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Williams LS, Nagaradona T, Nalamalapu P, Lai C. Breaking down frailty: Assessing vulnerability in acute myeloid leukemia. Blood Rev 2024:101224. [PMID: 39095278 DOI: 10.1016/j.blre.2024.101224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/27/2024] [Accepted: 07/16/2024] [Indexed: 08/04/2024]
Abstract
Acute myeloid leukemia (AML) is a disease primarily affecting older adults. However, not all patients at older ages are suitable for curative treatment with intensive chemotherapy due to "frailty" demonstrated by their functional status, physiologic reserve, and vulnerability to disease and treatment morbidity. Lack of consensus exists on how to select older, less fit patients most appropriate for standard intensive chemotherapy (IC), hypomethylating agents (HMA) with venetoclax, or less intensive regimens. A total of 37 studies of frailty assessments and composite indices in AML show heterogeneous results regarding the ability of frailty and Comprehensive Geriatric Assessment (CGA) measures to predict treatment outcomes. CGA, Geriatric 8 (G8) risk score, and hematopoietic cell transplant comorbidity index (HCT-CI) show association with prognosis, and should be validated in larger therapeutic trials. Studies of biomarkers, like albumin and C-reactive protein, and patient-reported outcomes demonstrate the potential to enhance information gained from rigorous geriatric assessment.
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Affiliation(s)
- Lacey S Williams
- Lombardi Clinical Cancer Center, Georgetown University, Washington, DC, USA.
| | - Teja Nagaradona
- St. George's University, School of Medicine, West Indies, Grenada
| | | | - Catherine Lai
- University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
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2
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La J, Lee MH, Brophy MT, Do NV, Driver JA, Tuck DP, Fillmore NR, Dumontier C. Baseline correlates of frailty and its association with survival in United States veterans with acute myeloid leukemia. Leuk Lymphoma 2023; 64:2081-2090. [PMID: 37671705 DOI: 10.1080/10428194.2023.2254434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/09/2023] [Accepted: 08/27/2023] [Indexed: 09/07/2023]
Abstract
Frailty is an important construct to measure in acute myeloid leukemia (AML). We used the Veterans Affairs Frailty Index (VA-FI) - calculated using readily available data within the VA's electronic health records - to measure frailty in U.S. veterans with AML. Of the 1166 newly diagnosed and treated veterans with AML between 2012 and 2022, 722 (62%) veterans with AML were classified as frail (VA-FI > 0.2). At a median follow-up of 252.5 days, moderate-severely frail veterans had significantly worse survival than mildly frail, and non-frail veterans (median survival 179 vs. 306 vs. 417 days, p < .001). Increasing VA-FI severity was associated with higher mortality. A model with VA-FI in addition to the European LeukemiaNet (ELN) risk classification and other covariates statistically outperformed a model containing the ELN risk and other covariates alone (p < .001). These findings support the VA-FI as a tool to expand frailty measurement in research and clinical practice for informing prognosis in veterans with AML.
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Affiliation(s)
- Jennifer La
- CSP Informatics Center, Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA, USA
| | - Michelle H Lee
- Department of Internal Medicine, Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Mary T Brophy
- CSP Informatics Center, Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA, USA
- Department of Internal Medicine, Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Nhan V Do
- CSP Informatics Center, Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jane A Driver
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David P Tuck
- Department of Internal Medicine, Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Nathanael R Fillmore
- CSP Informatics Center, Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA, USA
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Clark Dumontier
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
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3
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Wu YH, Xiao HY, Quan RC, Tang XD, Liu WY, Lyu Y, Chen Z, Liu C, Hu XM. Comparing Arsenic-Containing Qinghuang Powder and Low-Intensity Chemotherapy in Elderly Patients with Acute Myeloid Leukemia. Chin J Integr Med 2023; 29:832-837. [PMID: 37222831 DOI: 10.1007/s11655-023-3603-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To compare the clinical effect of arsenic-containing Qinghuang Powder (QHP) and low-intensity chemotherapy (LIC) in treatment of elderly acute myeloid leukemia (eAML) patients. METHODS Clinical data of 80 eAML patients treated at Xiyuan Hospital of China Academy of Chinese Medical Sciences from January 2015 to December 2020 were retrospectively analyzed. The treatment scheme was designed by real world study according to patients' preference, and patients were divided into a QHP group (35 cases) and a LIC group (45 cases). The median overall survival (mOS), 1-, 2-, and 3-year OS rates, and incidence of adverse events were compared between the two groups. RESULTS The mOS of 80 patients was 11 months, and the 1-, 2-, and 3-year OS rates were 45.51%, 17.96%, and 11.05%, respectively. The QHP and LIC groups demonstrated no significant difference in mOS (12 months vs. 10 months), 1- (48.57% vs. 39.65%), 2- (11.43% vs. 20.04%), and 3-year OS rates (5.71% vs. 13.27%, all P>0.05). Moreover, the related factors of mOS demonstrated no significant difference in patients with age>75 years (11 months vs. 8 months), secondary AML (11 months vs. 8 months), poor genetic prognosis (9 months vs. 7 months), Eastern Cooperative Oncology Group performance status score ⩾ 3 (10 months vs. 7 months) and hematopoietic stem cell transplant comorbidity index ⩾ 4 (11 months vs. 7 months) between the QHP and LIC groups (all P>0.05). However, the incidence of myelosuppression was significantly lower in the QHP group than that in the LIC group (28.57% vs. 73.33%, P<0.01). CONCLUSIONS QHP and LIC had similar survival rates in eAML patients, but QHP had a lower myelosuppression incidence. Hence, QHP can be an alternative for eAML patients who do not tolerate LIC.
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Affiliation(s)
- Yu-He Wu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Hai-Yan Xiao
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Ri-Cheng Quan
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Xu-Dong Tang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Wei-Yi Liu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Yan Lyu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Zhuo Chen
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Chi Liu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Xiao-Mei Hu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
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Venditti A, Cairoli R, Caira M, Finsinger P, Finocchiaro F, Neri B, De Benedittis D, Rossi G, Ferrara F. Assessing eligibility for treatment in acute myeloid leukemia in 2023. Expert Rev Hematol 2023; 16:181-190. [PMID: 36876439 DOI: 10.1080/17474086.2023.2185603] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Age has historically been considered the main criterion to determine eligibility for intensive chemotherapy in patients with acute myeloid leukemia (AML), but age alone can no longer be considered an absolute indicator in determining which patients should be defined as unfit. Assessment of fitness for a given treatment today serves an important role in tailoring therapeutic options. AREAS COVERED This review examines the main options used in real life to define eligibility for intensive and nonintensive chemotherapy in patients with AML, with a main focus on the Italian SIE/SIES/GITMO Consensus Criteria. Other published real-life experiences are also reviewed, analyzing the correlation between these criteria and short-term mortality, and thus expected outcomes. EXPERT OPINION Assessment of fitness is mandatory at diagnosis to tailor treatment to the greatest degree possible, evaluating the patient's individual profile. This is especially relevant when considering the availability of newer, less toxic therapeutic regimens, which have shown promising results in patients with AML who are older or considered unfit for intensive treatment. Fitness assessment is now a fundamental part of AML management and a critical step that can potentially influence outcomes and not just predict them.
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Affiliation(s)
- Adriano Venditti
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università di Roma "Tor Vergata", Rome, Italy
| | - Roberto Cairoli
- Dipartimento Ematologia, Oncologia e Medicina Molecolare, ASST Grande Ospedale Metropolitano Niguarda-Milano, Milan, Italy
| | - Morena Caira
- Medical Department, AbbVie srl, Campoverde di Aprilia, Latina, Italy
| | - Paola Finsinger
- Medical Department, AbbVie srl, Campoverde di Aprilia, Latina, Italy
| | - Fabio Finocchiaro
- Medical Department, AbbVie srl, Campoverde di Aprilia, Latina, Italy
| | - Benedetta Neri
- Medical Department, AbbVie srl, Campoverde di Aprilia, Latina, Italy
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Jiang S, Yan H, Lu X, Wei R, Chen H, Zhang A, Shi W, Xia L. How to improve the outcomes of elderly acute myeloid leukemia patients through allogeneic hematopoietic stem cell transplantation. Front Immunol 2023; 14:1102966. [PMID: 37207218 PMCID: PMC10189056 DOI: 10.3389/fimmu.2023.1102966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/19/2023] [Indexed: 05/21/2023] Open
Abstract
In recent years, with the gradual advancement of haploidentical transplantation technology, the availability of donors has increased significantly, along with the widespread use of reduced-intensity conditioning and the improvement of nursing techniques, giving more elderly acute myeloid leukemia (AML) patients the chance to receive allogeneic hematopoietic stem cell transplantation. We have summarized the classic and recently proposed pre-transplant assessment methods and assessed the various sources of donors, conditioning regimens, and post-transplant complication management based on the outcomes of large-scale clinical studies for elderly AML patients.
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Affiliation(s)
| | | | | | | | | | | | - Wei Shi
- *Correspondence: Linghui Xia, ; Wei Shi,
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Prognosis of older patients with newly diagnosed AML undergoing antileukemic therapy: A systematic review. PLoS One 2022; 17:e0278578. [PMID: 36469519 PMCID: PMC9721486 DOI: 10.1371/journal.pone.0278578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 11/20/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The prognostic value of age and other non-hematological factors in predicting outcomes in older patients with newly diagnosed acute myeloid leukemia (AML) undergoing antileukemic therapy is not well understood. We performed a systematic review to determine the association between these factors and mortality and health-related quality of life or fatigue among these patients. METHODS We searched Medline and Embase through October 2021 for studies in which researchers quantified the relationship between age, comorbidities, frailty, performance status, or functional status; and mortality and health-related quality of life or fatigue in older patients with AML receiving antileukemic therapy. We assessed the risk of bias of the included studies using the Quality in Prognostic Studies tool, conducted random-effects meta-analyses, and assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS We included 90 studies. Meta-analysis showed that age (per 5-year increase, HR 1.16 95% CI 1.11-1.21, high-quality evidence), comorbidities (Hematopoietic Cell Transplantation-specific Comorbidity Index: 3+ VS less than 3, HR 1.60 95% CI 1.31-1.95, high-quality evidence), and performance status (Eastern Cooperative Oncology Group/ World Health Organization (ECOG/WHO): 2+ VS less than 2, HR 1.63 95% CI 1.43-1.86, high-quality evidence; ECOG/WHO: 3+ VS less than 3, HR 2.00 95% CI 1.52-2.63, moderate-quality evidence) were associated with long-term mortality. These studies provided inconsistent and non-informative results on short-term mortality (within 90 days) and quality of life. CONCLUSION High-quality or moderate-quality evidence support that age, comorbidities, performance status predicts the long-term prognosis of older patients with AML undergoing antileukemic treatment.
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Stone RM. Consolidation chemotherapy in AML: Are we playing with a full deck of cards? Best Pract Res Clin Haematol 2022; 35:101408. [DOI: 10.1016/j.beha.2022.101408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fell G, Rosko AE, Abel GA, Dumontier C, Higby KJ, Murillo A, Neuberg DS, Burd CE, Lane AA. Peripheral blood CD3 + T-cell gene expression biomarkers correlate with clinical frailty in patients with haematological malignancies. Br J Haematol 2022; 199:100-105. [PMID: 35766906 PMCID: PMC10462450 DOI: 10.1111/bjh.18336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 11/26/2022]
Abstract
Older patients with cancer often receive treatment regimens based on their age without considering other objective factors that may influence outcomes. Assessment of frailty can identify older patients who are robust and therefore more likely to benefit from intensive treatment, or conversely, frail and might instead be offered alternative approaches. However, such assessment requires specialised training and dedicated clinical resources. Alternative quantitative biomarkers associated with frailty are lacking. Here, we asked if expression signatures of 74 immune cell, ageing, and senescence-related messenger RNAs in purified peripheral blood T cells could identify associations with clinical frailty in patients with haematological malignancies. We studied 69 patients between the ages of 36 and 92 years (median 76 years) with leukaemia, lymphoma, or multiple myeloma, across two institutions. Expression of four genes (aryl hydrocarbon receptor [AHR], CD27, CD28, and interleukin-2 receptor subunit alpha [IL2RA; CD25]) in T cells was associated with frailty, independent of age. An expression-based regression model had 76% sensitivity and 90% specificity to assign a patient as robust. These data identify measurable peripheral blood correlates of clinical frailty and suggest biomarkers for future prospective assessment.
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Affiliation(s)
- Geoffrey Fell
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ashley E. Rosko
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Gregory A. Abel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Clark Dumontier
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kelly J. Higby
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Anays Murillo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Donna S. Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christin E. Burd
- Departments of Molecular Genetics; Cancer Biology and Genetics, The Ohio State University, Columbus, Ohio, USA
| | - Andrew A. Lane
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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How Genetics Can Drive Initial Therapy Choices for Older Patients with Acute Myeloid Leukemia. Curr Treat Options Oncol 2022; 23:1086-1103. [PMID: 35687257 PMCID: PMC9898635 DOI: 10.1007/s11864-022-00991-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT Treatment of older adults with acute myeloid leukemia (AML) is challenging. Therapy decisions must be guided by multiple factors including aging-related conditions (e.g., comorbidities, functional impairment), therapy benefits and risks, patient preferences, and disease characteristics. Balancing these factors requires understanding the unique, and frequently higher-risk cytogenetic and molecular characteristics of AML in older adult populations, which should caution providers not to reduce therapy intensity on the basis of age alone. Instead, geriatric assessments should be employed to determine fitness for therapy. Treatment options in AML are increasingly targeted to specific mutations or recognized to have differential benefits on the basis of genomics, and representation of older adults and geriatric outcome reporting in clinical trials is improving. Additionally, newer studies have begun to explore personalized therapy strategies on the basis of initial genetic testing. Review and refinement of practice guidelines for older patients on the basis of these advances is needed and is anticipated to remain an important topic in ongoing hematology/oncology clinical education.
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Geriatric assessment for older adults receiving less intensive therapy for acute myeloid leukemia: Report of CALGB 361101. Blood Adv 2022; 6:3812-3820. [PMID: 35420672 PMCID: PMC9631575 DOI: 10.1182/bloodadvances.2021006872] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/29/2022] [Indexed: 11/20/2022] Open
Abstract
Baseline geriatric assessment measures are associated with survival among older AML patients treated with nonintensive chemotherapy. Baseline global quality of life is associated with survival among older AML patients treated with nonintensive chemotherapy.
Geriatric assessment (GA) predicts survival among older adults with acute myeloid leukemia (AML) treated intensively. We evaluated the predictive utility of GA among older adults treated with low-intensity therapy on a multisite trial. We conducted a companion study (CALGB 361101) to a randomized phase 2 trial (CALGB 11002) of adults ≥60 years and considered “unfit” for intensive therapy, testing the efficacy of adding bortezomib to decitabine therapy. On 361101, GA and quality of life (QOL) assessment was administered prior to treatment and every other subsequent cycle. Relationships between baseline GA and QOL measures with survival were evaluated using Kaplan-Meier estimation and Cox proportional hazards models. One-hundred sixty-five patients enrolled in CALGB 11002, and 96 (52%) of them also enrolled in 361101 (median age, 73.9 years). Among participants, 85.4% completed ≥1 baseline assessment. In multivariate analyses, greater comorbidity (hematopoietic cell transplantation-specific comorbidity index >3), worse cognition (Blessed Orientation-Memory-Concentration score >4), and lower European Organization for Research and Treatment of Cancer global QOL scores at baseline were significantly associated with shorter overall survival (P < .05 each) after adjustment for Karnofsky Performance Status, age, and treatment arm. Dependence in instrumental activities of daily living and cognitive impairment were associated with 6-month mortality (hazard ratio [HR], 3.5; confidence interval [CI], 1.2-10.4; and HR, 3.1; CI, 1.1-8.6, respectively). GA measures evaluating comorbidity, cognition, and self-reported function were associated with survival and represent candidate measures for screening older adults planned to receive lower-intensity AML therapies. This trial was registered at www.clinicaltrials.gov as #NCT01420926 (CALGB 11002).
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de Leeuw DC, Ossenkoppele GJ, Janssen JJWM. Older Patients with Acute Myeloid Leukemia Deserve Individualized Treatment. Curr Oncol Rep 2022; 24:1387-1400. [PMID: 35653050 PMCID: PMC9606099 DOI: 10.1007/s11912-022-01299-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Treatment of elderly patients with acute myeloid leukemia is a known challenge for hematologists due to patient diversity, heterogeneous disease biology, and a rapidly evolving treatment landscape. Here, we highlight the importance of determining fitness, review the latest therapeutic developments, and discuss clinical scenarios to provide guidance on individualized treatment for older AML patients. RECENT FINDINGS Several factors, like age, performance status, and comorbidities, play a role in fitness and are associated with outcome. Comorbidity scoring systems and geriatric assessments are tools to help physicians select the most appropriate treatment for each patient. The addition of venetoclax, targeted therapy with IDH1/2 and FLT3 inhibitors, and enhanced formulas of existing drugs like CPX-351 and oral azacitidine have improved responses and outcomes. New drugs and combination therapies have increased the therapeutic options for elderly AML patients but determination of fitness and disease biology is essential to select patient-tailored treatments.
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Affiliation(s)
- David C. de Leeuw
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Gert J. Ossenkoppele
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jeroen J. W. M. Janssen
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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12
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Woods JD, Zeidner JF, Van Deventer HW, Jamieson K, Matson M, Zhang J, Pulley W, Brenizer T, Muss H, Nyrop KA, Vohra SN, Deal AM, Ivanova A, Foster MC. Phase Ib trial of lenalidomide as post-remission therapy for older adults with acute myeloid leukemia: Safety and longitudinal assessment of geriatric functional domains. J Geriatr Oncol 2021; 13:499-504. [PMID: 34955443 PMCID: PMC9326773 DOI: 10.1016/j.jgo.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/19/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Novel, non-cytotoxic agents are driving a paradigm shift for treatment of older adults with acute myeloid leukemia (AML). Older patients who initially receive intensive cytotoxic induction may choose to not proceed with cytotoxic consolidation therapy. Lenalidomide is an orally-administered immunomodulatory small molecule with activity in AML and a favorable safety profile in older adults with active leukemia. We conducted a phase Ib study of lenalidomide as post-remission therapy in older adults and assessed its impact on geriatric functional domains. MATERIALS AND METHODS Participants were patients with AML over age 60 years who had undergone induction therapy and were poor candidates for cytotoxic consolidation. Lenalidomide was administered for 28 days in three dose cohorts. A Bayesian dose-escalation method determined cohort assignment and maximum tolerated dose (MTD). Geriatric assessment (GA) was performed before and after the cycle of lenalidomide. RESULTS Nineteen patients with median age 68 were treated with at least one 28-day course of lenalidomide. Dose-limiting toxicities were observed in three participants at 25 mg, zero participants at 35 mg, and one participant at 50 mg. MTD was 35 mg. Median relapse-free survival was 4.3 months. GA was completed before and after treatment in fifteen patients, demonstrating improved cognitive function and no changes in physical, psychological, or social function after lenalidomide. CONCLUSION Lenalidomide can be safely administered to older adults with AML with preservation of functional domains important to older patients. Serial GA can be performed in a novel drug study as a tool to characterize treatment tolerability.
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Affiliation(s)
- Justin D Woods
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Joshua F Zeidner
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Hendrik W Van Deventer
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Katarzyna Jamieson
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Melissa Matson
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jack Zhang
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - William Pulley
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Tucker Brenizer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Hyman Muss
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Kirsten A Nyrop
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sanah N Vohra
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Anastasia Ivanova
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Matthew C Foster
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
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Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021. Cancers (Basel) 2021; 13:cancers13205075. [PMID: 34680226 PMCID: PMC8534216 DOI: 10.3390/cancers13205075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021. Abstract Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.
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Patient-reported outcomes predict overall survival in older patients with acute myeloid leukemia. J Geriatr Oncol 2021; 13:935-939. [PMID: 34521609 DOI: 10.1016/j.jgo.2021.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 07/15/2021] [Accepted: 09/07/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Patient-reported outcomes (PROs) predict overall survival (OS) in many cancer types, but there is little evidence of their prognostic value in older patients with acute myeloid leukemia (AML). We examined whether the Functional Assessment of Cancer Therapy - Leukemia (FACT-Leu) predicted OS beyond established prognostic factors among these patients. MATERIALS AND METHODS Data were from AML2002 (n = 309), a randomized phase 2/3 study comparing decitabine plus talacotuzumab versus decitabine alone in older AML patients ineligible for intensive chemotherapy. We used ridge-penalized Cox proportional hazards models to estimate the association between baseline FACT-Leu scales and OS. We then conducted a bootstrap analysis to determine how often FACT-Leu scales appeared in forward- and backward- selected "final models" predicting OS relative to prognosticators from the AML Composite Model (AML-CM; e.g., chronic comorbidities, previous cancer, cytogenetic/molecular risk). RESULTS In ridge-penalized models, the FACT-Leu Physical Well-Being (PWB), Trial Outcomes Index (TOI), and Total scales predicted OS. Adjusting for AML-CM factors, an important increase (3 points) in PWB score was associated with a 14% reduction in the hazard of death. In the bootstrap analysis, the PWB scale appeared in 93% of backward- and 98% of forward selected models, while the TOI [57% (backward), 79% (forward)] and FACT-Leu Total [51% (backward), 78% (forward)] appeared less often in final models. DISCUSSION AND CONCLUSIONS These results indicate PROs' value for predicting outcomes among older AML patients and underscore the need to more systematically collect PRO data in routine care with these patients. ClinicalTrials.gov Registration: NCT02472145.
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Cladribine Combined with Low-Dose Cytarabine as Frontline Treatment for Unfit Elderly Acute Myeloid Leukemia Patients: Results from a Prospective Multicenter Study of Polish Adult Leukemia Group (PALG). Cancers (Basel) 2021; 13:cancers13164189. [PMID: 34439342 PMCID: PMC8391610 DOI: 10.3390/cancers13164189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 01/13/2023] Open
Abstract
Simple Summary Treatment of acute myeloid leukemia (AML) in elderly patients unfit for intensive chemotherapy (IC) is a challenge in clinical practice. Here we prospectively evaluated a novel low-intensity regimen consisting of low-dose cytarabine combined with cladribine (LD-AC+cladribine) for remission induction followed by LD-AC alone in the maintenance phase as the frontline treatment for elderly AML patients ineligible for IC. We included a cohort of 117 elderly patients in poor performance status or with significant comorbidities. High-risk or intermediate-risk cytogenetics were observed in almost 90% of patients. Treatment with LD-AC+cladribine led to the objective response rate of 54% and the median overall survival of 17.3 months in the responders group. The toxicity profile was predictable and infectious complications were the most common non-hematological adverse events. In conclusion, we found LD-AC+cladribine as a beneficial therapeutic option with an acceptable safety profile in the difficult-to-treat population of elderly AML patient ineligible for IC. Abstract Acute myeloid leukemia (AML) in older unfit patients is a therapeutic challenge for clinical hematologists. We evaluated the efficacy and safety of a novel low-intensity regimen consisting of low-dose cytarabine and cladribine (LD-AC+cladribine) in first-line treatment of elderly (≥60 years) AML patients not eligible for intensive chemotherapy (IC) who had either the Eastern Cooperative Oncology Group performance status (ECOG PS) ≥2 or the hematopoietic cell transplantation comorbidity index (HCT-CI) score ≥3. The induction phase included two cycles of LD-AC+cladribine. Patients who achieved at least partial remission (PR) received maintenance treatment with LD-AC alone. Overall, 117 patients with a median age of 70 years were enrolled. Adverse cytogenetics, ECOG PS ≥2 and HCT-CI score ≥3 was observed in 43.5%, 60%, and 58% of patients, respectively. The response rate (≥PR) was 54% (complete remission [CR], 32%; CR with incomplete hematologic recovery [CRi], 5%). A median overall survival (OS) was 21 and 8.8 months in CR/CRi and PR group, respectively. Advanced age (≥75 years) and adverse cytogenetics had a negative impact on OS. The 56-day mortality rate was 20.5%. In conclusion, LD-AC+cladribine is a beneficial therapeutic option with a predictable safety profile in elderly AML patients not eligible for IC.
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Multisite 11-year experience of less-intensive vs intensive therapies in acute myeloid leukemia. Blood 2021; 138:387-400. [PMID: 34351368 DOI: 10.1182/blood.2020008812] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 02/11/2021] [Indexed: 12/27/2022] Open
Abstract
Less-intensive induction therapies are increasingly used in older patients with acute myeloid leukemia (AML). Using an AML composite model (AML-CM) assigning higher scores to older age, increased comorbidity burdens, and adverse cytogenetic risks, we defined 3 distinct prognostic groups and compared outcomes after less-intensive vs intensive induction therapies in a multicenter retrospective cohort (n = 1292) treated at 6 institutions from 2008 to 2012 and a prospective cohort (n = 695) treated at 13 institutions from 2013 to 2017. Prospective study included impacts of Karnofsky performance status (KPS), quality of life (QOL), and physician perception of cure. In the retrospective cohort, recipients of less-intensive therapies were older and had more comorbidities, more adverse cytogenetics, and worse KPS. Less-intensive therapies were associated with higher risks of mortality in AML-CM scores of 4 to 6, 7 to 9, and ≥10. Results were independent of allogeneic transplantation and similar in those age 70 to 79 years. In the prospective cohort, the 2 groups were similar in baseline QOL, geriatric assessment, and patient outcome preferences. Higher mortality risks were seen after less-intensive therapies. However, in models adjusted for age, physician-assigned KPS, and chance of cure, mortality risks and QOL were similar. Less-intensive therapy recipients had shorter length of hospitalization (LOH). Our study questions the survival and QOL benefits (except LOH) of less-intensive therapies in patients with AML, including those age 70 to 79 years or with high comorbidity burdens. A randomized trial in older/medically infirm patients is required to better assess the value of less-intensive and intensive therapies or their combination. This trial was registered at www.clinicaltrials.gov as #NCT01929408.
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Geriatric assessment and survival among older adults receiving postremission therapy for acute myeloid leukemia. Blood 2021; 136:2715-2719. [PMID: 32698198 DOI: 10.1182/blood.2020005498] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/09/2020] [Indexed: 12/19/2022] Open
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Laribi K, Sobh M, Ghez D, Baugier de Materre A. Impact of age, functional status, and comorbidities on quality of life and outcomes in elderly patients with AML: review. Ann Hematol 2021; 100:1359-1376. [PMID: 33796898 DOI: 10.1007/s00277-020-04375-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/08/2020] [Indexed: 12/17/2022]
Abstract
The incidence of acute myeloid leukemia increases with age, and more than half of AML patients are over 60 years old. Treating elderly AML patients presents several challenges and uncertainties, linked partly to disease characteristics and partly to the difficulty of establishing which patients could benefit from the best treatment. Although some elderly fit patients can receive intensive therapy, many of them are not treated and not enrolled in clinical trials. Yet supportive care is associated with significantly lower survival rates compared to intensive therapy or lower intensive therapy. A poorer prognosis in elderly patients is related to age, functional status, and comorbidities, combined with leukemia characteristics. Chronological age is not the best surrogate factor for selecting patients eligible for intensive chemotherapy. Scoring systems-including patient characteristics (ECOG, comorbidities) and disease characteristics (cytogenetics and molecular parameters)-designed to evaluate probabilities of response to treatment, morbidity, and survival may be used to balance the risk-benefit ratio for intensive therapy. A geriatric assessment (GA) to evaluate physical function, comorbidities, nutritional status, cognitive function, and social support could help identify the most vulnerable patients so that they can receive intensive therapy. A GA would also help take the necessary steps to improve tolerance to treatment. Evaluating markers of fitness and quality of life as part of clinical trials should be favored.
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Affiliation(s)
- Kamel Laribi
- Department of Hematology, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72000, Le Mans, France.
| | - Mohamad Sobh
- Department of Hematology, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - David Ghez
- Department of Hematology, Institut Gustave Roussy, 114 rue Edouard Vaillant, 94805, Villejuif, France
| | - Alix Baugier de Materre
- Geriatric Department, Assistance Publique-Hôpitaux de Paris, Hôpital Broca, 54-56 Pascal, 75013, Paris, France
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Tang H, Jia S, Bi L, Jia W, Gao G. Treatment options for older unfit patients with acute myeloid leukemia. Future Oncol 2021; 17:837-851. [PMID: 33522289 DOI: 10.2217/fon-2020-0615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Older acute myeloid leukemia patients usually experience a bleak outcome, especially those in the unfit group. For this unfit category, intensive chemotherapy and allogeneic stem cell transplantation are usually accompanied by higher early mortality, which results from higher risk genetic profiles and worse psychological and physiological conditions. The significant improvement in genetic technology recently has driven the appearance of several mutation-targeted therapies, such as FLT3, Bcl-2, IDH and Hedgehog pathway inhibitors and an anti-CD33 antibody-drug conjugate, which have changed enormously the therapeutic landscape of acute myeloid leukemia. This review describes the treatment dilemma of the unfit group and discusses the objective clinical data of each targeted drug and mechanisms of resistance, with a focus on combination strategies with fewer toxicities and abrogation of drug resistance.
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Affiliation(s)
- Hailong Tang
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Shuangshuang Jia
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Lei Bi
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Weijing Jia
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Guangxun Gao
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
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Efficace F, Collins GS, Cottone F, Giesinger JM, Sommer K, Anota A, Schlussel MM, Fazi P, Vignetti M. Patient-Reported Outcomes as Independent Prognostic Factors for Survival in Oncology: Systematic Review and Meta-Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:250-267. [PMID: 33518032 DOI: 10.1016/j.jval.2020.10.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 08/05/2020] [Accepted: 10/19/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Assessment of patient-reported outcomes (PROs) in oncology is of critical importance because it provides unique information that may also predict clinical outcomes. METHODS We conducted a systematic review of prognostic factor studies to examine the prognostic value of PROs for survival in cancer. A systematic literature search was performed in PubMed for studies published between 2013 and 2018. We considered any study, regardless of the research design, that included at least 1 PRO domain in the final multivariable prognostic model. The protocol (EPIPHANY) was published and registered in the International Prospective Register of Systematic Reviews (CRD42018099160). RESULTS Eligibility criteria selected 138 studies including 158 127 patients, of which 43 studies were randomized, controlled trials. Overall, 120 (87%) studies reported at least 1 PRO to be statistically significantly prognostic for overall survival. Lung (n = 41, 29.7%) and genitourinary (n = 27, 19.6%) cancers were most commonly investigated. The prognostic value of PROs was investigated in secondary data analyses in 101 (73.2%) studies. The EORTC QLQ-C30 questionnaire was the most frequently used measure, and its physical functioning scale (range 0-100) the most frequent independent prognostic PRO, with a pooled hazard ratio estimate of 0.88 per 10-point increase (95% CI 0.84-0.92). CONCLUSIONS There is convincing evidence that PROs provide independent prognostic information for overall survival across cancer populations and disease stages. Further research is needed to translate current evidence-based data into prognostic tools to aid in clinical decision making.
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Affiliation(s)
- Fabio Efficace
- Italian Group for Adult Hematologic Diseases (GIMEMA) Data Center and Health Outcomes Research Unit, Rome, Italy.
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Francesco Cottone
- Italian Group for Adult Hematologic Diseases (GIMEMA) Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Johannes M Giesinger
- University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Kathrin Sommer
- Italian Group for Adult Hematologic Diseases (GIMEMA) Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Amelie Anota
- French National Platform Quality of Life and Cancer, Besançon, France; Methodology and Quality of Life in Oncology Unit (INSERM UMR 1098), University Hospital of Besançon, Besançon, France
| | - Michael Maia Schlussel
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Paola Fazi
- Italian Group for Adult Hematologic Diseases (GIMEMA) Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Marco Vignetti
- Italian Group for Adult Hematologic Diseases (GIMEMA) Data Center and Health Outcomes Research Unit, Rome, Italy
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A new tool for comprehensive geriatric assessment in elderly patients with acute myeloid leukemia: a pilot study from China. Chin Med J (Engl) 2020; 133:381-387. [PMID: 31934939 PMCID: PMC7046252 DOI: 10.1097/cm9.0000000000000645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) is a common type of hematological malignancy in elderly people. Geriatricians have developed comprehensive geriatric assessment (CGA) methods for elderly patients; however, the tools used for CGA in AML are not uniform. Thus, we aimed to validate the instrumental activities of daily living (IADL) scales, age, comorbidities (Charlson Comorbidity Index), and albumin (IACA) index, which is a new tool for CGA, in elderly patients with AML. METHODS Patients aged ≥60 years who had been diagnosed with AML were screened for eligibility. Among the IACA low-, intermediate-, and high-risk groups, continuous variables were compared using the Mann-Whitney U test, and categorical variables were compared using χ and Fisher exact tests. In addition, probabilities of overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS A total of 21, 34, and 6 patients were categorized into IACA low-risk (0 point), intermediate-risk (1-2 points), and high-risk (≥3 points) groups, respectively. The rates of relapse/progression-related mortality were 23.8%, 58.8%, and 100.0% in the IACA low-, intermediate-, and high-risk groups, respectively (χ = 12.81, P < 0.001). The 2-year probabilities of OS were 47.7% (95% confidence interval [CI] 22.8%-72.6%) and 20.2% (95% CI 5.9%-34.5%) in the IACA low- and intermediate-risk groups, respectively (χ = 5.99, P = 0.014), which were significantly higher than those in the high-risk group (low-risk [47.7% (95% CI 22.8%-72.6%)] vs. high-risk [0], χ = 20.80, P < 0.001; intermediate-risk [20.2% (95% CI 5.9%-34.5%)] vs. high-risk [0], χ = 7.56, P = 0.006; respectively). In the IACA low-risk group, the 2-year probability of OS in patients receiving induction chemotherapy (50.8% [95% CI 24.1%-77.5%]) was significantly higher than that in those receiving best supportive care (0, χ = 25.74, P < 0.001). CONCLUSION We suggest that the IACA index might be a simple and effective tool for comprehensive geriatric assessment in elderly AML patients.
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Borlenghi E, Pagani C, Zappasodi P, Bernardi M, Basilico C, Cairoli R, Fracchiolla N, Todisco E, Turrini M, Cattaneo C, Da Vià M, Ciceri F, Passamonti F, Mancini V, Sciumè M, Cerqui E, Sciumè M, Rossi G. Validation of the "fitness criteria" for the treatment of older patients with acute myeloid leukemia: A multicenter study on a series of 699 patients by the Network Rete Ematologica Lombarda (REL). J Geriatr Oncol 2020; 12:550-556. [PMID: 33097455 DOI: 10.1016/j.jgo.2020.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/19/2020] [Accepted: 10/07/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Treatment of older patients with acute myeloid leukemia (AML) is still controversial. To facilitate treatment decisions, the "fitness criteria" proposed by Ferrara et al. (Leukemia, 2013), including age > 75 years, performance status and comorbidities, were verified retrospectively in 699 patients with AML (419 de-novo, 280 secondary AML), diagnosed at 8 Hematological Centers (REL). METHODS Patients were categorized in FIT to intensive chemotherapy (i-T) (292, 42.5%), UNFIT to i-T (289, 42.1%), or unfit even to non-intensive therapy (non i-T) (FRAIL) (105, 15.3%). Biological characteristics and treatment actually received by patients [i-T, 274 patients (39.2%); non i-T, 134 (19.2%), best-supportive care (BSC), 291 (41.6%)] were recorded. RESULTS "Fitness criteria" were easily applicable in 98.1% of patients. Overall concordance between "fitness criteria" and treatment actually received by patients was high (79.4%), 76% in FIT, 82.7% in UNFIT and 80% in FRAIL patients. Fitness independently predicted survival (median survival: 10.9, 4.2 and 1.8 months in FIT, UNFIT and FRAIL patients, respectively; p = 0.000), as confirmed also by multivariate analysis. In FRAIL patients, survival with any treatment was no better than with BSC, in UNFIT non i-T was as effective as i-T and better than BSC, and in FIT patients i-T was better than non i-T or BSC. In addition, a non-adverse risk AML, an ECOG PS <2, and receiving any treatment other than BSC had a favorable effect on survival (p < 0.001). CONCLUSION These simple "fitness criteria" applied at the time of diagnosis could facilitate, together with AML biologic risk evaluation, the choice of the most appropriate treatment intensity in older AML patients.
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Affiliation(s)
- Erika Borlenghi
- Department of Hematology, ASST Spedali Civili of Brescia, Brescia, Italy.
| | - Chiara Pagani
- Department of Hematology, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Patrizia Zappasodi
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Massimo Bernardi
- San Raffaele Scientific Institute Haematology, Bone Marrow Transplantation Unit, Milano, Italy
| | - Claudia Basilico
- Division of Hematology, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Roberto Cairoli
- Dipartimento di Ematologia ed Oncologia, Niguarda Cancer Center ASST Grande Ospedale Metropolitano, Milano, Italy
| | - Nicola Fracchiolla
- U.O. Oncoematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | | | - Mauro Turrini
- Division of Haematology, Department of Medicine, Valduce Hospital, Como, Italy
| | - Chiara Cattaneo
- Department of Hematology, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Matteo Da Vià
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Fabio Ciceri
- San Raffaele Scientific Institute Haematology, Bone Marrow Transplantation Unit, Milano, Italy
| | - Francesco Passamonti
- Division of Hematology, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Valentina Mancini
- Dipartimento di Ematologia ed Oncologia, Niguarda Cancer Center ASST Grande Ospedale Metropolitano, Milano, Italy
| | - Mariarita Sciumè
- U.O. Oncoematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | - Elisa Cerqui
- Department of Hematology, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Margherita Sciumè
- Department of Hematology, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Giuseppe Rossi
- Department of Hematology, ASST Spedali Civili of Brescia, Brescia, Italy
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Sustkova Z, Semerad L, Weinbergerova B, Mayer J. How to select older patients with acute myeloid leukemia fit for intensive treatment? Hematol Oncol 2020; 39:151-161. [PMID: 32893381 DOI: 10.1002/hon.2798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 11/08/2022]
Abstract
Outcomes of the treatment of older patients with acute myeloid leukemia (AML) are unsatisfactory due to a higher incidence of negative patient- and disease-related risk factors connected with aging. Prediction of poor tolerance to aggressive treatment and low response to standard intensive chemotherapy are the main root causes why the treatment decision is challenging. For a long time, negative prognostic factors for treatment outcomes, overall survival, and early death such as the age itself, low-performance status, high-comorbidity burden, adverse cytogenetics, and secondary AML have been known, and they are routinely taken into account during therapeutic balance. In consideration of the risk factors and specific laboratory results, prognostic models have been created. Despite the abovementioned facts, the survival of older patients with AML remains very poor, that holds true even for the intensive therapy. For that reason, there is an increased effort to find a better approach how to select patients who would benefit from intensive treatment without decreasing their quality of life through severe complications with risk of high treatment-related mortality. Based on the results of clinical studies, the geriatric assessment could be the missing step which would help select older patients who are really fit for intensive treatment and who will benefit from it the most. This review focuses on the risk factors that should be taken under advisement when the decision about the treatment is made. With reference to the published information, we propose an algorithm how to identify fit, vulnerable, and frail patients.
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Affiliation(s)
- Zuzana Sustkova
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Lukas Semerad
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Barbora Weinbergerova
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Jiri Mayer
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Tallman MS, Wang ES, Altman JK, Appelbaum FR, Bhatt VR, Bixby D, Coutre SE, De Lima M, Fathi AT, Fiorella M, Foran JM, Hall AC, Jacoby M, Lancet J, LeBlanc TW, Mannis G, Marcucci G, Martin MG, Mims A, O'Donnell MR, Olin R, Peker D, Perl A, Pollyea DA, Pratz K, Prebet T, Ravandi F, Shami PJ, Stone RM, Strickland SA, Wieduwilt M, Gregory KM, Hammond L, Ogba N. Acute Myeloid Leukemia, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 17:721-749. [PMID: 31200351 DOI: 10.6004/jnccn.2019.0028] [Citation(s) in RCA: 283] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute myeloid leukemia (AML) is the most common form of acute leukemia among adults and accounts for the largest number of annual deaths due to leukemias in the United States. Recent advances have resulted in an expansion of treatment options for AML, especially concerning targeted therapies and low-intensity regimens. This portion of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for AML focuses on the management of AML and provides recommendations on the workup, diagnostic evaluation and treatment options for younger (age <60 years) and older (age ≥60 years) adult patients.
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Affiliation(s)
| | | | - Jessica K Altman
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Dale Bixby
- University of Michigan Rogel Cancer Center
| | | | - Marcos De Lima
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | - Aric C Hall
- University of Wisconsin Carbone Cancer Center
| | - Meagan Jacoby
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | - Michael G Martin
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Alice Mims
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Rebecca Olin
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | - Alexander Perl
- Abramson Cancer Center at the University of Pennsylvania
| | | | - Keith Pratz
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | - Paul J Shami
- Huntsman Cancer Institute at the University of Utah
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- National Comprehensive Cancer Network
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Sekeres MA, Guyatt G, Abel G, Alibhai S, Altman JK, Buckstein R, Choe H, Desai P, Erba H, Hourigan CS, LeBlanc TW, Litzow M, MacEachern J, Michaelis LC, Mukherjee S, O'Dwyer K, Rosko A, Stone R, Agarwal A, Colunga-Lozano LE, Chang Y, Hao Q, Brignardello-Petersen R. American Society of Hematology 2020 guidelines for treating newly diagnosed acute myeloid leukemia in older adults. Blood Adv 2020; 4:3528-3549. [PMID: 32761235 PMCID: PMC7422124 DOI: 10.1182/bloodadvances.2020001920] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/08/2020] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Mikkael A Sekeres
- Leukemia Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gregory Abel
- Leukemia Division, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Shabbir Alibhai
- Institute of Medical Sciences, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jessica K Altman
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rena Buckstein
- Odette Cancer Centre, Division of Medical Oncology and Hematology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hannah Choe
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Pinkal Desai
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Harry Erba
- Department of Medicine, School of Medicine, Duke University, Durham, NC
| | | | - Thomas W LeBlanc
- Department of Medicine, School of Medicine, Duke University, Durham, NC
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Laura C Michaelis
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sudipto Mukherjee
- Leukemia Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Kristen O'Dwyer
- Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY
| | - Ashley Rosko
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Richard Stone
- Leukemia Division, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Arnav Agarwal
- Department of Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - L E Colunga-Lozano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Health Science Center, Department of Clinical Medicine, Universidad de Guadalajara, Guadalajara, Mexico; and
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - QiuKui Hao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Center of Gerontology and Geriatrics/National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
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Abdallah M, Xie Z, Ready A, Manogna D, Mendler JH, Loh KP. Management of Acute Myeloid Leukemia (AML) in Older Patients. Curr Oncol Rep 2020; 22:103. [PMID: 32725515 DOI: 10.1007/s11912-020-00964-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The acute myeloid leukemia (AML) treatment landscape has rapidly evolved over the past few years. These changes have several implications for the care of older adults (≥ 60 years), who have inferior clinical outcomes. We review decision-making in older adults, focusing on patient- and disease-related factors. We then summarize current treatment options, including multiple recently approved therapies, based on hypothetical clinical scenarios. RECENT FINDINGS In lieu of using chronological age to determine fitness, we highlight the importance of standardized fitness assessments using geriatric assessments. Next, we review intensive and lower-intensity treatment options in the upfront setting. We focus on multiple newly approved medications, including venetoclax, midostaurin, CPX-351, gemtuzumab, glasdegib, enasidenib, and ivosidenib, and their specific indications. Lastly, we briefly discuss supportive care of older adults with AML. Outcomes of older adults with AML remain poor; fortunately, there are many new promising treatment options. Personalized treatment plans based on patient- and disease-specific factors are essential to the care of older adults with AML.
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Affiliation(s)
- Maya Abdallah
- Sections of Hematology/Oncology & Geriatrics, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Zhuoer Xie
- Depatment of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Audrey Ready
- Department of Medicine, University of Massachusetts - Baystate Medical Center, Springfield, MA, USA
| | - Dharmini Manogna
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Jason H Mendler
- Division of Hematology/Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA
| | - Kah Poh Loh
- Division of Hematology/Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA.
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27
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Chandhok NS, Lewis R, Prebet T. Hypomethylating agent based combinations in higher risk myelodysplastic syndrome. Leuk Lymphoma 2020; 61:1012-1027. [PMID: 31814484 DOI: 10.1080/10428194.2019.1697812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For over a decade the hypomethylating agents (HMA) azacitidine and decitabine have been the mainstay of therapy for myelodysplastic syndrome (MDS). There is a critical need to improve frontline therapy, given that only up to half of high-risk MDS patients will respond to HMA therapy, and responses are short-lived. Currently, a key strategy has been to combine HMAs with other novel agents to improve patient outcomes. While synergy of agents is the goal of combination therapy, combinations often come at the cost of increased side effects that are often intolerable in this vulnerable population. The purpose of this review is to critically examine clinically relevant HMA combinations and discuss the future of MDS management.
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Affiliation(s)
- Namrata S Chandhok
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Russell Lewis
- Smilow Cancer Center at Yale New Haven Hospital, New Haven, CT, USA
| | - Thomas Prebet
- Smilow Cancer Center at Yale New Haven Hospital, New Haven, CT, USA
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28
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Walter RB, Estey EH. Selection of initial therapy for newly-diagnosed adult acute myeloid leukemia: Limitations of predictive models. Blood Rev 2020; 44:100679. [PMID: 32249005 DOI: 10.1016/j.blre.2020.100679] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/24/2020] [Accepted: 03/18/2020] [Indexed: 12/20/2022]
Abstract
Acute myeloid leukemia (AML) remains difficult to treat: despite multiagent chemotherapy, allogeneic hematopoietic cell transplantation, and several newly approved agents, many patients will not be alive and in remission 3 years after diagnosis. However, with more agents available there are more options and a corresponding need to choose among them. Doing so is complicated by the molecular diversity of AML and the older age of many patients, predisposing them to both treatment-related mortality and, more commonly, resistance to treatment. There is no shortage of scoring systems to identify patients at high risk of early death or treatment resistance after conventional AML induction chemotherapy. As we point out here, their accuracy is limited. Furthermore, without periodic recalibration to account for new therapies and changes in supportive care, the accuracy of any prediction model will decrease over time. The limitations we describe here are important for clinicians to be aware of.
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Affiliation(s)
- Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109-1024, USA; Department of Medicine, Division of Hematology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7710, USA; Department of Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7470, USA; Department of Epidemiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7236, USA.
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109-1024, USA; Department of Medicine, Division of Hematology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7710, USA.
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29
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Delivering intensive therapies to older adults with hematologic malignancies: strategies to personalize care. Blood 2020; 134:2013-2021. [PMID: 31805199 DOI: 10.1182/blood.2019001300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/30/2019] [Indexed: 12/23/2022] Open
Abstract
Intensive therapies are often medically indicated for older adults with hematologic malignancies. These may include induction chemotherapy for acute myeloid leukemia (AML), as well as autologous hematopoietic cell transplant (autoHCT) and allogeneic hematopoietic cell transplant (alloHCT). However, it is not always clear how to best deliver these therapies, in terms of determining treatment eligibility, as well as adjusting or adding supportive measures to the treatment plan to maximize successful outcomes. Beyond performance status and presence of comorbidities, comprehensive geriatric assessment and individual geriatric metrics have increasingly been used to prognosticate in these settings and may offer the best approach to personalizing therapy. In the setting of AML induction, evidence supports the use of measures of physical function as independent predictors of survival. For patients undergoing alloHCT, functional status, as measured by instrumental activities of daily living (IADL) and gait speed, may be an important pretransplant assessment. IADL has also been associated with post-autoHCT morbidity and mortality. Current best practice includes assessment of relevant geriatric metrics prior to intensive therapy, and work is ongoing to develop complementary interventions.
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30
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Shallis RM, Boddu PC, Bewersdorf JP, Zeidan AM. The golden age for patients in their golden years: The progressive upheaval of age and the treatment of newly-diagnosed acute myeloid leukemia. Blood Rev 2020; 40:100639. [DOI: 10.1016/j.blre.2019.100639] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 12/25/2022]
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31
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Yates SJ, Lyerly S, Manuel M, Tooze JA, Klepin HD, Powell BL, Dralle S, Uprety A, Pardee TS. The prognostic value of standardized phase angle in adults with acute leukemia: A prospective study. Cancer Med 2020; 9:2403-2413. [PMID: 32049445 PMCID: PMC7131844 DOI: 10.1002/cam4.2835] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/16/2019] [Accepted: 12/27/2019] [Indexed: 12/13/2022] Open
Abstract
Standardized phase angle (SPhA) is a tool used to estimate body composition and cell membrane integrity. Standardized phase angle has been shown to predict survival in solid malignancies and hematopoietic stem cell transplant patients. We investigated the predictive value of SPhA on 60-day mortality, overall survival (OS), and length of hospital stay (LHS) for adults with acute myelogenous and lymphoblastic leukemia (AML and ALL). Consecutive patients ≥18 years with newly diagnosed acute leukemia receiving intensive chemotherapy were enrolled. Phase angle measurements were taken on day 1 of therapy for all patients and on the day of nadir marrow for AML patients. Measurements were standardized by BMI, gender, and age to calculate the SPhA. The difference between SPhA at nadir bone marrow compared to day 1 of induction was used to calculate change in SPhA. A cutoff of 25th percentile was used to dichotomize baseline SPhA. Among 100 patients, 88% were AML, 56% were female, and mean age was 59 years. Though not statistically significant, OS by Kaplan-Meier analysis was shorter for those below the 25th percentile SPhA compared to those above (median OS: 11.0 months vs 19.5 months; P = .09). Lower baseline SPhA was associated with increased incidence of 60-day mortality in univariable (odds ratio [OR] = 5.25; 1.35, 20.44; P = .02) but not multivariable analysis (OR = 3.12; 0.67, 14.48; P = .15) adjusted for age, creatinine, and cytogenetics. Increased change in SPhA was associated with worse OS (hazard ratio = 1.15; 1.00,1.33; P = .05) in multivariable analysis. Standardized phase angle is a rapid, noninvasive, and objective measure that may be used to inform risk stratification.
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Affiliation(s)
| | - Susan Lyerly
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Megan Manuel
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Janet A Tooze
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Heidi D Klepin
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Bayard L Powell
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Sarah Dralle
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Alok Uprety
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy S Pardee
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
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32
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Talati C, Dhulipala VC, Extermann MT, Ali NA, Kim J, Komrokji R, Sweet K, Kuykendall A, Sehovic M, Reljic T, Djulbegovic B, Lancet JE. Comparisons of commonly used front-line regimens on survival outcomes in patients aged 70 years and older with acute myeloid leukemia. Haematologica 2020; 105:398-406. [PMID: 31073071 PMCID: PMC7012500 DOI: 10.3324/haematol.2018.208637] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 05/07/2019] [Indexed: 12/03/2022] Open
Abstract
In older patients with acute myeloid leukemia, the more frequent presence of biologically inherent therapy-resistant disease and increased comorbidities translate to poor overall survival and therapeutic challenges. Optimal front-line therapies for older patients with acute myeloid leukemia remain controversial. We retrospectively evaluated survival outcomes in 980 elderly (≥70 years) acute myeloid leukemia patients from a single institution between 1995 and 2016. Four treatment categories were compared: high-intensity (daunorubicin/cytarabine or equivalent), hypomethylating agent, low-intensity (low-dose cytarabine or similar without hypomethylating agents), and supportive care therapy (including hydroxyurea). At a median follow up of 20.5 months, the median overall survival for the entire cohort was 7.1 months. Multivariate analysis identified secondary acute myeloid leukemia, poor-risk cytogenetics, performance status, front-line therapy, age, white blood cell count, platelet count, and hemoglobin level at diagnosis as having an impact on survival. High-intensity therapy was used in 360 patients (36.7%), hypomethylating agent in 255 (26.0%), low-intensity therapy in 91 (9.3%), and supportive care in 274 (28.0%). Pairwise comparisons between hypomethylating agent therapy and the three other treatment groups demonstrated statistically significant superior median overall survival with hypomethylating agent [14.4 months) vs. high-intensity therapy 10.8 months, hazard ratio 1.35, 95% confidence interval (CI): 1.10-1.65; P =0.004], low-intensity therapy (5.9 months, hazard ratio 2.01, 95%CI: 1.53-2.62; P<0.0001), and supportive care (2.1 months, hazard ratio 2.94, 95%CI: 2.39-3.61; P<0.0001). Our results indicate a significant survival benefit with hypomethylating agents compared to high-intensity, low-intensity, or supportive care. Additionally, high-intensity chemotherapy resulted in superior overall outcomes compared to low-intensity therapy and supportive care. Results from this study highlight the need for novel therapeutic approaches besides utilization of intensive chemotherapy in this specific aged population.
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Affiliation(s)
- Chetasi Talati
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Mar Tine Extermann
- Senior Adult Oncology Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Department of Oncology Sciences, University of South Florida, Tampa, FL
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jongphil Kim
- Maur y Regional Cancer Center, Columbia, TN.,Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL
| | - Rami Komrokji
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Malignant Hematology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kendra Sweet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Malignant Hematology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Andrew Kuykendall
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Maur y Regional Cancer Center, Columbia, TN
| | - Marina Sehovic
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Tea Reljic
- Maur y Regional Cancer Center, Columbia, TN
| | - Benjamin Djulbegovic
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Maur y Regional Cancer Center, Columbia, TN
| | - Jeffrey E Lancet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Malignant Hematology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Klepin HD, Ritchie E, Major-Elechi B, Le-Rademacher J, Seisler D, Storrick L, Sanford BL, Marcucci G, Zhao W, Geyer SA, Ballman KV, Powell BL, Baer MR, Stock W, Cohen HJ, Stone RM, Larson RA, Uy GL. Geriatric assessment among older adults receiving intensive therapy for acute myeloid leukemia: Report of CALGB 361006 (Alliance). J Geriatr Oncol 2020; 11:107-113. [PMID: 31668825 PMCID: PMC6943189 DOI: 10.1016/j.jgo.2019.10.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 10/10/2019] [Accepted: 10/12/2019] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To demonstrate feasibility of performing geriatric assessment (GA) in the National Clinical Trials Network (NCTN) and to explore the utility of GA to characterize treatment tolerance. MATERIALS AND METHODS We conducted a multisite companion study (CALGB 361006) to CALGB 11001, a phase 2 trial of adults ≥60 years old with newly diagnosed FLT3- mutated AML, testing the efficacy of adding sorafenib to intensive chemotherapy. On 361006, a GA was administered prior to induction and prior to post-remission therapy. The GA is divided into items requiring administration by a health care professional (HCP) and patient self-administered questionnaires. Feasibility outcomes were recruitment rate, time to GA completion, difficulty with GA administration, percent of patients requiring assistance, and satisfaction. Change in GA measures pre- and post-induction were compared using Wilcoxon signed rank test and McNemar's tests. RESULTS The recruitment rate was 80% (N = 43, median age 68 years). Median completion time of the GA was 30 min; (10 and 21 min for HCP and patients, respectively). HCP reported no difficulty completing assessments (100%). Most patients completed questionnaires without assistance (77%), and were satisfied with the length (89%). Self-reported physical function, mental health, social activity and nutritional parameters worsened after induction. CONCLUSION GA is feasible to administer in the setting of intensive induction for older adults with AML in the NCTN and provides evidence of the impact of induction therapy on physical and emotional health.
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Affiliation(s)
- Heidi D Klepin
- Wake Forest University Health Sciences, Winston-Salem, NC, United States of America.
| | - Ellen Ritchie
- Weill Medical College of Cornell University, New York, NY, United States of America
| | - Brittny Major-Elechi
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, United States of America
| | - Jennifer Le-Rademacher
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, United States of America
| | - Drew Seisler
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, United States of America
| | - Libby Storrick
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, United States of America
| | - Ben L Sanford
- Alliance Statistics and Data Center, Duke University, Durham, NC, United States of America
| | - Guido Marcucci
- City of Hope Comprehensive Cancer Center, Duarte, CA, United States of America
| | - Weiqiang Zhao
- The Ohio State University Cancer Center, Columbus, OH, United States of America
| | - Susan A Geyer
- Alliance Statistics and Data Center, The Ohio State University Medical Center, Columbus, OH, United States of America
| | - Karla V Ballman
- Weill Medical College of Cornell University, New York, NY, United States of America
| | - Bayard L Powell
- Wake Forest University Health Sciences, Winston-Salem, NC, United States of America
| | - Maria R Baer
- Greenebaum Cancer Center, University of Maryland, Baltimore, MD, United States of America
| | - Wendy Stock
- University of Chicago Comprehensive Cancer Center, Chicago, IL, United States of America
| | - Harvey Jay Cohen
- Duke Cancer Institute, Duke University, Durham, NC, United States of America
| | - Richard M Stone
- Dana-Farber/Partners CancerCare, Boston, MA, United States of America
| | - Richard A Larson
- University of Chicago Comprehensive Cancer Center, Chicago, IL, United States of America
| | - Geoffrey L Uy
- Washington University School of Medicine, St. Louis, MO, United States of America
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34
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Olin RL. Delivering intensive therapies to older adults with hematologic malignancies: strategies to personalize care. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:63-70. [PMID: 31808886 PMCID: PMC6913447 DOI: 10.1182/hematology.2019001300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Intensive therapies are often medically indicated for older adults with hematologic malignancies. These may include induction chemotherapy for acute myeloid leukemia (AML), as well as autologous hematopoietic cell transplant (autoHCT) and allogeneic hematopoietic cell transplant (alloHCT). However, it is not always clear how to best deliver these therapies, in terms of determining treatment eligibility, as well as adjusting or adding supportive measures to the treatment plan to maximize successful outcomes. Beyond performance status and presence of comorbidities, comprehensive geriatric assessment and individual geriatric metrics have increasingly been used to prognosticate in these settings and may offer the best approach to personalizing therapy. In the setting of AML induction, evidence supports the use of measures of physical function as independent predictors of survival. For patients undergoing alloHCT, functional status, as measured by instrumental activities of daily living (IADL) and gait speed, may be an important pretransplant assessment. IADL has also been associated with post-autoHCT morbidity and mortality. Current best practice includes assessment of relevant geriatric metrics prior to intensive therapy, and work is ongoing to develop complementary interventions.
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Affiliation(s)
- Rebecca L Olin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
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35
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Loh KP, Abdallah M, Kumar AJ, Neuendorff NR, Dahiya S, Klepin HD. Health-Related Quality of Life and Treatment of Older Adults with Acute Myeloid Leukemia: a Young International Society of Geriatric Oncology Review Paper. Curr Hematol Malig Rep 2019; 14:523-535. [PMID: 31776773 PMCID: PMC6938300 DOI: 10.1007/s11899-019-00552-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The treatment landscape for older patients with acute myeloid leukemia (AML) is evolving. Many treatments have comparable efficacy making their impact on quality of life (QoL) an important differentiating factor. In this review, we discuss QoL in older adults with AML, focusing on therapeutic and observational trials that have incorporated QoL assessments. RECENT FINDINGS Health-related quality of life (HRQoL) is a multi-dimensional concept incorporating physical, mental, emotional, and social functioning domains. HRQoL components overlap with components of geriatric assessment, a multidisciplinary diagnostic process that identifies underlying vulnerabilities of older adults and guides subsequent management strategies. HRQoL questionnaires may be general, cancer-specific, leukemia-specific, or symptom-focused. Therapeutic and observational cohort studies suggest HRQoL improves, or at least remains stable, during intensive and lower-intensity therapies. Nonetheless, HRQoL is not routinely incorporated in AML therapeutic trials. HRQoL assessments can inform both decision-making and management for older adults with AML.
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Affiliation(s)
- Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA.
| | - Maya Abdallah
- Department of Internal Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Anita J Kumar
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
- Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Nina R Neuendorff
- Department of Internal Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Saurabh Dahiya
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Heidi D Klepin
- Section on Hematology and Oncology, Wake Forest Baptist Comprehensive Cancer Center, Medical Center Blvd, Winston-Salem, NC, USA
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36
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Hypomethylating agents in the treatment of acute myeloid leukemia: A guide to optimal use. Crit Rev Oncol Hematol 2019; 140:1-7. [PMID: 31153036 DOI: 10.1016/j.critrevonc.2019.05.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 12/21/2022] Open
Abstract
The hypomethylating agents (HMAs), decitabine and azacitidine, are valuable treatment options in acute myeloid leukemia patients who are not eligible for intensive chemotherapy. Both agents are generally well tolerated, and complications most commonly relate to myelosuppression. Antibiotic / antifungal use, regular monitoring, and proactive patient education are important to minimize these events, and reduce the need for dose delay. Responses to HMAs are often not evident for up to 6 cycles, and there is currently no validated clinical marker for predicting response. Hence, treatment should be continued for at least 4-6 cycles to ensure that patients have sufficient opportunity to respond. Delivery of insufficient numbers of cycles is a key reason for HMA failure, and premature discontinuation must be avoided. Genetic factors offer potential for better predicting responders to HMAs in future, but require further study.
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Bai JF, Mei D, Han HX, Zhang S, Feng R, Li JT, Wang T, Zhang CL, Ning SY, Liu H. [The prognosis value of comprehensive geriatric assessment in elder patients with acute myeloid leukemia in a single center]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:200-203. [PMID: 30929386 PMCID: PMC7342533 DOI: 10.3760/cma.j.issn.0253-2727.2019.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Indexed: 11/25/2022]
Abstract
Objective: To evaluate the prognostic significance of comprehensive geriatric assessment (CGA) in Chinese elderly acute myeloid leukemia (AML) patients. Methods: 73 AML patients over the age of 60 were enrolled. CGA stratification included the following 3 instrument assessment: activity of daily living (ADL) ; instrumental activity of daily living (IADL) ; comorbidity score according to the Modified cumulative illness rating score for geriatrics (MCIRS-G) . According to CGA and age, the enrolled patients were grouped into 'fit', 'unfit' and 'frail' categories. Results: The median age of 73 elderly AML patients were 75 years old. According to CGA, 37 (50.1%) patients were classified as 'fit', 14 (19.2%) as 'unfit', and 22 (30.7%) as 'frail'. 33 (89.2%) patients in fit group received induction chemotherapy, or demethylation treatment, as 8 (57.9%) in unfit, 10 (45.5%) in frail. The overall response rate was 68.7%、62.5%, 75.0% in fit, unfit, and frail group, respectively (χ(2)=0.615, P=0.769) .The early mortality (8 weeks) in three groups were different: 5.4%, 7.1%, 27.3%, respectively (P<0.05) . The 1-year overall survival in the 'fit', 'unfit' and 'frail' groups was 64.9%, 28.6% and 22.7%, respectively (P<0.05) . The CGA score, age, ECOG score, WHO classification (2016) were the prognostic factors of AML patients. Conclusion: CGA can be used to determine the prognosis of elderly AML patients.
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Affiliation(s)
- J F Bai
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
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Wu Q, Fu R, Zhao MF, Ma YG, Jiang H, Hu LD, Jing Y, Liu H, Wang LR, Su L, Zhang YQ, Zhou CL, Zhang Y, Ren HY, Jiang B, Zhou HB, Kang L, Zhang L, Zhou DB, Li J. [The usage of comprehensive geriatric assessment in elderly patients with acute myeloid leukemia: a multicenter, prospective study]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:35-39. [PMID: 30704226 PMCID: PMC7351700 DOI: 10.3760/cma.j.issn.0253-2727.2019.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Indexed: 12/12/2022]
Abstract
Objective: To evaluate the feasibility and potential value of comprehensive geriatric assessment (CGA) in elderly (≥60 years) patients with newly diagnosed acute myeloid leukemia (AML) in China. Methods: The CGA results of 83 newly diagnosed AML (non-APL) patients from 16 hospitals in Beijing and Tianjin between March 2016 and December 2017 were prospectively collected and analyzed. The clinical data, treatment and follow-up information were also collected. Results: Of 83 newly diagnosed elderly AML patients, 81 patients (97.6%) completed all designated CGA assessment. The median number of impaired scales of the CGA assessment in the studied population was 2(0-6). Sixteen patients (19.3%) showed no impairments according to the geriatric assessment scales implem ented by this study. The distributions of impaired scales were as follows: impairment in ADL, 55.4%; IADL impairment, 42.2%; MNA-SF impairment, 48.2%; cognitive impairment, 15.7%; GDS impairment, 31.7%; HCT-CI impairment, 19.5%, respectively. In patients with "good" ECOG (n=46), the proportion of impairment for each CGA scale ranged from 6.5% to 37.0% and 32 patients (68.9%) had at least one impaired CGA scale. Survival analysis showed that the number of impaired scales of the CGA was significantly correlated with median overall survival (P=0.050). Conclusions: CGA was a tool with feasibility for the comprehensive evaluation in elderly AML patients in China. Combined with age and ECOG, CGA may be more comprehensive in assessing patients' physical condition.
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Affiliation(s)
- Q Wu
- Peking Union Medical College Hospital, Beijing 100730, China
| | - R Fu
- General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - M F Zhao
- Tianjin First Central Hospital, Tianjin 300192, China
| | - Y G Ma
- China-Japan Friendship Hospital, Beijing 100029, China
| | - H Jiang
- People's Hospital, Peking University, Beijing 100044, China
| | - L D Hu
- 307 PLA Hospital, Beijing 100071, China
| | - Y Jing
- Chinese PLA General Hospital, Beijing 100853, China
| | - H Liu
- Beijing Hospital, Beijing 100730, China
| | - L R Wang
- Fuxing Hospital, Capital Medical University, Beijing 100038, China
| | - L Su
- Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Y Q Zhang
- the 309th Hospital of Chinese PLA, Beijing 100091, China
| | - C L Zhou
- Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Y Zhang
- Beijing Longfu Hospital, Beijing 100010, China
| | - H Y Ren
- Peking University First Hospital, Beijing 100034, China
| | - B Jiang
- Peking University International Hospital, Beijing 102206, China
| | - H B Zhou
- Beijing Luhe Hospital, Capital Medical Unversity, Beijing 101100, China
| | - L Kang
- Peking Union Medical College Hospital, Beijing 100730, China
| | - L Zhang
- Peking Union Medical College Hospital, Beijing 100730, China
| | - D B Zhou
- Peking Union Medical College Hospital, Beijing 100730, China
| | - J Li
- Peking Union Medical College Hospital, Beijing 100730, China
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Klepin HD, Estey E, Kadia T. More Versus Less Therapy for Older Adults With Acute Myeloid Leukemia: New Perspectives on an Old Debate. Am Soc Clin Oncol Educ Book 2019; 39:421-432. [PMID: 31099627 DOI: 10.1200/edbk_239097] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Most patients with newly diagnosed acute myeloid leukemia (AML) are at least age 65 and continue to have short survival, with many patients receiving no specific anti-AML therapy, particularly if they are older than age 75. Although consensus regarding optimal treatment of this growing population is lacking, treatment options are expanding even for the oldest patients. A fundamental question when seeing an older patient with AML is whether to recommend "more intensive" or "less intensive" induction therapy. Existing data can support more intensive treatment strategies for selected older adults, although there is growing evidence to support less intensive therapies as well. Randomized trials to provide clear comparisons between treatment strategies among well-characterized older adult populations are lacking. Reliance on age alone to determine treatment choice is problematic, as "fitness" or "unfitness" varies dramatically among patients of the same chronologic age and remains poorly characterized in existing studies. This article will provide differing perspectives on the "more" versus "less" question, with particular attention to recent drug approvals. Issues relevant to both treatment decision-making in practice and alternative trial design to inform gaps in knowledge will be discussed. Given the heterogeneity, an important conclusion will be that there is unlikely to be a single best approach and that appropriate decision-making requires considerations of many factors specific to individual patients.
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Affiliation(s)
- Heidi D Klepin
- 1 Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC
| | - Elihu Estey
- 2 University of Washington and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Tapan Kadia
- 3 The University of Texas MD Anderson Cancer Center, Houston, TX
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Abstract
PURPOSE OF REVIEW Older adults with hematologic malignancy are a growing demographic. Estimating risk of chemotherapy toxicity based on age alone is an unreliable estimate of quality of life, functional capacity, or risk of treatment complications. RECENT FINDINGS Dedicated geriatric assessment tools can aid the clinician in identifying geriatric syndromes such as frailty, resulting in improved prognostication to decrease morbidity and mortality. Frailty is not synonymous with individual performance status and is dynamic. Establishing the patient goals, values, and preferences is central to the consideration of malignant hematology decision process. Careful considerations of available data on the patient's prognosis based on estimated life expectancy, geriatric assessment data, and age-specific cancer mortality, with and without treatment, can reconcile the risks and benefits. Assessments of frailty can aid the clinical feasibility and burden of the treatment to the patient and family in the context of each patient's unique needs.
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Michaelis LC. Cytotoxic therapy in acute myeloid leukemia: not quite dead yet. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:51-62. [PMID: 30504291 PMCID: PMC6246033 DOI: 10.1182/asheducation-2018.1.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Given the recent approvals of new agents for acute myeloid leukemia (AML), a clinical trial pipeline stocked with novel therapies, and the rapid integration of imaginative approaches in diseases like acute lymphocytic leukemia and chronic lymphocytic leukemia, it is reasonable to ask whether treatment of AML might finally depart from the classical cytotoxic induction therapy that has been employed since the 1970s. However, for better or worse, in 2018, cytotoxic induction regimens remain the standard of care for most patients. Indeed, the future likely lies in combinations of therapies that act with a spectrum of mechanisms. Using a case-based format, this review will outline current treatment expectations for patients according to karyotypic risk and familiarize readers with the basis for common induction choices. Relapsed/refractory disease may be especially amenable to interventions with novel agents or clinical trials; however, there are still some patients who most benefit from intensive chemotherapy. This review will outline risk systems that help the practitioner identify those with the best chances for response and survival. Finally, clinical tools, including geriatric assessments and comorbidity calculators, may help clinicians recognize patients for whom disease risk and comorbidity tip the balance against classical chemotherapy, a frequent challenge for those who treat this devastating disease.
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Affiliation(s)
- Laura C Michaelis
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
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Geriatric Assessment in Older Patients with Acute Myeloid Leukemia. Cancers (Basel) 2018; 10:cancers10070225. [PMID: 29986389 PMCID: PMC6070943 DOI: 10.3390/cancers10070225] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/16/2022] Open
Abstract
The incidence of acute myeloid leukemia (AML) increases with age, but the outcomes for older adults with AML are poor due to underlying tumor biology, poor tolerance to aggressive treatment, and the physiologic changes of aging. Because of the underlying heterogeneity in health status, treatment decisions are difficult in this population. A geriatric assessment (GA) refers to the use of various validated tools to assess domains that are important in older adults including physical function, cognition, comorbidities, polypharmacy, social support, and nutritional status. In older patients with cancer, a GA can guide treatment decision-making, predict treatment toxicity, and guide supportive care interventions. Compared to solids tumors, there is a relative lack of studies evaluating the use of a GA in older patients with AML. In this review, we will discuss the principles, common domains, feasibility, and benefits of GA, with a focus on older patients with AML that includes practical applications for clinical management.
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Loh KP, Klepin H. Incorporating Physical Function and Cognition Into Mortality Risk Assessment for Acute Myeloid Leukemia. JAMA Oncol 2018; 4:1014. [DOI: 10.1001/jamaoncol.2018.0674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kah Poh Loh
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Heidi Klepin
- Wake Forest Baptist Health, Winston-Salem, North Carolina
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Can we incorporate geriatric assessment in the management of acute lymphoblastic leukemia in older adults? J Geriatr Oncol 2018; 9:296-301. [DOI: 10.1016/j.jgo.2018.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/07/2018] [Accepted: 03/23/2018] [Indexed: 02/03/2023]
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Myelodysplastic syndromes current treatment algorithm 2018. Blood Cancer J 2018; 8:47. [PMID: 29795386 PMCID: PMC5967332 DOI: 10.1038/s41408-018-0085-4] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 01/03/2023] Open
Abstract
Myelodysplastic syndromes (MDS) include a group of clonal myeloid neoplasms characterized by cytopenias due to ineffective hematopoiesis, abnormal blood and marrow cell morphology, and a risk of clonal evolution and progression to acute myeloid leukemia (AML). Because outcomes for patients with MDS are heterogeneous, individual risk stratification using tools such as the revised International Prognostic Scoring System (IPSS-R) is important in managing patients-including selecting candidates for allogeneic hematopoietic stem cell transplantation (ASCT), the only potentially curative therapy for MDS. The IPSS-R can be supplemented by molecular genetic testing, since certain gene mutations such as TP53 influence risk independent of established clinicopathological variables. For lower risk patients with symptomatic anemia, treatment with erythropoiesis-stimulating agents (ESAs) or lenalidomide (especially for those with deletion of chromosome 5q) can ameliorate symptoms. Some lower risk patients may be candidates for immunosuppressive therapy, thrombopoiesis-stimulating agents, or a DNA hypomethylating agent (HMA; azacitidine or decitabine). Among higher risk patients, transplant candidates should undergo ASCT as soon as possible, with HMAs useful as a bridge to transplant. Non-transplant candidates should initiate HMA therapy and continue if tolerated until disease progression. Supportive care with transfusions and antimicrobial drugs as needed remains important in all groups.
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Michaelis LC, Klepin HD, Walter RB. Advancements in the management of medically less-fit and older adults with newly diagnosed acute myeloid leukemia. Expert Opin Pharmacother 2018; 19:865-882. [PMID: 29697000 DOI: 10.1080/14656566.2018.1465562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Treating acute myeloid leukemia (AML) in older adults remains daunting. The unique biology often renders conventional chemotherapies less effective. Accurately predicting the toxicities of treatment is another unresolved challenge. Treatment planning thus requires a good knowledge of the current trial data and familiarity with clinical tools, including formal fitness and geriatric assessments. Both obstacles - disease biology and patient fitness - might be easier overcome with specific, AML cell-targeted agents rather than traditional cytotoxic chemotherapy. This may be the future of AML therapy, but it is not our current state. AREAS COVERED Herein, the authors appraise the data supporting a standard induction approach, including an outline of how to predict treatment-related mortality and a review of the most up-to-date methods of geriatric assessment. They also discuss treatment expectations with less-intense therapies and highlight novel agents in development. Finally, they provide a basic approach to choosing treatment intensity. EXPERT OPINION In an older and/or medically less-fit patient, treatment choice should begin with a thorough disease assessment, a formal evaluation of patient fitness and frailty. There should also be a clear communication with the patient and patient's family about the risks and anticipated benefits of either an intense or nonintense treatment approach.
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Affiliation(s)
- Laura C Michaelis
- a Associate Professor of Medicine, Department of Hematology and Oncology , Medical College of Wisconsin , Milwaukee , WI , USA
| | - Heidi D Klepin
- b Associate Professor of Internal Medicine, Section on Hematology and Oncology , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Roland B Walter
- c Associate Member, Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,d Associate Professor of Medicine, Department of Medicine, Division of Hematology , University of Washington , Seattle , WA , USA.,e Adjunct Associate Professor, Department of Epidemiology , University of Washington , Seattle , WA , USA
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Sawalha Y, Advani AS. Management of older adults with acute lymphoblastic leukemia: challenges & current approaches. Int J Hematol Oncol 2018; 7:IJH02. [PMID: 30302234 PMCID: PMC6176956 DOI: 10.2217/ijh-2017-0023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/14/2018] [Indexed: 11/21/2022] Open
Abstract
The management of acute lymphoblastic leukemia (ALL) in older patients is challenging. Older patients often have multiple comorbidities and poor performance status, and disease factors associated with poor prognosis are more common in this age group. Patient and disease-related factors should be taken into account to determine whether intensive therapy is appropriate. The use of comorbidity indices and comprehensive geriatric assessment tools can be valuable in this setting. Fit patients should be considered for aggressive therapies including allogeneic hematopoietic stem cell transplantation, whereas low intensity options may be more suitable for the frail. The Philadelphia (Ph) chromosome is present in up to half of the cases of ALL in older patients. The incorporation of TK inhibitors into the treatment plans of older patients with Ph-positive ALL has improved the outcomes significantly. For less fit patients with Ph-positive ALL, the use of TK inhibitors with reduced-intensity chemotherapy or steroids alone results in high rates of remission, but, without further consolidation, relapses are inevitable. Many novel targeted and immunotherapeutic agents are being developed, offering more effective and tolerable treatment options.
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Affiliation(s)
- Yazeed Sawalha
- Department of Medical Oncology & Hematology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Anjali S Advani
- Department of Medical Oncology & Hematology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
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Breccia M, Palandri F, Luciano L, Benevolo G, Bonifacio M, Caocci G, Castagnetti F, Palumbo GA, Iurlo A, Landi F. Identification and assessment of frailty in older patients with chronic myeloid leukemia and myelofibrosis, and indications for tyrosine kinase inhibitor treatment. Ann Hematol 2018; 97:745-754. [DOI: 10.1007/s00277-018-3258-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/23/2018] [Indexed: 12/27/2022]
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Frailty and the management of hematologic malignancies. Blood 2017; 131:515-524. [PMID: 29141942 DOI: 10.1182/blood-2017-09-746420] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/18/2017] [Indexed: 12/13/2022] Open
Abstract
The majority of blood cancers occur in the elderly. This fact conspires with an aging population in many countries to make rigorous assessment for frailty increasingly important for hematologic oncologists. In this review, we first define frailty and its relevance for patients with hematologic malignancy. Next, we review current data regarding the effect of domains of frailty on outcomes for blood cancers including myelodysplastic syndromes, acute leukemia, non-Hodgkin lymphomas such as chronic lymphocytic leukemia, and multiple myeloma. Finally, after presenting assessment and treatment options for the practicing hematologist, we propose elements of a new research agenda for geriatric hematology: the exchange of age limits for rigorous frailty screening, development of disease-specific measures, and inclusion of functional and patient-reported outcomes alongside survival.
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Abstract
INTRODUCTION Treatment of elderly patients with acute leukemia is challenging. Older age is associated with increased risk of treatment-related toxicity. Currently, no consensus exists regarding optimal therapy in this patient population. Areas covered: The following review is a comprehensive summary of various therapeutic options reported over the past few years in elderly patients with acute leukemia. Expert commentary: While evidences can guide identification of frail older patients, sensitive assessment strategies are required to identify fit and vulnerable patients regardless of chronologic age. Individualized treatments may take into account not only an increase in survival, but also the maintenance or improvement in terms of quality of life, the management of symptoms, and a maximization of time outside of hospital care. In this setting, comprehensive geriatric assessments have been shown to improve routine assessment. Molecular abnormalities provide the genomic footprint for the development of targeted therapies. The addition of new monoclonal antibodies to conventional treatments also demonstrated promising primary results. Ongoing clinical trials testing the activity of these new agents may reshape treatment strategies in the elderly patient population.
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Affiliation(s)
- Xavier Thomas
- a Hospices Civils de Lyon, Hematology Department , Lyon-Sud Hospital , Pierre Bénite , France
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