The treatment of elderly patients with acute myeloid leukemia

Abstract

Background: In patients over age 60 with acute myeloid leukemia (AML), cure rates are under 10% despite intensive chemotherapy. These patients often have comorbidities, and their treatment must be chosen with care. For those who are not candidates for intensive chemotherapy, one of the available options for palliative treatment should be chosen on the basis of an individual risk-benefit assessment.

Methods: Selective literature review.

Results: An evaluation of the patient's general condition and comorbidities, a geriatric assessment, and specially designed risk scores are useful aids to the choice of an appropriate treatment. Some elderly patients with AML can benefit from intensive chemotherapy despite their age; for highly selected elderly patients, allogeneic stem-cell transplantation is an increasingly feasible option. Hypomethylating agents or low-dose cytarabine can be suitable for some patients. Further options include experimental treatment as part of a clinical trial, and supportive care alone. In the special case of acute promyelocytic leukemia, more than half of all patients can be cured with combination chemotherapy including all-trans retinoic acid.

Conclusion: The prognosis of elderly AML patients remains poor despite recent therapeutic advances. The appropriate treatment for each patient can be chosen on the basis of a risk-benefit assessment. Clinical trials evaluating new treatments are urgently needed.

Figure 1

Prognosis of older patients with AML

Figure 2

Flowchart for the stratification of primary treatment in older patients with acute myelocytic leukemia (AML) For patients with acute promyelocytic leukemia (APL), aggressive substitution therapy in case of coagulopathy and the rapid initiation of combination therapy including ATRA can be life-saving. For all other AML patients, intensive chemotherapy is recommended if the patient is a suitable candidate, possibly supplemented by allogeneic stem-cell transplantation in selected patients, once complete remission has been attained. Patients for whom intensive chemotherapy is not feasible and have 30% or fewer blasts in their bone marrow can benefit from hypomethylating therapy with 5-azacitidine, while those with more than 30% blasts can benefit from treatment with low-dose cytarabine. The notion that patients with cytogenetic changes signifying high risk do not benefit from low-dose cytarabine is derived from a subgroup analysis and has not been further tested; this issue must be addressed in a prospective study. No other specific treatments are available for patients for whom the above treatments are not feasible. They should receive supportive care or be enrolled in clinical trials of new drugs according to their wishes. APL, acute promyelocytic leukemia; ATO, arsenic trioxide; ATRA, all-trans retinoic acid; BSC, best supportive care.