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Acute myeloid leukemia (AML) is a genetically heterogenous disease with multiple cytogenetic markers used as outcome predictors that help stratify patients in different risk groups and guide treatment.1 Some of these markers include, NPM1, TP53, FLT3, and IDH1/2, while overexpression of the B-cell leukemia/lymphoma 2 (BCL-2) protein has been associated with poor responses and even resistance to AML chemoimmunotherapy.2 The selective BCL-2 inhibitor, venetoclax, has been approved by the U.S. Food & Drug Administration (FDA) in combination with a hypomethylating agent (HMA; azacitidine or decitabine) or low-dose cytarabine (LDAC) for the treatment of previously-untreated older patients with AML, where standard chemotherapy is not the best treatment option (Read more here).3
During the 61st American Society of Hematology Meeting & Exposition on Monday 9th December 2019, Brenda Chyla from AbbVie Inc., IL, US, presented an exploratory biomarker analysis from two phase Ib/II studies that examined the combination of venetoclax with HMA (NCT02203773) or LDAC (NCT02287233) in older patients with AML, who were ineligible for induction chemotherapy. The primary objectives of this study were to evaluate baseline genomic data from these two clinical trials and to correlate them to patient outcomes.4
CR, Complete response; Cri, CR with incomplete hematologic recovery
AML mutation CR (%) Cri (%) CR + Cri (%) NPM1 (n= 21) 67 14 81 IDH1 (n= 19) 37 37 74 IDH2 (n= 14) 71 22 93 FLT3 (n= 17) 41 6 47 TP53 (n= 30) 30 27 57 Other mutation (n= 18) 49 27 76 All patients (N= 119) 46 26 72CR, Complete response; Cri, CR with incomplete hematologic recovery
AML mutation CR (%) CRi (%) CR + Cri (%) NPM1 (n= 9) 78 11 89 IDH1 (n= 9) 71 21 93 IDH2 (n= 11) 55 18 73 FLT3 (n= 16) 19 25 44 TP53 (n= 13) 8 31 38 Other mutation (n= 21) 22 28 50 All patients (N= 79) 25 28 53For further details on the effect of both treatment options on the median overall survival (mOS) and one-year overall survival (OS) see Table 3.
Table 3. mOS and 12 month OS estimate in both treatment groups by mutationmOS, median overall survival; NR, not reached; OS, overall survival
Mutation mOS (95% CI), months 12 month OS estimate (95% CI), % NPM1 (n= 30) NR (12.5-NR) 73 (53-85) IDH1 (n= 28) 15.9 (10.7-NR) 67 (46-81) IDH2 (n= 25) NR (19.4-NR) 76 (54-88) FLT3 (n= 33) 9.9 (4.8-17) 47 (29-63) TP53 (n= 43) 6.4 (3.8-8.9) 23 (11-37) FLT3mut NPM1wt(n= 22) 5.9 (3-14) 35 (16-54) FLT3wt NMP1mut NR (11-NR) 74 (48-88) FLT3mut NMP1mut(n= 11) 27.8 (4.8-NR) 72 (35-90)Patients with NPM1 or IDH1/2 mutations achieved high response rates (> 70%) and prolonged OS irrespective of the venetoclax combination therapy they received. Interestingly, outcomes (OS and CR/CRi rate) were better in patients with concurrent FLT3 and NPM1 mutations than those with a FLT3 mutation alone. Patients with TP53 mutations managed to achieve good responses but they were not sustained, with a mOS of 6.4 months. BCL-2 expression was not prognostic of response to venetoclax combination therapy (HMA or LDAC) in this naïve, older patient population that is not eligible for standard induction therapy.
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