VIDEO: Maintaining remission a major challenge in AML

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The major cause of disease failure in patients of acute myeloid leukemia is not our ability to achieve remission in the majority of our patients, but is our inability to maintain that remission and convert that disease response to active cure. And so in the past we've known with younger fitter patients, the most reliable way to achieve a long-term response is to administer chemotherapy followed by allogeneic stem-cell transplantation in more than half of patients. How do we detect relapse? How do we determine who of the patients that we're putting into remission are going to relapse?

We've been focusing now on exploiting methods and technologies to develop ways to standardize and utilize minimal or measurable residual disease by either multi-parameter flow cytometry or molecular methods to detect those individuals whose disease is not completely eradicated by our upfront therapy. Early identification of patients that are MRD-positive who are most likely to relapse is probably going to be a fruitful way for us to determine which individuals need to go for transplant, which need to go for other therapies, and to be on the lookout for additional monitoring for that relapse. Those methods, however, at this point in this country, have not been standardized.

Many of us at academic centers are using local institutional MRD methods, both molecular and PCR-based or flow cytometry-based. I think what's really needed is a universal standard and guidelines similar to what have been developed in Europe as to when to use MRD, what endpoints to measure, and what to do, most importantly, with patients that are MRD-positive. I think one thing that's, again, an area that has garnered much interest is determining what could be MRD erasers, potentially immunotherapeutic approaches or bispecific or some other approach that we could use to eradicate MRD in our AML patients before disease recurrence similar to what we have with blinatumomab in the relapsed or upfront ALL treatment paradigm.