On today’s debate stage, Mariam Nawas, MD, will debate Betul Oran, MD, on whether transplant is appropriate in patients with TP53-mutatedacute myloid leukemia (AML). Dr. Nawas gives a preview of her position.
In your opinion, why is this debate question still controversial?
TP53-mutated myeloid neoplasms are a vexing disease subset that have eluded medical progress. As transplanters, we are optimists by nature as we offer our patients potential cures. It is tempting to gravitate toward the most optimistic interpretation of otherwise dismal outcome data and to resist the reality that there are subsets of disease we still cannot cure.
What is the biggest weakness in your own argument?
I am convinced that allogeneic hematopoietic cell transplant (alloHCT) rarely cures this disease subset, but I am willing to accept that it may prolong survival compared with alternative options (eg, chemotherapy alone).
Data from Versluis et al analyzing results from the BMT CTN 1102 study demonstrate this (JCO 2023). However, I think it is important to consider whether a limited survival benefit is worth the rigors and perils of alloHCT and whether those results are generalizable to the average patient with this disease. The patient in question faces a prohibitively high risk of post-transplant morbidity and mortality and is not representative of patients on the 1102 study. I hope as transplant safety improves with time that gradually moves the needle on the risk/benefit analysis of transplant in this subgroup.
If we revisit this debate in three years, what do you think the answer will be?
I worry we will be having the same debate in 3+ years. Clearly, the graft-versus-leukemia effect alone is not enough to overcome this disease. I pray that within my career, we see a potential cure—perhaps a novel therapy that induces a deep response that alloHCT can effectively consolidate. It always seems impossible until it is done.
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