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Reduced-Intensity transplants, conventional transplants or chemotherapy for acute myeloid leukemia in 1st remission: who knows; ask your wife?

Leukemia volume 29, pages 1448–1449 (2015)Cite this article

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In this issue of Leukemia, Russell et al.1 present select data from the Medical Research Council (MRC) acute myeloid leukemia AML15 trial. The authors say their aim is to compare the conventional (often mistakenly termed myelo-ablative) and reduced-intensity conditioning (RIC) transplants from HLA-identical or -matched or -partially-matched unrelated donors in persons 35–65 year old with AML in 1st remission. They also propose to compare these transplant outcomes with those of chemotherapy focusing on cytogenetic risk groups.

These are heady goals for which the authors should be commended. But can they deliver? How they might do so is a bit foggy given the complex design of MRC 15 and the un-pre-specified nature of this analysis. A tricky business at best. For example, in MRC 15 persons 35–44 years were recommended to have a conventional or RIC transplant and those >44 years were assigned to receive a RIC transplant. The choice between a conventional and RIC allotransplant in the younger cohort (everything is relative) may have been reasonable 14 years ago when the study began but reasonableness does not mitigate the complexity and biased recommendation rather than randomization imposes on a comparison of outcomes. Choosing whether to do a transplant or not and which type of transplant to do depended, in part, on having a suitable donor. However, the final decision was left to the physician. As expected, not all subjects meant to receive either type of transplant did so, some because they had no appropriate donor, some because they relapsed before a transplant could be done, some because they, their physician or the donor (or combinations thereof) refused and others for other specified and unspecified reasons. And because there was no randomization we cannot consider an intent-to-treat analysis but must simply look at what happened and hope for the best.

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References

  1. Russell N, Kjeldsen L, Craddock C, Pagliuca A, Yin J, Clark R et al. A comparative assessment of the curative potential of reduced intensity allografts in acute myeloid leukaemia. Leukemia 2015; 29: 1478–1484.

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  2. Mohty M, Malard F . To RIC or not to RIC: that is the question. Leukemia. 2015; 29: 1450–1451.

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Acknowledgements

This study supported by the NIHR Biomedical Research Centre funding scheme.

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  1. Division of Experimental Medicine, Department of Medicine, Haematology Research Centre, Imperial College London, London, UK

    R P Gale

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  1. R P Gale
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Correspondence to R P Gale.

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Gale, R. Reduced-Intensity transplants, conventional transplants or chemotherapy for acute myeloid leukemia in 1st remission: who knows; ask your wife?. Leukemia 29, 1448–1449 (2015). https://doi.org/10.1038/leu.2015.84

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