title: The fludarabine, cytarabine, and granulocyte colony-stimulating factor (FLAG) chemotherapy regimen is an alternative to anthracycline-based therapy for the treatment of acute myeloid leukemia for patients with pre-existing cardiac disease.
abstract: We conducted a retrospective study assessing FLAG (fludarabine, cytarabine, and granulocyte colony-stimulating factor) as first-line treatment in 56 newly diagnosed acute myeloid leukemia patients considered ineligible for anthracycline-based treatment due to advanced age, significant comorbidities, or pre-existing cardiac disease. The median age was 69 (21-80); 46% received FLAG for pre-existing cardiac disease and others due to age (32%), non-cardiac comorbidities (20%), or previous anthracycline exposure (2%). The induction mortality was 16% and, among evaluable patients, 48% achieved a complete remission after the first induction course with an additional patient achieving a remission after a second course for a total complete remission rate of 50%. Four patients proceeded to an allogeneic stem cell transplant including two with pre-existing cardiac disease. Among non-transplanted patients, the relapse rate (RR) was 47%. When censored at time of stem cell transplant, the median relapse-free survival was 14.7 months. The median overall survival was 9.3 months with 1- and 2-yr survivals of 44% and 22%, respectively. There was no difference in clinical outcomes between patients treated with FLAG for cardiac reasons vs. other reasons. In conclusion, FLAG is a useful alternative to anthracycline-based induction for Acute myeloid leukemia in those with significant comorbidities including pre-existing cardiac disease.
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada. lsaini@ualberta.ca.
authors.forename: Lalit
authors.initials: L
authors.lastname: Saini
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Joseph
authors.initials: J
authors.lastname: Brandwein
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Turner
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Loree
authors.initials: L
authors.lastname: Larratt
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Marlene
authors.initials: M
authors.lastname: Hamilton
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Anthea
authors.initials: A
authors.lastname: Peters
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Wu
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Nancy
authors.initials: N
authors.lastname: Zhu
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Jeffery M
authors.initials: JM
authors.lastname: Patterson
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Lauren
authors.initials: L
authors.lastname: Bolster
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Mant
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Bruce
authors.initials: B
authors.lastname: Ritchie
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Elena
authors.initials: E
authors.lastname: Liew
authors.affiliation: Department of Medical Oncology, University of Alberta, Edmonton, AB, Canada.
authors.forename: Sunita
authors.initials: S
authors.lastname: Ghosh
authors.affiliation: Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Irwindeep
authors.initials: I
authors.lastname: Sandhu
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018943:Anthracyclines / Q000008:administration & dosage / Q000627:therapeutic use*; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D015897:Comorbidity; D003561:Cytarabine / Q000009:adverse effects / Q000627:therapeutic use; D005260:Female; D016179:Granulocyte Colony-Stimulating Factor / Q000009:adverse effects / Q000627:therapeutic use; D006331:Heart Diseases / Q000150:complications*; D006801:Humans; D015470:Leukemia, Myeloid, Acute / Q000150:complications* / Q000188:drug therapy* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D016609:Neoplasms, Second Primary; D012189:Retrospective Studies; D016896:Treatment Outcome; D014740:Vidarabine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D018943:Anthracyclines; D003561:Cytarabine; D016179:Granulocyte Colony-Stimulating Factor; D014740:Vidarabine
keywords: FLAG chemotherapy; acute myeloid leukemia; induction