AUDIO JOURNAL OF ONCOLOGY—Don't Delay Stem Cell Transplant For Patients with Relapsed or Refractory Acute Myeloid Leukemia Audio Journal of Oncology Podcast

Interview with Matthias Stelljes MD, Head of the Allogeneic Stem Cell Program at the University of Münster, Germany
NEW ORLEANS, USA—For your patients with acute myeloid leukemia (AML) the benefit of prompt allogeneic hematopoietic cell transplantation (alloHCT)  extends to those whose disease has relapsed or is refractory to induction therapy, and should not be delayed in favor of further intensive chemotherapy in an attempt to achieve a complete remission. That’s according to conclusions from the randomized phase three ASAP (As Soon As Possible) Trial, reported by German researchers at the American Society of Hematology (ASH) 2022 Annual Meeting.
https://ashpublications.org/blood/article/140/Supplement%201/9/488703/In-Patients-with-Relapsed-Refractory-AML
“Allogeneic stem cell transplantation is a very potent strategy which is curative for many patients,” said senior author of the study, Johannes Schetelig, Prof. Dr. med., at the University of Dresden in Germany. “Our study suggests that the international standard of bringing patients into remission first should be questioned, as it proves that allotransplant should be considered a standard treatment option even for patients with active disease.”
The new study was the first prospective randomized trial to assess whether or not high-dose “salvage chemotherapy” (to attempt to bring about a complete remission)  made a difference in long-term outcomes after a stem cell transplant. Patients whose AML had relapsed or who did not respond to initial chemotherapy had similar outcomes when they proceeded directly to alloHCT compared with those who underwent intensive chemotherapy in the attempt to achieve complete remission first.
Retrospective data had established that having a complete remission prior to allogeneic hematopoietic cell transplantation was indeed a favorable risk factor for patients with AML. But the ASAP Trial had been the first to examine this relationship prospectively, the researchers noted.
“We were astonished. We never expected these results,” Schetelig said. “Patients did not gain additional benefit from salvage chemotherapy at all. It suggests we should think about starting the process of allotransplantation as soon as possible.”
In previous phase two trials the researchers had found transplanting patients who had active disease brought a benefit. “We had some good experience in the past where we were able to successfully treat patients with an allogeneic stem cell transplantation even in the setting of active disease,” said first author of the ASAP study, Matthias Stelljes MD, Head of the Allogeneic Stem Cell Program at the University of Münster, Germany.
Stelljes acknowledged that the majority of centers did not usually perform alloHCT in patients with relapsed or refractory AML with active disease. The new findings from ASAP, however, ran counter to the common practice of offering prompt transplantation only to patients who were in complete remission and clearly imply that many patients could skip the additional step of having salvage chemotherapy before receiving a transplant.
The study enrolled 281 patients treated for relapsed or refractory AML in Germany. Half of them were randomized to proceed directly to alloHCT and remaining half had salvage chemotherapy first. The median time from randomization to transplant was four weeks among those proceeding directly to a transplant and eight weeks among those receiving salvage chemotherapy first. Researchers tracked outcomes for a median of just over three years.
In the standard arm patients had salvage therapy with high dose cytarabine (ara-C) and mitoxantrone and then received an allogeneic transplant. This was either in subsequent remission or with active disease in those in whom no remission could be achieved, Stelljes told the Audio Journal of Oncology. “In the experimental arm we did not perform any salvage tre