DR COLE: Some supportive care-type questions and style of practice-type questions that I struggle with day to day when I’m taking care of these leukemia patients. I want to know your thoughts about growth factor use in acute leukemia. Do you ever use them? Do you never use them? When somebody is in consolidation and they are in remission and they come in with neutropenic fever, what do you think about that? Thoughts on prophylactic antibiotics?

DR STONE: So those are 2 very important questions which we often neglect: The supportive care for AML, because we think we know what we’re doing. But there’s still unanswered questions there. So let’s talk about growth factors. The use of growth factors was initially eschewed in AML because of the concern that you would be stimulating the leukemia to grow. Indeed, there were trials in which they were given before ara-C to try to potentiate the effect of ara-C. But using them as supportive agents has been largely unsuccessful, to be honest with you. I don’t use them ever during remission/induction, although it’s probably safe. There’s really not much data supporting doing that. I will use them occasionally in consolidation, especially in people who are going to get high-dose ara-C, because they have favorable cytogenetics or genetics, and especially if they’ve had one real problem.

But I would not use it when they walk in with fever or neutropenia. If you’re going to use G-CSF, it should be used the day after chemotherapy.

Prophylactic antibiotics is a real morass. It’s very infectious disease doctor-dependent. While there are individual trials supporting the issue of posaconazole or fluoroquinolones, my ID doctors are very much against prophylactic antibiotics in leukemia. They support them, obviously, in post-transplant where their immune system is deranged.

So the answer is, I’m nihilistic. No growth factors except in selected cases for consolidation and no prophylactic antibiotics period in AML outside the context of transplant.

DR LOVE: Jorge, agree or disagree?

DR CORTES: We approach it a little differently. The growth factor, yes, I don’t use them routinely at all, even in consolidation. Maybe in a patient that comes and — even if they come with neutropenic fever, not my first approach. If the patient’s really septic, very sick and you need to try to do something then maybe, but not as a routine strategy.

Some of these studies show that they improve the recovery of the neutrophils by a day or two but they didn’t improve the mortality or anything like that. So you are just throwing the growth factor for —

DR COLE: Is there any real data about whether it stimulates leukemia?

DR CORTES: There is. And at some point, it was — certainly in preclinical studies, you can stimulate leukemia. And they’ve actually been used to try to sensitize the cells to chemotherapy, because you make them cycle. And then you come in with the chemotherapy and then try to kill them while they’re cycling. There’s still some attempts of that now with mobilizing with the CXCR4 inhibitors, kind of the same concept of those kinds of things. So they do stimulate leukemia, and that’s why some of the concerns and use it only in CR, et cetera. But I think, even if you don’t buy that argument, the benefit is so minimal that it really doesn’t — with the cost and all these things, it doesn’t make sense.

Antibiotics, I agree with Rich in the sense that the data is all over the place. And you can find whatever data to support what you are doing and convince you that you’re doing the smart thing and somebody else is doing the wrong thing. We do prophylactic antibiotics on every patient. So we use, usually, an antibiotic, an antifungal and an antiviral, definitely during induction but even during consolidation, especially for patients who are getting intensive chemotherapy, not for hypomethylating agents, for example.

But for the younger patients getting high-dose chemotherapy or, for example, in the ALL patients that are getting hyper-CVAD or something like that, we do routinely use, during the periods of neutropenia, prophylactic, the three.

Module 1: Current and future approaches to targeted therapy for acute myeloid leukemia (AML)

Module 2: Other clinical issues in AML management

Module 3: Case discussions