Survival from Acute MyeloidLeukaemia in Patients Over 55 Years of Age in Northern Ireland: A Discrete Population

American Society of Hematology 2020 guidelines for treating newly diagnosed acute myeloid leukemia in older adults

BACKGROUND

Older adults with acute myeloid leukemia (AML) represent a vulnerable population in whom disease-based and clinical risk factors, patient goals, prognosis, and practitioner- and patient-perceived treatment risks and benefits influence treatment recommendations.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about management of AML in older adults.

METHODS

ASH formed a multidisciplinary guideline panel that included specialists in myeloid leukemia, geriatric oncology, patient-reported outcomes and decision-making, frailty, epidemiology, and methodology, as well as patients. The McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline-development process, including performing systematic evidence reviews (up to 24 May 2019). The panel prioritized clinical questions and outcomes according to their importance to patients, as judged by the panel. The panel used the GRADE approach, including GRADE's Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 6 critical questions in managing older adults with AML, mirroring real-time practitioner-patient conversations: the decision to pursue antileukemic treatment vs best supportive management, the intensity of therapy, the role and duration of postremission therapy, combination vs monotherapy for induction and beyond, duration of less-intensive therapy, and the role of transfusion support for patients no longer receiving antileukemic therapy.

CONCLUSIONS

Treatment is recommended over best supportive management. More-intensive therapy is recommended over less-intensive therapy when deemed tolerable. However, these recommendations are guided by the principle that throughout a patient's disease course, optimal care involves ongoing discussions between clinicians and patients, continuously addressing goals of care and the relative risk-benefit balance of treatment.

Relevance of pathologic classifications and diagnosis of acute myeloid leukemia to clinical trials and clinical practice

Many new insights into the diagnosis, pathogenesis, clinical manifestation, treatment and prognosis of patients with AML reflect the heterogeneity of the disease. The initial descriptions of the various subtypes of AML, established by the FAB classification, were based on morphology and cytochemical stains. Although morphology remains the foundation for the diagnosis, additional diagnostic studies including immunophenotyping, cytogenetic evaluation, and molecular genetic studies have become critical, and in some specific cases, mandatory, complementary tools. Several specific subtypes of AML are now treated with directed or targeted therapy. Acute promyelocytic leukemia is currently the only example of a subtype of AML to which specific therapy targeted to a molecular genetic abnormality is available and this subtype now is highly curable. Future studies will address newly identified prognostic factors and gene mutations such as FLT3, Wilm's tumor (WTI), and CEBPA which will enable the further pathologic classification of patients with AML. Finally, microarray analysis will likely identify genes critically involved in the pathogenesis of specific pathologic subtypes.

Acute myeloid leukemia in elderly patients: experience of a single center

Acute myeloid leukemia (AML) is a disease predominantly of older adults. Treatment of AML in the elderly is complicated not only by comorbidities but also by the high prevalence of poor prognosis markers. Thirty-one consecutive unselected patients with AML older than 60 years (representing 33% of all AML cases diagnosed at our institution during the same period) were followed over a period of 5 years (1997-2002). A high incidence of AML with multilineage dysplasia (45%) and no favorable cytogenetic abnormalities but 62% intermediate and 38% unfavorable karyotypes were found. Sixteen patients (52%) were selected for induction of intensive cytotoxic treatment and complete remission was achieved only by some of these intensively treated patients (7 of 16). Of these, 3 remained alive without disease (median: 11 months), 1 patient died shortly after complete remission, and 3 patients relapsed and died from refractory disease. Only 1 patient that was refractory to intensive cytotoxic treatment remained alive with disease under supportive care. Fifteen patients (48%) were managed with palliative/supportive care: 7 received palliative treatment and supportive care, 8 received supportive care only, and 4 patients remained alive with disease under supportive care (median: 9 months). Mortality rate was 74% and overall survival at two years was 12%. To the best of our knowledge, there is no previous report regarding elderly patients with AML in Brazilian subsets. The present data are similar to previously reported studies showing that elderly AML patients are not only older but also biologically distinct from younger AML patients, particularly in terms of the high incidence of poor prognostic karyotypes and resistance to therapy.