PART 3! If you’re not sold on moderately intensive chemo, outcomes with HMA +/- ven also rival outcomes with CPX-351 in sAML. One could argue the control group in the CPX-351 paper should have been hypomethylating agent-based regimens!
CR/CRi rates with 10-d decitabine are consistently >50%, irrespective of sAML, age, and cytogenetics. Median OS in Blum, PNAS 2010 ~13 months. pnas.org/content/107/16… 
Whether venetoclax adds anything to this remains to be seen. In the phase I/II study of HMA+ven, CR/CRi in elderly sAML was 67%, median OS NR. Wait for the phase III before you make any conclusions #oncstewardship #anothertweetorial? ncbi.nlm.nih.gov/pubmed/30361262
We can’t go through CPX-351 without mentioning its exorbitant cost. Depending on BSA and # of cycles required, you’re looking at up to Up to $116,250 for induction (grade 5 financial toxicity). You'll need a loan from the iron bank
TL;DR Summary1! Many flaws to the CPX-351 phase III trial. What should you do to be an #oncsteward? At a minimum, don’t use CPX-351 where it hasn’t been studied rigorously:
oYounger sAML (worse outcomes)
oAML-MRC by morphology
oRelapsed/refractory setting
oPrior HMA
oYounger sAML (worse outcomes)
oAML-MRC by morphology
oRelapsed/refractory setting
oPrior HMA
TL;DR Summary2: Alternative: consider HMA-based regimens (similar CR in poor risk patients, less toxicity), or purine analogue/cytarabine combinations. These won’t be compared prospectively to CPX-351 because there is no $ incentive to do so… and keep promoting #oncstewardship
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