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776 Follow-up of the Randomized ASAP Trial Shows No Survival Advantage for Patients with Poor Responsive or Relapsed AML Who Received Intensive Salvage Chemotherapy for Remission Induction Prior to Allogeneic Transplantation Compared to Immediate Allogeneic Transplantation

Program: Oral and Poster Abstracts
Type: Oral
Session: 732. Allogeneic Transplantation: Disease Response and Comparative Treatment Studies: Novel Approaches to Risk Stratification and Optimization for Transplant
Hematology Disease Topics & Pathways:
Acute Myeloid Malignancies, Research, Clinical trials, AML, Combination therapy, Clinical Research, Therapy sequence, Diseases, Biological therapies, Treatment Considerations, Myeloid Malignancies, Transplantation (Allogeneic and Autologous)
Monday, December 9, 2024: 10:45 AM

Matthias Stelljes, MD1, Jan Moritz Middeke, MD2*, Gesine Bug, MD3*, Eva-Maria Wagner Drouet4*, Lutz Peter Hermann Mueller, MD5*, Christoph Schmid, MD6*, Stefan W. Krause, MD7*, Wolfgang Andreas Bethge, MD8*, Edgar Jost, MD9*, Uwe Platzbecker, MD10, Stefan Klein, MD11, Judith Niederland, MD12*, Martin Kaufmann, MD13, Kerstin Schäfer-Eckart, MD14*, Henning Baldauf, M.Sc.15*, Friedrich Stölzel16*, Sarah Trost, M.Sc.15*, Christoph Röllig, MD17*, Malte von Bonin, MD18*, Katharina Egger-Heidrich, MD19*, Désirée Kunadt2*, Björn Steffen, MD20*, Beate Hauptrock, MD21*, Christoph Schliemann, MD22*, Katja Sockel, MD23*, Fabian Lang, MD24*, Oliver Kriege, MD25*, Judith Schaffrath, MD26*, Christian Reicherts, MD27*, Wolfgang E. Berdel, MD28, Hubert Serve, MD29, Gerhard Ehninger, M.D.30,31, Alexander H. Schmidt, MD32*, Jan-Henrik Mikesch, MD27*, Martin Bornhäuser, MD23,33* and Johannes Schetelig, MD, MSc15,17

1Department of Medicine A (Hematology, Hemostaseology, Oncology, Pneumology), University of Muenster, Muenster, Germany
2Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
3Department of Medicine 2, Goethe University Frankfurt, Frankfurt, Germany
4Medical Clinic III, University Medical Center Mainz, Mainz, Germany
5Department of Internal Medicine IV, University Hospital Halle Martin Luther, University Halle-Wittenberg, Halle, Germany
6Department of Hematology, University Hospital Augsburg, Augsburg, Germany
7Medical Clinic V, University Clinic Erlangen, Erlangen, Germany
8Department of Internal Medicine II, Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Tübingen, Germany
9University Hospital Aachen & Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Aachen, Germany
10Department for Hematology, Cell Therapy, Hemostaseology and Infectious Diseases, University of Leipzig Medical Center, Leipzig, Germany
11Department of Hematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
12Clinic for Haematology and Celltherapie, Helios Clinic Berlin-Buch, Berlin, DEU
13Department of Hematology, Oncology and Palliative Care, Robert Bosch Hospital, Stuttgart, Germany
14Department of Internal Medicine V, Paracelsus University Hospital Nuremberg, Nuremberg, Germany
15Clinical Trials Unit, DKMS Group gGmbH, Dresden, Germany
16Division of Stem Cell Transplantation and Cellular Immunotherapies, University Hospital Schleswig-Holstein, Kiel, Germany
17Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Saxony, Germany
18University Hospital Carl Gustav Carus Technical University Dresden, Dresden, Germany
19Department of Internal Medicine 1, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
20Goethe-University Frankfurt, University Hospital, Department of Medicine II - Hematology and Oncology, Frankfurt am Main, Germany
21Department of Internal Medicine III, University Medical Center Mainz, Mainz, Germany
22Department of Medicine A, University Hospital Muenster, Muenster, Germany
23University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
24Department of Medicine, Hematology/Oncology, Goethe University Frankfurt, University Hospital, Frankfurt/Main, Germany
25Department of Internal Medicine III, University Hospital Medical Center Mainz, Mainz, Germany
26Department of Internal Medicine IV, Hematology and Oncology, Martin Luther University Halle-Wittenberg, Halle, Germany
27Department of Medicine A, Hematology, Oncology and Pneumology, University Hospital Muenster, Muenster, Germany
28Department of Medicine A (Hematology, Hemostaseology, Oncology, Pneumology), University Hospital Muenster, Muenster, Germany
29Department of Medicine, Hematology/Oncology, Goethe-University Frankfurt, University Hospital, Frankfurt am Main, Germany
30Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, DEU
31Cellex Cell Professionals GmbH, Cologne, Germany, Cologne, Germany
32DKMS Group gGmbH, Dresden, Germany
33National Center for Tumor Diseases Dresden (NCT/UCC), Technical University Dresden, Dresden, Germany

INTRODUCTION

To attempt inducing a complete remission (CR) prior to allogeneic hematopoietic cell transplantation (alloHCT) in patients with active AML after first induction or untreated first relapse is considered as standard of care. This standard, however, has never been tested in a randomized controlled trial (RCT). With the availability of highly potent sequential conditioning regimens the value of CR induction prior to alloHCT is unclear for patients with poor responsive or relapsed AML. Against this background, the ASAP trial was conducted (NCT 02461537, Stelljes et al Lancet Hematology 2024). Here, we report the long-term follow-up (FU) and outcome according to genetic risk groups.

METHODS

To test salvage chemotherapy prior to alloHCT, patients aged between 18 and 75 years with AML and poor response after first induction or untreated first relapse and available HLA-compatible donor were randomized 1:1 to remission induction (RIST) with high-dose cytarabine plus mitoxantrone or immediate alloHCT with sequential conditioning after disease control (DisC). Disease control consisted preferentially of watchful waiting only. Overall survival (OS) from randomization according to the intention-to-treat (ITT) was the major secondary endpoint and is reported here with a median FU of 5 years. To improve molecular risk assessment available baseline samples were re-analyzed and classified according to the ELN 2022 risk classification.

RESULTS

281 patients were enrolled between September 2015 and January 2022. Of 140 patients randomized to DisC 135 proceeded to alloHCT (96%) and of 141 patients randomized to RIST 128 patients (91%) were transplanted. Treatment success was documented for 82.9% (116/140) of patients in the DisC arm and 79.4% (112/141) of patients in the RIST arm, resulting in a difference for treatment success of +3.4% (95% CI, –5.8% to 12.6%) for DisC versus RIST. OS at 3 years from randomization analyzed according to ITT was 54.8% (95% CI, 46% to 63%) versus 54.5% (95% CI, 46% to 62%) (p=0.95) and at 5 years 46.1% (95% CI, 37% to 55%) versus 47.5% (95% CI, 39% to 56%) (p=0.8), for DisC versus RIST, respectively, indicating no benefit of remission induction prior to alloHCT. Among patients with treatment success, disease-free survival (DFS) was not statistically different by treatment arm (4-year DFS from treatment success, 48.3% (95% CI, 39% to 57%) for DisC versus 49.1% (39% to 58%) for RIST, p=0.9). In multivariable Cox regression models for OS from randomization, ELN risk and age significantly predicted survival, but not treatment arm. TP53-lesions were detected in 21 patients randomized to DisC and 9 patients randomized to RIST. Three-year OS since randomization in patients with adverse risk AML with TP53-lesions was 24% (95% CI, 9% to 34%) versus 33% (95% CI, 8% to 62%) (log-rank test, p=0.5) and with adverse risk AML without TP53-lesions 48% (95% CI, 33% to 62%) versus 45% (95% CI, 29% to 59%) (log-rank test, p=0.8) for DisC versus RIST, respectively. With intermediate risk AML 3-year OS was 60% (95% CI, 46% to 72%) compared to 63% (95% CI, 51% to 73%) for patients randomized to DisC or RIST (log-rank test, p=0.52), respectively. Patients with favorable risk AML (94% enrolled with untreated relapse) randomized to DisC had 3-year OS of 90% (95% CI, 64% to 97%) compared to 46% (95% CI, 18% to 70%) for patients randomized to RIST (log-rank test, p=0.01).

CONCLUSIONS

In summary, longer follow-up of the ASAP trial confirms our previous results and shows no survival advantage for remission induction prior to alloHCT as opposed to immediate alloHCT. This result questions the general concept of remission induction prior to alloHCT, since immediate alloHCT after sequential conditioning may reduce time in hospital and treatment exposure. More potent bridging concepts with targeted drugs prior to alloHCT are warranted especially for adverse risk AML and need to be tested in RCTs to demonstrate sustained survival advantage. Together with the profound impact of genetic risk on long-term survival the results may be interpreted as a sign that patients with poor responsive or relapsed AML benefit rather from relapse prevention after alloHCT than conventional CR induction prior to alloHCT.

Disclosures: Middeke: Novartis Oncology: Research Funding; Beigene: Honoraria; Novartis: Honoraria; Synagen: Current equity holder in private company; Cancilico GmbH: Current Employment, Current equity holder in private company; Roche: Honoraria; Janssen: Honoraria; Abbvie: Honoraria; Pfizer: Honoraria; Astellas: Honoraria; Sanofi: Honoraria; Janssen: Research Funding; Jazz: Research Funding; Glycostem: Consultancy; AstraZeneca: Consultancy; Novartis: Consultancy; Pfizer: Consultancy; Astellas: Consultancy; Jazz: Consultancy; Abbvie: Consultancy; Gilead: Consultancy; Janssen: Consultancy; Roche: Consultancy. Wagner Drouet: Novartis: Membership on an entity's Board of Directors or advisory committees; Kite: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel grant; Incyte: Membership on an entity's Board of Directors or advisory committees; BMS: Other: travel grant. Mueller: Abbvie: Honoraria, Other: travel grant; Amgen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees, Other: travel grant; Pfizer: Membership on an entity's Board of Directors or advisory committees; Squibb: Honoraria, Other: travel grant; BMS: Honoraria, Other: Travel grant. Krause: Eickeler: Honoraria; Abbvie: Other: travel expense; Jazz pharmaceuticals: Other: travel expense; Alexion: Other: travel expense. Platzbecker: Amgen: Consultancy, Research Funding; BMS: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel support, Research Funding; MDS Foundation: Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy, Research Funding; Curis: Consultancy, Honoraria, Research Funding; Geron: Consultancy; Janssen: Consultancy, Honoraria, Research Funding; Merck: Research Funding; Novartis: Consultancy, Research Funding. Röllig: Astellas: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria; Jazz: Consultancy, Honoraria; Johnson & Johnson: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Otsuka: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria; Bristol-Meyer-Squibb: Consultancy, Honoraria; Servier: Consultancy, Honoraria; Daiichi Sankyo: Consultancy, Honoraria. Schliemann: Jazz Pharmaceuticals: Honoraria, Other: Travel- & congress-support, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria, Other: Travel- & congress-support; AstraZeneca: Honoraria; BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel- & congress-support; Laboratories Delbert: Honoraria, Membership on an entity's Board of Directors or advisory committees; Servier: Honoraria, Membership on an entity's Board of Directors or advisory committees; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees; Anturec Pharmaceuticals: Research Funding; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel- & congress-support; Astellas: Honoraria, Membership on an entity's Board of Directors or advisory committees. Lang: Incyte: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria; Enliven Therapeutics: Honoraria; BMS: Consultancy, Honoraria. Berdel: Elvesca Biotherapeutics: Current equity holder in private company, Patents & Royalties: Ownership, Patent; Philogen: Current holder of stock options in a privately-held company, Other: Travel- & congress-support, Research Funding; Anturec Pharmaceuticals: Current equity holder in private company, Patents & Royalties: Ownership, Patent, Intelectual Property, Research Funding. Serve: Gilead Sciences: Consultancy, Honoraria; Novartis: Honoraria; IKP Stuttgart: Consultancy, Honoraria, Other: advisory role. Ehninger: Cellex Cell Professionals: Current equity holder in private company; Avencell: Membership on an entity's Board of Directors or advisory committees. Mikesch: Servier: Honoraria; GSK: Membership on an entity's Board of Directors or advisory committees; Astellas: Other: Travel- & congress-support; Alexion: Membership on an entity's Board of Directors or advisory committees, Other: Travel- & congress-support; BeiGene: Honoraria; Novartis: Honoraria, Other: Travel- & congress-support; Jazz Pharmaceuticals: Honoraria, Other: Travel- & congress-support; Celgene: Honoraria, Other: Travel- & congress-support; BMS: Honoraria; Otsuka: Membership on an entity's Board of Directors or advisory committees; Lab. Delbert: Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel- & congress-support; Daiichi Sankyo: Membership on an entity's Board of Directors or advisory committees. Schetelig: Astellas: Honoraria; Medac: Honoraria; Janssen: Consultancy, Honoraria; AstraZeneca: Consultancy, Honoraria; MSD: Consultancy; Novartis: Honoraria; Eurocept: Honoraria.

*signifies non-member of ASH