycles to CR/CRi was one (range 1 - 2). The median overall survival (OS) was 12.9 months (95% CI, 3.1 - not reached, NR, Figure 1). The median relapse-free survival (RFS) was 8.7 months (95% CI, 3.1 -NR). 7/9 (77.8%) of responding pts underwent an allogeneic stem cell transplant (SCT) after attaining CR/CRi. There were 90 adverse events (AE) in 10 (83.3%) pts. 80 (88.9%) were grade 1 or 2, 10 (11.1%) were grade ≥3. The most common AE was gastrointestinal with seven (7.8%) occurrences. Four (33.3%) pts developed grade ≥3 infections; of these, one (8.3%) died. The cause of death was neutropenic septic shock due to pneumonia. Conclusion CPX-ven is a feasible option for remission induction in pts with high-risk, newly diagnosed AML. The combination produced high rates of response and MRD negativity in a cohort of pts with adverse risk features, including pts with adverse karyotype and AML following prior HMA-based treatment, allowing them to proceed with SCT. Toxicities are as expected for an intensive chemotherapy regimen. Further studies are needed to confirm the efficacy of this combination.

Acute Myeloid Leukemia Patients Who Stopped Venetoclax or/and Azacytidine for Other Reasons Than Progression Have a Prolonged Treatment Free Remission and Overall Survival. a Filo Study

Background Recent update of the VIALE-A study showed a long-term survival for approximately 30% of acute myeloid leukemia (AML) patients treated with venetoclax and azacitidine (VEN-AZA) for a newly-diagnosed AML (ND-AML) (Pratz K.W et al., ASH 2022). A recent report of a small cohort of responding patients who interrupted VEN-AZA displayed a sustained treatment-free remission (TFR) period suggesting that treatment interruptions might be considered (Chua CC. et al., Blood Adv. 2022). To evaluate the impact of VEN-AZA discontinuation on survival and time without treatment, we retrospectively analyzed the characteristics and outcomes of patients who stopped VEN and/or AZA for reasons other than progression (e.g. hematological or other toxicities). We presented the first 51 patients from our cohort last year at ASH meeting (Garciaz S. et al, ASH 2022). In this abstract, we analyzed separately ND-AML and relapsed/refractory (R/R) AML. Methods Eligible patients 1) have been treated with VEN-AZA for a ND or R/R AML, 2) have stopped AZA and/or VEN for more than 3 months, 3) are in remission (CR, CRi or Morphologic leukemia-free state, [MLFS]) at the time of treatment interruption, 4) are ≥ 18-year-old. Main endpoints were overall survival (OS) and treatment-free remission (TFR) calculated from the time between the last day of VEN to relapse, retreatment, or death. We measured the impact of prognostic factors on OS by a Cox regression taking disease status (ND vs R/R), the discontinued treatment (VEN vs VEN-AZA), the cytogenetics and NPM1 or IDH mutations. Results We included 83 patients from French Innovative Leukemia Organization (FILO) centers and Moffit Cancer Center (US) treated with VEN-AZA for a ND-AML or a R/R AML between 11/18 and 07/23. Regarding the ND-AML patients (n=60; 32 males and 28 females), the median age was 76 (range, 26-86.5), median platelet count, WBC, ANC and bone marrow blast involvement was 52 G/L (range, 9-296), 2.8 G/L (range, 0.6-200), 0.6 G/L (range, 0.02-31.6) and 40% (range, 10-99), respectively. Cytogenetics was intermediate (int.) in 48 cases (80%) and unfavorable (unfav.) in 12 patients (20%). Eleven AML (18.3%) had NPM1 mutations, and 19 (31.6%), IDH alterations including 7 IDH1, 8 IDH2R140 and 4 IDH2R172. Six (10%) and 5 (8.3%) patients had FLT3 or TP53 mutations, respectively. The median number of VEN-AZA cycle was 4 (1-17). The best response was CR (n=44, 73.3%), CRi (n=13, 18.3%) and MLFS (n=3, 5%). Twenty-one patients out of 25 (78%) reached MRD negativity assessed by molecular (n=11) or flow cytometry (n=10) techniques. Twenty-six patients (43.3%) stopped VEN-AZA and 34 (56.7%) stopped VEN and continued AZA monotherapy for a median number of 7 AZA cycles (1-41). Reasons for treatment discontinuation were prolonged cytopenia, non-hematological toxicities, patient choice or unknown in 35 (58%), 6 (10%), 8 (13.3%), and 11 (18.3%) patients, respectively. We registered 27 relapses and 24 deaths. Fourteen patients were retreated including 11 patients who were rechallenged with VEN-AZA. Second CR/CRi rate with VEN-AZA was 3/11 (27.7%). With a median follow of 23 months, median TFR was 15 months (ranges, 3-47) and median OS was 44 months (ranges, 7-50). We also analyzed a smaller cohort of 23 R/R responding patients who stopped AZA and/or VEN. The median age was 73, median number of previous lines was 1 (1-3). Twenty-one patients (91.3%) received prior intensive chemotherapy and 4 (17.4%) prior allogeneic hematopoietic transplantation. Cytogenetic risk was int. in 17 (73.9%) and unfav. in 5 patients (21.7%) and missing in one patient. NPM1 and IDH genes were mutated in 6 (26%) and 10 (43.4%) cases, respectively. Sixteen patients (69.6%) stopped VEN-AZA and 7 (30.4%) interrupted VEN only. Nine patients resumed a treatment including 6 patients rechallenged with VEN-AZA. Among them, 3/6 (50%) obtained a second CR/CRi. Median TFR and OS were 10 (ranges, 3-23) and 19 (ranges, 7-32), respectively. Factor impacting OS in multivariate analysis were R/R AML disease status (Hazard Ratio [HR] =0.47, ranges, 0.23-0.87), and IDH mutations (HR= 2.1, ranges, 1.05-4.34), but not unfav. cytogenetics, NPM1 mutations, or the discontinued treatment (VEN vs VEN-AZA). Conclusion: Discontinuation of VEN and/or AZA in responding patients was associated with sustained responses and long-term survival rates. Resuming treatment may induce a second remission in some patients.

Feasibility, Safety and Predictors of Outcomes of Patients with Newly Diagnosed Acute Myeloid Leukemia Discharged “Early” after Intensive Induction Therapy

Background: Patients (pts) treated with intensive induction therapy for newly diagnosed acute myeloid leukemia (AML) traditionally remain admitted until an absolute neutrophil count (ANC) &amp;gt;0.5 x 10 3/L. Although a small number of centers reported on pt discharge with ANC &amp;lt;0.5 x 10 3/L via an “early” discharge (DC) program (EDP) post-intensive induction, little is known about the safety and outcomes among this group of pts, including the rates and predictors of post-DC complications (e.g., febrile neutropenia (FN), microbiologically proven infection) and both early- and long-term outcomes. We sought to describe our experience with an EDP and identify predictors of differential outcomes. Methods: We conducted a single-center, retrospective study of pts with newly-diagnosed AML admitted to Yale Cancer Center (YCC) for intensive induction during December 2014-January 2023. Re-induced patients were excluded. Patients were eligible for the EDP if they: 1) were afebrile x 7 days, 2) required no parenteral therapies, 3) required transfusion support less than daily, 4), lived within 60 minutes of YCC with “average” traffic, and 5) had a dedicated care giver available 24 hours per day with reliable transportation to/from clinic. Chi-square and Wilcoxon rank-sum tests were applied to categorical and continuous variables, respectively. Overall survival (OS) was estimated using the Kaplan-Meier method and was compared using log-rank test. Statistical significance was determined by p-value &amp;lt;0.05. Results: A total of 188 pts were evaluated. Amongst this population, 99 (52.7%) pts were DC under the EDP, while 89 (47.3%) were not. To remove confounding from peri-DC ANC kinetics, we focused on pts DC with an ANC &amp;lt;0.1 x 10 3/L (n=53, “EDP pts”) and compared them with non-EDP pts (DC ANC &amp;gt;0.5 x 10 3/L). There were no significant differences in age, sex, ECOG performance status (PS), baseline LVEF on echocardiography or other comorbidities. With regards to disease-specific factors, there was no difference in pre-induction blood counts (e.g., WBC 7.2 vs. 8.1, p=0.610), serum creatinine, uric acid, lactate dehydrogenase, AML subtype, or disease biology e.g., karyotypic or molecular features (Table 1). Pts received 7+3 without (47%) or with (27%) other therapy, while 22% received liposomal daunorubicin/cytarabine. There were no differences in the rates of regimens used between EDP and non-EDP pts. The incidence of induction-related complications like FN (81.1% vs 89.9%, p=0.220), DIC, TLS, and bleeding were similar between groups, although there was a trend toward more documented infection among non-EDP pts (48.3% vs 30.2%, p=0.052). Findings on the D14 marrow (performed in 79% of pts) were similar between groups (chemoablation, p=0.131; D14 blast %, p=0.546). Median days admitted from induction to DC was nearly a week less for EDP pts (22 [interquartile range (IQR): 19-29] vs 28 days [IQR: 25-32], p&amp;lt;0.0001). Amongst EDP patients, 12 (22.6%) were re-admitted, 10 (83%) due to FN with 4 of these pts having an infectious source identified. The median duration of re-admission was 6.5 days (IQR: 4.5-13). When considering re-admissions prior to ANC/count recovery or initiation of consolidation, EDP pts still had lower time spent in hospital prior to eventual count recovery (24 vs 28, p&amp;lt;0.0001). ANC at DC did not predict OS amongst the larger cohort (n=188, p=0.949), but was associated with re-admission amongst pts DC with ANC &amp;lt;0.5 in univariate analysis ( p=0.02). Time to DC and ANC at DC were strongly associated amongst the larger cohort (n=188, p=0.01 from linear regression) and pts DC with ANC &amp;lt;0.5 ( p&amp;lt;0.00001 from linear regression)(Figure 1). Although non-EDP pts had a shorter time to first response (33 vs 36 days, p=0.020), there were no differences in rates of CR/CRi/CRh (73.0% vs 60.4%, p=0.167) when compared with EDP pts. Similarly, there were no differences in early (60- and 90-day) mortality, or median OS between EDP and non-EDP pts (32.3 vs 26.4 months, p=0.695)(Table and Figure 1). Conclusions: Our study shows that pts treated intensively for newly-diagnosed AML and meeting several criteria can be safely DC prior to count recovery without detriment to early mortality or OS. EDP pts spent up to a week more out of hospital when compared with non-EDP counterparts. Healthcare utilization, cost effectiveness and patient satisfaction evaluations of the EDP are underway.

Outcomes of Patients (pts) with Newly Diagnosed Acute Myeloid Leukemia (AML) and TP53 mutation/Loss Treated on the Phase 2 Study of Venetoclax (Ven) Added to Alternating Cladribine (Clad) Plus Low-Dose Cytarabine (LDAC) and Azacitidine (Aza): A Subgroup Analysis

Background: Despite the introduction of newer drugs and combination therapies, outcomes of patients with AML and TP53mutation (mut) and/or loss continue to remain poor, with a median survival of 6-12 months. The phase 2 study of venetoclax (Ven) added to Clad+ LDAC alternating with azacitidine (Aza) in pts with newly diagnosed (ND) AML demonstrated a composite complete remission (CRc) rate of 93% and median overall survival (OS) not reached (NR) at 22 months (mos) (Kadia et al, JCO, 2022) (NCT03586609) . The trial was amended to increase enrollment, including a prespecified cohort of pts with AML with TP53mut/loss. Methods: This is a subgroup analysis of pts with TP53mut/loss on the phase 2 clinical trial. The treatment protocol has been previously published. Pts with AML with TP53 mut (next generation sequencing, lower limit of detection: 2% variant allele frequency [VAF]) or loss by conventional cytogenetics/fluorescent in situ hybridization and/or array comparative genomic hybridization at AML diagnosis were included. CRc was defined as complete remission (CR) plus CR with incomplete count recovery (CRi). Relapse free survival (RFS) was calculated from response to relapse/death and OS from treatment initiation to death; neither censored for allogeneic hematopoietic stem cell transplantation (HSCT). Results: From Nov 2018-Apr 2023, 124 pts with ND AML were treated on this trial, 14 (11%) of whom had TP53mut/loss. The median age in this subgroup was 66 years (yrs) (range 48-75 yrs) and 8 pts (57%) were male. Two pts (14%) had secondary AML (one treated secondary, post HSCT) and another 2 pts (14%) had therapy-related AML. Twelve pts (86%) had a TP53 mut, 8 of whom had bi-allelic loss (two mut, 1 mut with chromosome 17 loss or 1 mut with VAF≥50%). Two pts (14%) had only TP53 deletion (ie. -17/del17p). CRc was attained in 8 pts (57%) [7 CR (50%) and 1 CRi (7%)] and another pt attained partial remission (PR) with 5% bone marrow blasts as best response. 5/8 pts (63%) pts with CRc attained measurable residual disease (MRD) negativity and 4/8 (50%) also had normalization of their TP53 abnormality . The median therapy cycle to best response was 1. Notably 3 pts (21%) had erythroid leukemia, one of whom attained an MRD+ CR. Nine pts had a complex karyotype, 4 (44%) of whom attained a CRc. 4/8 pts (50%) with bi-allelic TP53 loss attained a CRc (2 became MRD negative by flow cytometry and one cleared both TP53 mutations). Pts received a median of 1 cycle (range, 1-5) of therapy. At a median follow-up of 9 mos from study initiation, the median RFS in the responders was not reached (NR) and 1-yr RFS was 56%; median OS for the entire cohort was NR and 1-yr OS was 56%. The 1 yr-OS in responders was 75%. 4/8 pts with CRc and the pt with PR underwent HSCT at a median of 4.5 mos (range 3.9-5.9 mos) from study therapy initiation; all are alive and in remission at a median of 6 mos (range 1-12.3 mos) from HSCT. Conclusion: The phase 2 trial of Ven added to alternating Clad+LDAC and Aza showed promising remission rates of 57% in pts with ND AML having TP53 mut/loss and high rates of MRD negativity in responders; median RFS and OS was not reached at 9 mos follow-up. Five pts (36% overall, and 50% of the responders) could be consolidated with HSCT, with none of them relapsing after HSCT. The trial continues to accrue pts.

Real-World Treatment Patterns and Overall Survival Among Newly Diagnosed and Relapsed/Refractory Acute Myeloid Leukemia (AML) Patients: A Retrospective Cohort Study Using Claims Data

Introduction: Acute myeloid leukemia (AML) is a malignant disorder of the bone marrow, characterized by abnormal clonal proliferation and differentiation arrest of myeloid progenitor cells. Prognosis is generally poor and worsens with age. While curative therapies are available, they are often unavailable to older patients and those with significant comorbidities due to high morbidity and mortality associated with intensive therapy. Since 2017, seven new systemic therapies have been approved for various AML patient populations, including those unfit for intensive therapy. This study aims to characterize first-line (1L) and second-line (2L) treatment patterns and outcomes in newly diagnosed (ND) and relapsed/refractory (R/R) AML patients, in the context of these newly available therapies. Methods: A large US administrative claims database (Optum) was used to identify ND AML patients between January 1, 2016, and August 31, 2022. The “ND index date” was defined as the first date a non-R/R AML diagnosis code was observed. To confirm that the initial AML diagnosis represented a true case of AML, ≥2 subsequent AML diagnoses within 60 days post-index were required. A washout period of 12 months was used to confirm no previous AML diagnosis. ND patients were required to have continuous enrollment from 1 year prior to the index until ≥30 days after the index date or death, whichever was earlier. A subgroup of R/R patients was then identified: all ND cohort members who 1) had an R/R AML diagnosis code, 2) had continuous enrollment between ND index date and ≥30 days after the RR index date, and 3) did not receive 1L hematopoietic stem cell transplant (HSCT) after the ND index date were eligible for inclusion. In this subgroup, the “RR index date” was defined as the first date an R/R AML diagnosis code was observed. Demographic characteristics, clinical characteristics, and treatment patterns over time were reported descriptively. Treatment regimens over time were described using the following classification: HSCT, intensive chemotherapy without targeted agents, intensive chemotherapy with targeted agents, hypomethylating agent (HMA) therapy only, other targeted therapy, Venetoclax-based therapy, unspecified/other treatment, no treatment/supportive care only. Overall survival (OS) was described using the Kaplan-Meier estimator. All analyses were stratified by line of therapy and transplant status. Results: We identified 5,135 ND AML patients and 934 R/R AML patients (ND cohort: mean age at initial AML diagnosis 73.5 years, mean follow-up time 6.1 months). ND patients receiving transplant in 1L tended to be younger and had fewer comorbidities than those not receiving transplant ( Table 1). Over the entire study period, 61% of ND patients and 69% of R/R patients received some treatment for AML; older patients were more likely to receive supportive care only. In 1L, Venetoclax-based and intensive chemotherapy without targeted agents were the most common treatment regimens (21% and 17% of all ND patients). In 2L, Venetoclax-based and HMA-only therapies were most common (17% and 16% of all R/R patients). Increases in the use of novel therapies (Venetoclax, intensive chemotherapy with targeted agents, or other targeted therapies) were observed in both 1L and 2L over the study period ( Figure 1). 1-year OS among ND patients was 32% in non-transplant recipients, and 84% in transplant recipients; among R/R patients, 1-year OS from RR index date was 21% in non-transplant recipients and 81% in transplant recipients. Conclusions: The findings from the present study indicate substantial disease burden and ongoing unmet need among ND and R/R AML patients in the USA. While treatment patterns for AML have changed significantly following the advent of novel therapies (with 41% of 1L patients and 31% of 2L patients being treated with novel therapies in 2022), OS remained low. Notably, around 1/3 of patients with RR AML did not receive active treatment; these patients tended to be older and were more frail. Increasing off-label use of Venetoclax in 2L further underscores high unmet need for patients who require more effective treatment options.

Selinexor in Combination with Venetoclax and Azacitidine for Newly Diagnosed (ND) Unfit Acute Myeloid Leukemia (AML): A Multicenter, Open-Label Prospective Study

Introduction: Acute myeloid leukemia (AML) predominantly affects the elderly, with a median age at diagnosis around 68 years (Bhansali, 2023). Due to existing or potential comorbidities and frailty, many patients are unable to undergo conventional intensive chemotherapy at the time of diagnosis. The combination of venetoclax with azacytidine has shown improved clinical response rates of 64% with a median overall survival of 14.7 months (DiNardo, 2020). However, subgroup data demonstrated no significant benefits in the Chinese population, in pts with poor risk, or in those with TP53 mutations. Therefore, managing AML in elderly or unfit pts remains a significant challenge. Selinexor has shown promising tolerability and clinical activity in AML through various phase 1/2 trials. The triple regimen of selinexor, venetoclax, and azacytidine (SAV) has demonstrated favorable results in AML pts with severe co-morbidities in real-world settings. To further evaluate its efficacy and safety, we have designed a prospective study (NCT05736965) to assess the SAV regimen for ND AML pts who are ineligible for intensive therapy. Methods: To report the efficacy and safety of ND AML pts ineligible for intensive chemotherapy, treated with a triple regimen from 6 sites. The study enrolled pts who were unfit for intensive chemotherapy, ≥75 years, had significant comorbidities, an Eastern Cooperative Oncology Group Performance Status (ECOG PS) of ≥3, organ dysfunction, or had abandoned intensive chemotherapy. The primary study objectives were the complete response (CR)/complete response with incomplete count recovery (CRi) rate and overall response rate (ORR). Responses were assessed according to the ELN2022 criteria. Pts received the following treatment regimen: Selinexor 60mg on days 3, 10, and 17; Azacitidine 75mg/m2 on days 1-3, 8-9, and 15-16; Venetoclax 100mg on day 1, 200mg on day 2, and 400mg on days 3 to 14. Each treatment cycle lasted for 28 days. Pts who achieved CR, CRh, or CRi, as per the center's treatment guidelines, were eligible for transplantation at any time point. Remaining pts continued to receive the SAV regimen until disease progression or intolerable toxicity. Results: From March 2023 to the data cutoff on June 10, 2023, a total of 20 pts were enrolled in the study, of which 16 had de novo or therapy-related AML, and 4 had secondary AML with a history of myelodysplastic syndrome. Table 1 displays the baseline characteristics and responses of the newly diagnosed AML pts. The median age of the 20 pts was 64 years (range: 28-80), and the majority of them had high-risk disease: 12/20 (60%) had intermediate-risk, and 8/20 (40%) had adverse-risk according to the ELN 2022 criteria. Additionally, 4/20 (20%) of the pts had therapy-related AML, 6/20 (30%) were aged ≥75 years, 12/20 (60%) had ≥2 high-risk molecular mutations, and a significant proportion had high blast counts. All pts completed at least 1 cycle of treatment (range: 1-4). Specifically, 1patient completed 4 cycles, 2pts completed 3 cycles, and 7pts completed 2 cycles. The remaining 10pts have just completed their first cycle of treatment and evaluation. With the exception of one patient with disease progression (PD), all other pts are still undergoing treatment. As the treatment duration extends, the depth of remission in pts may further deepen. The CR/CRi rates and ORR across the ELN 2022 risk groups for all pts, intermediate-risk group, and adverse-risk group were as follows: 80% (16/20) and 90% (18/20), 75% (9/12) and 91.7% (11/12), 87.5% (7/8) and 87.5% (7/8), respectively. In comparison, the VIALE-A data showed a CR/CRi rate of 52.9% for adverse-risk pts, indicating a higher remission rate observed in this study. As of now, 3 pts were MRD-negative. The reported adverse events of grade 3 or higher occurring in ≥10% of pts in the triple regimen were thrombocytopenia (35%), neutropenia (35%), and infections (15%). The most frequently reported adverse events of Grade 1-2 included anemia, nausea, fatigue, anorexia, and hyponatremia. All adverse events could be managed and improved through dose adjustments and supportive treatment. Conclusions: The SAV regimen has been found to be safe and effective, with encouraging complete response (CR) rates in newly diagnosed AML pts, especially in adverse risk patients. Further trial enrollment and correlative analysis are currently underway to thoroughly observe the efficacy and safety of the SAV regimen.

Survival and Prognosis Among 301 Patients with Newly-Diagnosed Acute Myeloid Leukemia Following Venetoclax Plus Hypomethylating Agent Therapy

Background: Venetoclax (Ven) in combination with hypomethylating agent (HMA) is the preferred treatment for elderly/unfit patients with newly-diagnosed acute myeloid leukemia (AML). Current prognostication for AML is based on European LeukemiaNet (ELN) genetic risk stratification which has limited applicability in patients treated with Ven-HMA ( Blood, 2022). Accordingly, our primary objective was to determine predictors of treatment response and survival outcomes in treatment-naïve AML patients receiving Ven-HMA. Methods: Our study population was recruited from Mayo Clinic (MN, FL, AZ), after institutional review board approval and based on documentation of newly-diagnosed AML treated with Ven-HMA outside of clinical trials between November 2018 and April 2023. Cytogenetic and molecular studies were performed by conventional karyotype, and next-generation sequencing, respectively. Response was assessed according to the 2022 ELN criteria Results: Patient characteristics A total of 301 newly-diagnosed AML patients (median age 73 years, 66% male, 62% de novo) received a median of 3 cycles (range 1-48) of azacitidine 75 mg/m2 days 1-7 ( n=100) or decitabine 20 mg/m2 days 1-5 ( n=201) with Ven. ELN 2022 cytogenetic risk included favorable (1%, n=4), intermediate (61%, n=184) or adverse (38%, n=113). Mutations involved TP53 in 77/301 (25%), ASXL1 in 54/279 (19%), RUNX1 in 54/296 (18%), NPM1 in 44/299 (15%), DNMT3A in 40/296 (13%), K/NRAS in 41/296 (14%), IDH1 in 20/301 (6%), IDH2 in 30/301 (10%), FLT3-ITD in 25/301 (8%) and DDX41 in 9/247 (4%) of informative cases. Predictors of response Complete remission, with (CR) or without (CRi), count recovery, was documented in 182 (60%) patients, including CR in 36% and measurable residual disease (MRD) negative by flow cytometry in 77% of 105 informative cases that achieved CR/CRi. Median time to CR/CRi was 1.4 months. In univariate analysis, CR/CRi was more likely to occur in the presence of NPM1 mutation, (86% vs. 56%; p &amp;lt; .01), IDH2 mutation, (80% vs. 58%; p = .02), DNMT3A mutation, (78% vs. 57%; p = .01), or DDX41 mutation, (100% vs. 58%; p &amp;lt;.01), and in the absence of adverse karyotype, (71% vs. 42%; p &amp;lt; .01), TP53 mutation, (67% vs. 40%; p &amp;lt;.01), FLT3-ITD mutation, (63% vs. 36%; p = .01), or RUNX1 mutation, (64% vs. 44%; p = .01); in multivariable analysis, adverse karyotype, ( p &amp;lt; .01), FLT3-ITD ( p &amp;lt; .01), RUNX1 ( p &amp;lt; .01), NPM1 ( p = .03), IDH2 ( p = .04), and DDX41, ( p = .01) mutations remained significant. Predictors of survival After a median follow-up of 8.5 months (range 0.5-56), 13.2 months for living patients, 174 (58%) deaths, 73 relapses (40% of those achieving CR/CRi), and 41 (14%; including 35 in CR/CRi) allogeneic hematopoietic stem cell tranplants (AHSCT) were documented. In univariate analysis of pre-treatment variables, thrombocytopenia &amp;lt; 100 x 10 9/l, (HR 1.5, 95% CI 1.03-2.2; p = .03), adverse karyotype, (HR 2.8, 95% CI 2.1-3.8; p &amp;lt; .01) TP53 mutation, (HR 2.5, 95% CI 1.8-3.5; p &amp;lt; .01), or absence of IDH2 mutation, (HR 3.5, 95% CI 1.7-7.6; p &amp;lt; .01) predicted inferior survival. Failure to achieve CR/CRi (HR 4.5, 95% CI 3.3-6.1; p &amp;lt; .01) was also associated with inferior survival and in multivariable analysis, failure to achieve CR/CRi, (HR 3.4, 95% CI 2.5-4.8; p&amp;lt; .01), presence of adverse karyotype, (HR 1.6, 95% CI 1.1-2.6; p = .02), TP53 mutation, (HR 1.6, 95% CI 1.002-2.4; p = .04), and absence of IDH2 mutation (HR 2.2, 95% CI 1.004-4.7; p = .04) were identified as risk factors for survival. Subsequent HR-weighted scoring resulted in three-tiered risk stratification: low (0-1 point; n= 130), intermediate (2-3 points; n= 105), and high (4-5 points; n= 66), with respective median survival (3-year rate) of 28.9 (48%), 9.6 (6%), and 3.1 (0%) months ( p &amp;lt; .01) (Figure). AHSCT had an independent favorable impact on survival (HR 0.3, 95% CI 0.1-0.6; p &amp;lt; .01), most apparent in low ( p =0.04), and intermediate ( p &amp;lt;.01), as opposed to high ( p = .06) risk. Conclusions: In the current single institutional series of Ven-HMA treated newly-diagnosed AML, response to Ven-HMA was the foremost predictor of survival. Additional risk factors for survival included adverse karyotype, presence of TP53 and absence of IDH2 mutations. These observations allowed for a three-tiered genetics-enhanced survival model with CR/CRi as a backbone, and also confirmed survival advantage from AHSCT, regardless of risk category.