Recent improvements in outcome for elderly patients with de novo acute myeloblastic leukemia

Long-term follow-up of the AML97 study for patients aged 60 years and above with acute myeloid leukaemia: a study of the East German Haematology and Oncology Study Group (OSHO)

INTRODUCTION

Treatment of patients (pts) with acute myelogenous leukaemia (AML) above 60 years remains a challenge. We report long-term follow-up of the AML97 study, where pts were registered at diagnosis and received treatment dependent on their comorbidities: dose-intense cytarabine (AraC) and anthracycline in the curative arm, and low-dose chemotherapy in the palliative arm or best supportive care.

MATERIALS AND METHODS

A total of 618 pts were enrolled in this protocol (curative 471, palliative 115 and supportive 32). In the curative arm, complete remission (CR) was obtained in 66.8 % of pts and the estimated probability of being alive at 2 years was 0.30 (±0.02 SE). In multivariate analysis, gender (p = 0.005), performance status (p = 0.04) and cytogenetics (p = 0.002) were significant factors for CR. With a median follow-up of 10 (range 0.1-11.8) years, the estimated probability of being event-free after 2 and 5 years according to cytogenetics was 0.48 ± 0.11 and 0.48 ± 0.11 for favourable, 0.20 ± 0.03 and 0.09 ± 0.03 for normal, 0.18 ± 0.06 and 0.10 ± 0.05 for other standard risk and 0.10 ± 0.03 and 0.05 ± 0.02 for unfavourable karyotypes, respectively. The median survival time for pts treated with palliative chemotherapy was 54 and 11 days with best supportive care only.

CONCLUSION

In conclusion, treatment of older AML pts with dose-intense AraC is feasible in the majority of pts and induces high rates of CR. Nevertheless, except for favourable karyotype, OS and event-free survival remain low. These results need to be viewed in relation to the new modalities including stem cell transplantation following non-myeloablative conditioning, epigenetic and molecular therapies.

Diagnosis and management of acute myeloid leukemia in adults: recommendations from an international expert panel, on behalf of the European LeukemiaNet

In 2003, an international working group last reported on recommendations for diagnosis, response assessment, and treatment outcomes in acute myeloid leukemia (AML). Since that time, considerable progress has been made in elucidating the molecular pathogenesis of the disease that has resulted in the identification of new diagnostic and prognostic markers. Furthermore, therapies are now being developed that target disease-associated molecular defects. Recent developments prompted an international expert panel to provide updated evidence- and expert opinion–based recommendations for the diagnosis and management of AML, that contain both minimal requirements for general practice as well as standards for clinical trials. A new standardized reporting system for correlation of cytogenetic and molecular genetic data with clinical data is proposed.

High-dose daunorubicin in older patients with acute myeloid leukemia

BACKGROUND

A complete remission is essential for prolonging survival in patients with acute myeloid leukemia (AML). Daunorubicin is a cornerstone of the induction regimen, but the optimal dose is unknown. In older patients, it is usual to give daunorubicin at a dose of 45 to 50 mg per square meter of body-surface area.

METHODS

Patients in whom AML or high-risk refractory anemia had been newly diagnosed and who were 60 to 83 years of age (median, 67) were randomly assigned to receive cytarabine, at a dose of 200 mg per square meter by continuous infusion for 7 days, plus daunorubicin for 3 days, either at the conventional dose of 45 mg per square meter (411 patients) or at an escalated dose of 90 mg per square meter (402 patients); this treatment was followed by a second cycle of cytarabine at a dose of 1000 mg per square meter every 12 hours [DOSAGE ERROR CORRECTED] for 6 days. The primary end point was event-free survival.

RESULTS

The complete remission rates were 64% in the group that received the escalated dose of daunorubicin and 54% in the group that received the conventional dose (P=0.002); the rates of remission after the first cycle of induction treatment were 52% and 35%, respectively (P<0.001). There was no significant difference between the two groups in the incidence of hematologic toxic effects, 30-day mortality (11% and 12% in the two groups, respectively), or the incidence of moderate, severe, or life-threatening adverse events (P=0.08). Survival end points in the two groups did not differ significantly overall, but patients in the escalated-treatment group who were 60 to 65 years of age, as compared with the patients in the same age group who received the conventional dose, had higher rates of complete remission (73% vs. 51%), event-free survival (29% vs. 14%), and overall survival (38% vs. 23%).

CONCLUSIONS

In patients with AML who are older than 60 years of age, escalation of the dose of daunorubicin to twice the conventional dose, with the entire dose administered in the first induction cycle, effects a more rapid response and a higher response rate than does the conventional dose, without additional toxic effects. (Current Controlled Trials number, ISRCTN77039377; and Netherlands National Trial Register number, NTR212.)

Day 14 bone marrow biopsy in predicting complete remission and survival in acute myeloid leukemia

We retrospectively analyzed 194 previously untreated acute myeloid leukemia (AML) patients to evaluate the role of Day 14 bone marrow (BM) biopsy in predicting complete remission (CR). Sixty-seven percent received induction therapy. Achieving Day 14 BM < or =5% blasts was strongly predictive of Day 28 CR with 90% sensitivity and 79% positive predictive value; but weak 43% specificity and 29% negative predictive value. Day 14 BM biopsy is highly sensitive in predicting CR, but did not predict overall survival. Some patients with BM blast >5% at Day 14 may still achieve a Day 28 CR, and not necessarily need reinduction therapy though high risk cytochemical or cytogenetic phenotype predicts a need for retreatment.

Outcomes and charges of elderly patients with acute myeloid leukemia

A retrospective database analysis was conducted to evaluate hospitalization outcomes and charges among elderly acute myeloid leukemia (AML) patients. The data source was a longitudinal (2000-2003) inpatient database from 28 US hospitals. Data on 275 AML patients aged 60 and older were analyzed for demographic and treatment characteristics, hospital mortality, length of stay (LOS), overall days of stay (DOS), and charges across multiple admissions. Multivariate modeling was performed to determine factors that influenced outcomes. Overall, 115 (41.8%) patients received inpatient chemotherapy (CT); most (90.4%) received it on the first admission. Of all initial CT regimens 40.9% consisted of a single agent. The mean LOS for initial hospitalization was 23.0 (SD 21.8) days for patients who received CT and 6.7 (SD 7.5) days for those who did not. One quarter (25.3%) of initial hospitalizations resulted in death. On initial hospitalization, mean total charges were $113,118 (SD $220,417) for patients who received CT and $43,999 (SD $190,533) for those who did not; for both groups mean charges were higher than respective subsequent admission charges. Overall, in-hospital mortality did not differ significantly between on-CT and off-CT groups (43.5 and 38.8%, respectively). In multivariate modeling, CT was significantly associated (P < 0.0001) with increased charges and LOS. Elderly patients with AML incurred substantial hospital charges and inpatient mortality. The highest charges and a substantial number of deaths occurred during first admission. Although treatment with CT was associated with increased charges and days in-hospital, inpatient mortality in the two groups was found to be similar.

Treatment concepts for elderly patients with acute myeloid leukemia

The majority of patients with acute myeloid leukemia (AML) are over 60 years of age at diagnosis. Unlike treatment options for younger adults, those for older patients are limited to non-myeloablative therapy, and many patients are not treatable because of poor performance status. In those who are treatable, long-term survival can be achieved using intensive induction and consolidation chemotherapy. Such curative treatment can be administered in about 70% of elderly patients with AML. In responding patients (up to 60%) the disease-free survival may be almost comparable to that of younger adults. However, treatment-related toxicity results in a higher mortality rate in the elderly patients. Moreover, aggressive chemotherapy cannot be used for 30% of the patients, due to their poor performance status. Currently, palliative cytoreductive treatment and supportive care are considered appropriate for these patients. Recently, however, targeting antileukemic antibodies and inhibitors of signal transduction have been introduced as promising new treatment options. The therapeutic efficiency and toxicity-profiles of these novel drugs are currently under investigation in clinical trials.