Secondary acute myeloid leukemia and the role of allogeneic stem cell transplantation in a population-based setting

Abstract Background Secondary AML (s-AML), including AML with an antecedent hematological disorder (AHD-AML) and therapy-related AML (t-AML), constitutes a large proportion of AML patients and is considered to confer a dismal prognosis. Still, the role of allogeneic hematopoietic cell transplantation (HCT) in s-AML and to what extent transplantation is performed is poorly studied. Methods We used the population-based Swedish AML Registry encompassing 3337 intensively treated adult patients during a 17-year period to study the role of HCT, within s-AML as well as compared to de novo AML. Results HCT was performed in 576 (22%) patients with de novo AML, 74 (17%) with AHD-AML and 57 (20%) with t-AML. At five years, there were no survivors among patients with previous myeloproliferative neoplasms without HCT, and corresponding survival for patients with antecedent myelodysplastic syndromes and t-AML was and 2% and 4%, respectively. HCT was compared with chemotherapy consolidation in s-AML using three models: i) in a 200 day landmark analysis HCT was favorable compared to conventional consolidation (P = 0.04, log-rank); ii) in a multivariable Cox regression with HCT as a time-dependent variable the mortality hazard ratio was 0.73 (95% CI 0.64-0.83) for HCT, and favored HCT in all subgroups; iii) in a propensity score matching analysis, the 5-year overall and relapse-free survival for s-AML patients in CR1 was 48% and 43% respectively for patients receiving HCT versus 20% and 21% for patients receiving chemotherapy consolidation (p = 0.01 and 0.02; log-rank). Conclusion Observational data suggests that HCT improves survival and offers the only realistic curative treatment option in patients with s-AML.