Management of older or unfit patients with acute myeloid leukemia

Abstract

Acute myeloid leukemia (AML) is primarily a disease of older adults, for whom optimal treatment strategies remain controversial. Because of the concern for therapeutic resistance and, in particular, excessive toxicity or even treatment-related mortality, many older or medically unfit patients do not receive AML-directed therapy. Yet, evidence suggests that outcomes are improved if essentially all of these patients are offered AML therapy, ideally at a specialized cancer center. Medical fitness for tolerating intensive chemotherapy can be estimated relatively accurately with multiparameter assessment tools; this information should serve as basis for the assignment to intensive or non-intensive therapy. Until our accuracy in predicting the success of individual therapies improves, all patients should be considered for participation in a randomized controlled trial. Comparisons between individual trials will be facilitated once standardized, improved response criteria are developed, and standard treatment approaches have been defined against which novel therapies can be tested.

Figure 1. Incidence and Mortality of AML

Surveillance, Epidemiology, and End Results (SEER) Cancer Registry estimates of incidence and mortality of AML in the U.S. (A) Age-specific incidence rates, SEER 18 areas, 2007–2011. Rates are given per 100,000 and are age-adjusted to the 2000 U.S. Standard Population. (B) 5-year relative survival for men and women of all races, SEER 18 areas, 2004–2010.

Figure 2. Life Expectancy of Older Adults

U.S. Social Security Administration estimates of the average remaining number of years expected prior to death for man or woman of that exact age, born on January 1, using the mortality rates for 2009 over the course of his/her remaining life in the Social Security area population (period life table).