Figure 2.

Impact of maintenance therapy on survival in acute myeloid leukemia. Several clinical trials with maintenance therapy in acute myeloid leukemia (AML) have shown benefits in relapse-free survival (RFS), but overall survival (OS) benefits have been reported exceedingly rarely. Maintenance therapy by virtue of suppressing the residual disease clone can improve the duration of morphological RFS. However, the effectiveness of salvage regimens in post-maintenance therapy relapse settings needs to be studied. Prolonged exposure to maintenance regimens in some patients can make the AML more resistant through increased subclonal heterogeneity under therapy pressure, especially if the maintenance therapy is not able to diminish the residual leukemia clones to significant depths. This might make the likelihood of response to subsequent salvage therapy low. Thus, OS might not increase proportionally to RFS with maintenance therapy. In randomized clinical trials with maintenance therapy, response to salvage therapy and survival outcomes of patients after relapse in both maintenance therapy arms, and observation arms should be detailed for better understanding of these dynamics. CR1: first complete remission; RFS: relapse-free survival; OS: overall survival. Figure made on BioRender.com