Evaluation of the European LeukemiaNet recommendations for predicting outcomes of patients with acute myeloid leukemia treated in low- and middle-income countries (LMIC): A Brazilian experience

•ELN recommendations may be used for risk stratification of AML patients in LMIC.•OS, DFS and EFS in LMIC were shorter than the reported in Europe and US.•Socioeconomic issues should be consider for treatment failure in LMIC.

BackgroundCurrent results regarding treatment outcomes in acute myeloid leukemia (AML) point to significant differences between low- and middle-income countries (LMIC) and high-income countries (HIC). Excluding well-known socioeconomic issues, genetic markers important for prognosis have not been properly incorporated into the clinical practice so far and their usefulness outside of well-controlled clinical trials remain unknown.MethodsHere, we assessed the clinical significance of the European LeukemiaNet (ELN) recommendations in 196 consecutive patients with AML in a real-life setting. All patients were younger than 60 years of age (49% male) and treated with conventional chemotherapy for induction and consolidation in three Brazilian Institutions that well represent Brazilian geographic and socioeconomic diversity.FindingsMultivariable analysis showed that ELN recommendations had a slight association with complete remission achievement (odds ratio: 0.74, 95% confidence interval, CI: 0.53-1.01; P = 0.06), but were independently associated with poor overall survival (OS) (hazard ratio, HR: 1.3, 95% CI: 1.1-1.54; P = 0.002), disease-free survival (DFS) (HR: 1.42, 95% CI: 1.03-1.95; P = 0.028) and event-free survival (EFS) (HR: 1.24, 95% CI: 1.06-1.47; P = 0.007), considering initial leukocyte counts and age as confounders. ELN recommendations had no impact on cumulative incidence of relapse (P = 0.09).InterpretationOur results suggest that within the context of LMIC, the prognostic markers recommended by ELN may be useful to predict patient's clinical outcomes; however, the OS, DFS and EFS were shorter than the reported in Europe and US for the respective risk groups.