Intensive induction for older patients with AML in a resource-constrained setting: insights from a Brazilian multicenter cohort

• Older AML patients treated with intensive chemotherapy in reference centers in Brazil face a high early death rate and low overall survival. • Infections, particularly by multi-drug-resistant bacteria, and early relapses are the main drivers of these results. Acute myeloid leukemia (AML) affects mainly older patients, a particularly challenging-to-treat population due to factors related to aging and disease characteristics. Real world data from intensively treated older AML patients in low- and middle-income countries are scarce and can aid in the therapy selection. This is a multi-site retrospective cohort study performed in reference centers in Brazil. Newly diagnosed AML patients aged 60 years-old or more, diagnosed between 2012 and 2024 and treated with intensive therapy were included, reaching 185 patients. Median age was 65 (62-67) years, with a male predominance (58.9%). Most patients (61.1%) had no comorbidity accounting for the Charlson’s score and the disease risk was classified as intermediate/adverse in 59.5%. More than 90% (176 – 95.1%) of patients were treated with anthracycline plus continuous infusion of cytarabine. CR/CRi rate was 37.8% after one cycle of induction and 38.4% of subjects died within 30 days of the start of chemotherapy, with infection accounting for 84.5% of the cases. Male gender, higher Charlson comorbidity score and higher C-reactive protein level at admission were predictors of early death. With a median follow-up of 52.5 months, the median overall survival was 3.4 months. Most deaths affecting those who survived after the induction occurred in the setting of relapsed/refractory disease. Genetic disease risk was the sole predictor of post-induction survival and relapse-free survival. This cohort reveal a high early death rate and low overall survival of this subset of AML patients, despite a relatively young and fit population.