Published on September 21, 2020
What are the Drug Options for Older Relapsed AML Patients?
Dr. Eunice Wang, acute myeloid leukemia (AML) expert from Roswell Park Comprehensive Cancer Center, joins Patient Power Co-Founder Andrew Schorr to discuss the treatment options available to older AML patients whose remission has ended.
Dr. Wang explains that AML "is not a static disease, it evolves over the course of therapy” and emphasizes the importance of retesting at the time of relapse to discover any new AML mutations that may have developed. Dr. Wang also discusses targeted therapies, often oral medications, that address individual mutations and offer personalized treatment.
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Transcript | Oral Drug Options for Relapsed AML Patients
Hello, and welcome to Patient Power, I'm Andrew Schorr. We're visiting with Dr. Eunice Wang, who is the Chief of the Leukemia Service at the Roswell Park Comprehensive Cancer Center in Buffalo, New York. And we're talking about AML, acute myeloid leukemia, Dr. Wang, welcome back to Patient Power.
Thank you. I'm delighted to be here, Andrew.
What are the signs of AML remission ending?
Typically, AML is in older patients and we wish we could cure AML, but people's remission can end. First of all, what are the signs when remission is ending?
Typically, they are related to a progression in the bone marrow. Patients coming in and their counts are just dropping and dropping. They're more tired, they're more fatigued. They're requiring more and more transfusions. In the past, maybe they were transfusion independent. Now when they come in and they get therapy, they're just not recovering the counts.
Sometimes they start to develop complications due to profound neutropenia and immunosuppression so they can develop infections frequently, they can get put on antibiotics, they can have bleeding episodes. I certainly have patients that tell me, "You know what, Dr. Wang? When I first started therapy for the leukemia, I felt great. My energy came back. I was doing all these activities. Now I just don't feel good. I don't feel like doing anything." Some people start to have weird aches and pains, and I think any of those signs, when you've previously been doing really well on therapy should lead one to say, "You know what? Maybe I need to go in and get an evaluation."
Genomics can identify AML mutations
What testing are you going to do? Bone marrow biopsy, for sure. But also, are you going to do any genomic testing to see what version of AML are we dealing with now to then talk about therapy?
Yes, we would want to do the bone marrow biopsy because leukemia is not a static disease. It evolves over the course of therapy. It can develop resistance. It can have mutations. And why do we want to characterize the genomics? Because we now have pills that we can give individuals to effectively treat their leukemia. There are pills that target IDH1, IDH2, FLT3 mutations. And particularly for the patients with FLT3 mutant AML, there is a phase three study, and it turned out, you know what, Andrew? Taking a pill once a day for FLT3 mutant relapsed leukemia was better and lead to longer survival and better remission than patients getting high dose chemotherapy in the hospital. It is really important at the time of the disease recurrence if you find that on the bone marrow or the blood that you recharacterize to see whether your disease has those mutations.
The medicine may not have been a targeted approach for you at the outset, with relapse that might be the targeted approach that you need.
Exactly. I have patients whose disease comes back two or three times, and again, it's important to look.
What about side effects? It sounds like these targeted approaches are great, but there's no free lunch in cancer care. There are side effects that go with them, right?
One of the side effects we see is that the cancer cells, which are very immature cells, early in development, can undergo a process where they become more differentiated, more mature. The white count actually can go up and you can develop what we call differentiation syndrome. And that is having fevers, having something that looks very much like pneumonia and having weight gain, fluid retention. And that is something that can occur even up to 30 or 60 or even 90 days after starting these pills. These pills still need to be monitored. These are not pills that you can just take and then come back in a month.
Other things to remember, it can take up to three or four or five months for some of these pills to work. What we start to see early that they start to become transfusion independent. Their requirements for red cells and platelets go down and then over a period of two, three or four months, that's when we start to see the remission and we start to see the disease control.
Older AML patients now have better options
When you put it all together, Dr. Wang, it sounds like for older patients who relapse, you have better options than ever, and working with an AML specialist, such as you, people can live longer and live better.
Yes. That's our goal. For most, particularly for our older patients, as you know, Andrew, when you're in your older decades, you know what's important to you, you know the priorities in life, what you want to do with yourself with the time that you have remaining. The pills and the drugs and the increase availability of targeted therapy has given us an increased armamentarium to allow us to give patients not just more life, but better life for whatever time they have.
Well, it's a very hopeful story. Dr. Eunice Wang from Roswell Park. Thank you so much for being with us and your dedication to patients.
No problem. It's a pleasure as always, Andrew.
Okay. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.