Substantially improved survival for intermediate-risk AML: an Australian statewide network experience spanning 20 years

• Improved survival across 20 years for younger adults with AML associated with enhanced risk stratification and increased transplantation. • Allogeneic transplant independently predicts improved outcomes, while achieving remission from induction is a potent predictor of survival. The management of acute myeloid leukemia (AML) continues to evolve with ongoing improvements in risk stratification and the appropriate use of allogeneic transplantation. However, evidence of real-world AML survival improvements consistent with guideline adoption remains limited. We therefore evaluated survival outcomes and management of AML in younger adults aged ≤65 years across 2 decades (2002-2021) in an Australian statewide health network, contrasting differences between the more recent decade (2012-2021) and the preceding decade. A total of 329 patients were evaluated retrospectively using Kaplan-Meier methodology and multivariate Cox proportional hazards regression. Significantly, we observed an improvement in median overall survival between 2012 and 2021 compared with the 2002-2011 period (54 vs 22.2 months; P = .06). This was directly related to improvement in relapse-free survival (60 vs 21.3 months; P = .02) and the accompanying increased use of allogeneic transplantation (45% vs 28%; P = .003). Improvements were most profound in the intermediate cytogenetic risk group (median overall survival not reached vs 22 months; P = .02), with significant benefit observed for patients who underwent transplantation in this group, including those with FLT3-ITD mutations. Importantly, among patients with AML who did not undergo transplantation, we observed a lower relapse rate for those who had ≥3 consolidation cycles (58%) than those who had ≤2 (81%; P = .04). Notably, expert guidelines for transplantation were released and adopted by local hematologists immediately before this period, in 2010. Overall, our statewide registry data provide evidence of improved outcomes in AML, principally related to increased appropriate utilization of allogeneic transplantation and more granular risk assessment.