Correspondence

Acute Myeloid Leukemia

N Engl J Med 2000; 342:358-359February 3, 2000

Article

To the Editor:

In their otherwise informative review of new developments in the diagnosis and treatment of acute myeloid leukemia (AML), Löwenberg and colleagues (Sept. 30 issue)1 state that before the 1970s, the five-year survival rate among patients with AML was less than 15 percent but that survival among patients under the age of 65 years is currently 40 percent. These statistics differ markedly from U.S. population–based survival rates among patients with AML from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute,2 a consortium of 11 geographically defined cancer registries. Data from the SEER program indicate that five-year overall (observed) survival among all patients with AML was 5 percent for patients given a diagnosis in the mid-1970s, the earliest period for which data are available (Table 1Table 1Five-Year Overall Survival Rates among Patients with Acute Myeloid Leukemia, According to Age and Year of Diagnosis.). Although this survival rate has improved steadily over time, it reached only 11 percent for patients given a diagnosis in the most recent years for which five-year follow-up is complete (1988 to 1991). Moreover, for patients under the age of 65, the most recent five-year survival rate was 21 percent, according to the data from the SEER program — about half that cited for this age group by Löwenberg and colleagues (although they did not specify whether they were reporting a five-year overall rate).

Table 1 also highlights the striking association between age and survival among patients with AML. Over the past 20 years, improvements in survival have been realized almost entirely by persons under the age of 65, with equivalent gains among patients up to 19 years old and those 20 to 64 years old. In contrast, five-year observed survival is exceedingly poor and has not improved with time among patients 65 and older, who account for half of all cases of AML.

Löwenberg et al. do not give the source of the survival rates presented in their review. If these statistics were derived from a clinical setting, they may very well be more favorable than those observed in a geographically defined area, which summarize outcomes of disease among an entire population. With regard to general observations about the outcome of cancer, survival data from the population-based SEER program have the distinct advantages of large numbers of patients, uniform follow-up, and demographic representativeness. In addition, up-to-date data on incidence and survival can be obtained easily through the Internet at http://www-seer.ims.nci.nih.gov.

Regardless of the source of the data, the survival statistics for patients with AML convey the fact that grave outcomes continue to be associated with this disease, particularly in older patients.

Christina A. Clarke, Ph.D.
Sally L. Glaser, Ph.D.
Northern California Cancer Center, Union City, CA 94587

2 References

1. 1

   Lowenberg B, Downing JR, Burnett A. Acute myeloid leukemia. N Engl J Med 1999;341:1051-1062
   Full Text | Web of Science | Medline

2. 2

   National Cancer Institute. SEER*Stat CD-ROM with 1973–1996 incidence data. Silver Spring, Md.: Information Management Services, 1999.
   

Author/Editor Response

The authors reply:

To the Editor: Drs. Clarke and Glaser raise the important issue of difference in survival rates between patients in the general population who are given a diagnosis of acute myeloid leukemia and those who are enrolled in clinical trials. They suggest that a survival rate of 40 percent for patients under the age of 65 years is overly optimistic.

We agree that most published data on survival among patients with AML are derived from clinical trials and that there are too few population-based data available. This issue has been addressed in a limited way by Stiller et al. through regional surveys of patients under 30 years of age in the United Kingdom.1 The population survival rate is virtually the same as that among the patients enrolled in the national trial2 — 42 percent at 5 years and 39 percent at 10 years. There was no difference in survival between patients who were enrolled in the national trial and those who were not — possibly because patients who were not enrolled tended to follow the schedule of the trial. A high proportion of younger patients (<55 years old) in the United Kingdom entered the national trial.

Data from the Netherlands Cancer Registry obtained during the period from 1989 through 1995 indicate five-year survival rates among patients with AML of 47 percent (for those up to 14 years of age) and 30 percent (for those 15 to 19 years of age).3 We agree that these data are incomplete and that there has been little evidence of improved survival among older patients. In the Netherlands, patients are usually not offered suitable treatment in a trial and are usually treated according to a more obviously palliative approach. Data from trials involving older patients are relevant only to the minority of patients who are considered suitable for entry into the trials, and the results derived are not always applicable to the majority who do not enter such trials. It is also difficult to find evidence of improvement in survival among older patients who do not enter trials.

Bob Löwenberg, M.D.
University Hospital Rotterdam, 3008 AE Rotterdam, the Netherlands

Alan K. Burnett, M.D.
University of Wales College of Medicine, Cardiff CF4 4XN, United Kingdom

3 References

1. 1

   Stiller CA, Benjamin S, Cartwright RA, et al. Patterns of care and survival for adolescents and young adults with acute leukaemia -- a population-based study. Br J Cancer 1999;79:658-665
   CrossRef | Web of Science | Medline

2. 2

   Hann IM, Stevens RF, Goldstone AH, et al. Randomized comparison of DAT versus ADE as induction chemotherapy in children and younger adults with acute myeloid leukemia: results of the Medical Research Council's 10th AML trial. Blood 1997;89:2311-2318
   Web of Science | Medline

3. 3

   Haematological malignancies in the Netherlands 1989–1995. Utrecht: Netherlands Cancer Registry, 1995.
   

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