Deciding between chemotherapy and epigenetic therapy in patients with AML
| Factors in favor of ICT . | Factors in favor of epigenetic therapy . |
|---|---|
| Age <70 y | Age ≥80 y |
| ECOG PS < 2 | ECOG PS ≥ 2 |
| Low CCI, HCT-CI (<3) | High CCI, HCT-CI (≥3) |
| Higher WBC* | Lower WBC* |
| De novo AML | Secondary AML (post-MDS, post-MPN) |
| AML not classified as WHO MRC-AML | AML classified as WHO MRC-AML |
| Favorable genetics: favorable ELN category (Table 1) | Unfavorable genetics: monosomy 5 or 7, del(5q); complex, monosomal karyotype; TP53 gene mutation |
| FLT3-ITD | No FLT3-ITD |
| No epigenetic gene mutation? | Epigenetic gene mutations (TET2, DNMT3A)? |
| Factors in favor of ICT . | Factors in favor of epigenetic therapy . |
|---|---|
| Age <70 y | Age ≥80 y |
| ECOG PS < 2 | ECOG PS ≥ 2 |
| Low CCI, HCT-CI (<3) | High CCI, HCT-CI (≥3) |
| Higher WBC* | Lower WBC* |
| De novo AML | Secondary AML (post-MDS, post-MPN) |
| AML not classified as WHO MRC-AML | AML classified as WHO MRC-AML |
| Favorable genetics: favorable ELN category (Table 1) | Unfavorable genetics: monosomy 5 or 7, del(5q); complex, monosomal karyotype; TP53 gene mutation |
| FLT3-ITD | No FLT3-ITD |
| No epigenetic gene mutation? | Epigenetic gene mutations (TET2, DNMT3A)? |
CCI, Charlson Comorbidity Index; ELN, European LeukemiaNet; HCT-CI, Hematopoietic Cell Transplantation Comorbidity Index; ITD, internal tandem duplication; MPN, myeloproliferative neoplasm; MRC, myelodysplastic-related change.
Higher WBC is associated with a worse prognosis after ICT; nevertheless, the prognosis of patients with WBC > 15 000 G9/L might be even worse after HMA therapy, at least when treated with AZA55 and maybe less when treated with DAC.41