AML Risk Stratification and Fitness Assessment: ELN Systems and Objective Criteria

This episode, "AML Risk Stratification and Fitness Assessment: ELN Systems and Objective Criteria," features the leukemia panel examining how clinicians classify disease risk and patient fitness before choosing therapy.

Dr. Mahmoudjafari notes that AML management has evolved considerably during her career. She asks Dr. Stein which risk classification systems are most widely used and most practical. Dr. Stein identifies the European LeukemiaNet, or ELN, system as the most widely used. Historically, a single classification applied to all patients regardless of the therapy they received. ELN 2022 stratifies patients into favorable, intermediate, and adverse risk. That framework was used primarily to predict remission and relapse, and to decide whether a patient should be referred for allogeneic stem cell transplant.

In 2024, a separate schema was published for patients receiving lower-intensity therapy. Dr. Stein considers it important for patients receiving azacitidine plus venetoclax, because it clarifies their likelihood of responding. He also flags an anticipated ELN update for intensive therapy, likely in 2027, following the 2017 and 2022 versions. Asked whether the systems might eventually be consolidated, he agrees a single framework would be welcome. He explains that the lower-intensity system was created because the original system did not stratify those patients well.

Dr. Murthy then describes the clinical features that distinguish fit from unfit patients. He calls fitness one of the major determinants of first-line and subsequent treatment selection. Commonly used criteria provide objective evidence based on age, performance status, and comorbid conditions. Comorbidities are measured across multiple organ systems, including cardiac, renal, and pulmonary function. Patients meeting any of these criteria are candidates for lower-intensity treatment, while those meeting none are candidates for intensive therapy. Since azacitidine plus venetoclax became commercially available, he estimates that up to half of patients seen are unfit for intensive therapy. Dr. Murthy adds that this shift has raised awareness of the need for objective criteria rather than the eyeball test. Dr. Mahmoudjafari agrees that subjective impressions vary widely between clinicians.

In "Fit vs Curable in AML: Psychosocial Burden and Older-Patient Treatment Decisions," Dr. Zeidan and Dr. Stein will share patient cases that challenge the line between fit and curable.