Dr Zeidan on Balancing Disease and Patient Factors in AML Treatment

Amer M. Zeidan, MBBS, MHS, explains how treatment selection for acute myeloid leukemia (AML) in real-world practice depends on weighing both disease-related and patient-related factors, and why the patient populations seen in clinical trials do not always reflect the patients seen in the clinic.

Zeidan, of Yale Cancer Center, notes that clinical trials generally enroll highly selected patients. These patients tend to have adequate organ function, a solid understanding of their disease, reliable compliance with study visits, and social support systems that help them navigate their disease journey. Outside of a trial, those layers are not always in place. Some patients may not have insurance or someone to drive them to and from the clinic, and others may have comorbidities that were not part of the clinical trial, such as patients on dialysis or those with significant liver damage. In these situations, Zeidan emphasizes the importance of applying clinical judgment when counseling patients about different treatment approaches and their goals of care.

According to Zeidan, those goals generally fall into 2 broad directions: curative-intent therapy aimed at curing the patient, or treatment focused on quality of life and extending survival when a cure is not an option. He describes these as key considerations in the real-world practice of medicine.

Zeidan then outlines how disease factors shape the treatment plan. The type of AML and its genetic profile, including whether a FLT3, NPM1, IDH1, IDH2, or TP53 mutation is present, can affect the aggressiveness of therapy and whether intensive or non-intensive treatment is used. These molecular features also guide the choice of combinations, such as pairing a FLT3 inhibitor or an IDH inhibitor with the treatment backbone.

Patient factors carry equal weight in his framework. Zeidan points to whether a patient has the support to return for very regular visits, whether that support is sufficient for a transplant, which is often needed as part of treatment, and which comorbid conditions are present. Those comorbidities influence treatment selection as well as the patient's ability to tolerate both the treatment and its monitoring paradigm.

Zeidan explains that bringing disease and patient factors together allows the care team to present patients with their different options and arrive at a treatment decision through a shared decision-making process.