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Mangan BL, DuMontier C, Hopkins JO, Abel GA, McCurdy SR. Tailoring Therapy in Older Adults With Hematologic Malignancies. Am Soc Clin Oncol Educ Book 2024; 44:e432220. [PMID: 38788182 DOI: 10.1200/edbk_432220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Hematologic malignancies most often present in the sixth or seventh decade of life. Even so, many older adults may be unable to tolerate standard chemotherapy or require supplementary care or dose adjustments to do so. Both in community and academic centers, geriatric assessment (GA) can be used to improve the care of older adults with blood cancers. For example, hematologic oncologists can use GA to guide treatment selection, adjusting for patient frailty and goals, as well as prompt initiation of enhanced supportive care. After initial therapy, GA can improve the identification of older adults with aggressive myeloid malignancies who would benefit from hematopoietic cell transplantation (HCT), inform shared decision making, as well as allow transplanters to tailor conditioning regimen, donor selection, graft-versus-host disease prophylaxis, and pre- and post-HCT treatments. As in HCT, GA can improve the care of older patients with relapsed lymphoma or multiple myeloma eligible for chimeric antigen receptor-T therapy, identifying patients at higher risk for toxicity and providing a baseline for subsequent neurocognitive testing. Here, we review the data supporting GA for the care of older adults with blood cancers, from the community to the academic center. In addition, we explore future directions to optimize outcomes for older adults with hematologic malignancies.
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Affiliation(s)
- Brendan L Mangan
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA
| | - Clark DuMontier
- Brigham and Women's Hospital, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | | | - Gregory A Abel
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Shannon R McCurdy
- Division of Hematology-Oncology/Department of Medicine, University of Pennsylvania, Philadelphia, PA
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Ramdany H, Lofaro T, Deplano S. The Haemato-Oncology Frailty (HOF) score to assess frailty in lymphoma. Eur J Haematol 2024; 112:611-620. [PMID: 38112247 DOI: 10.1111/ejh.14152] [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] [Received: 10/23/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
Morbidity and mortality during chemotherapy in older adults with haematological malignancy can be unpredictable. The Haemato-Oncology Frailty (HOF) score was previously found to predict outcomes in a cohort of patients with plasma cell myeloma. In this study, we assess its utility in assessing frailty in patients with lymphoma, and compare its performance to that of two other frailty scores. The HOF score was able to predict progression-free survival in this population, and was also shown to have potential in assessing the dynamism of frailty during chemotherapy. It performed well when compared to the Charlson Comorbidity Index (CCI) score and the Haematopoietic Cell Transplantation-Specific Comorbidity Index (HCTCI), although the study was not powered to assess for non-inferiority. The HOF score is a new score with the potential for application in different haematological malignancies.
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Affiliation(s)
- Hena Ramdany
- Imperial College London, Isle of Wight NHS Trust, Newport, UK
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Bhatt VR, Uy GL, Klepin HD. Determining treatment tolerance and fitness for intensive chemotherapy in older adults with AML: a call to action. Blood 2024; 143:483-487. [PMID: 38048592 PMCID: PMC10950471 DOI: 10.1182/blood.2023022611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 12/06/2023] Open
Abstract
ABSTRACT Determining fitness for intensive chemotherapy in an older adult with acute myeloid leukemia (AML) is an unanswered age-old question. Geriatric assessment captures any variation in multidimensional health, which can influence treatment tolerance. A prospective study is necessary to validate fitness criteria, determine whether geriatric assessment-based fitness performs superiorly to other criteria, and what components of geriatric assessment are associated with treatment tolerance. A validation study should enroll diverse patients from both academic and community centers and patients receiving intensive and lower-intensity chemotherapy. Geriatric assessment should include at minimum measures of comorbidity burden, cognition, physical function, and emotional health, which in previous smaller studies have shown to be associated with mortality in AML. These assessments should be completed before or within a few days of initiation of chemotherapy to reduce the influence of chemotherapy on the assessment results. Treatment tolerance has been measured by rates of toxicities in patients with solid malignancies; however, during the initial treatment of AML, rates of toxicities are very high regardless of treatment intensity. Early mortality, frequently used in previous studies, can provide a highly consequential and easily identifiable measure of treatment tolerance. The key end point to assess treatment tolerance, thus, should include early mortality. Other end points may include decline in function and quality of life and treatment modifications or cessation due to toxicities. Validating fitness criteria can guide treatment selection and supportive care interventions and are crucial to guide fitness-based trial eligibility, inform the interpretation of trial results, and facilitate drug labeling.
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Affiliation(s)
- Vijaya Raj Bhatt
- Fred & Pamela Buffett Cancer Center, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Geoffrey L. Uy
- Division of Oncology, Washington University School of Medicine, St. Louis, MO
| | - Heidi D. Klepin
- Department of Internal Medicine, Section on Hematology and Oncology, Wake Forest University Health System, Winston-Salem, NC
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Neuendorff NR, Gagelmann N, Singhal S, Meckstroth S, Thibaud V, Zhao Y, Mir N, Shih YY, Amaro DMC, Roy M, Lombardo J, Gjærde LK, Loh KP. Hypomethylating agent-based therapies in older adults with acute myeloid leukemia - A joint review by the Young International Society of Geriatric Oncology and European Society for Blood and Marrow Transplantation Trainee Committee. J Geriatr Oncol 2023; 14:101406. [PMID: 36435726 PMCID: PMC10106360 DOI: 10.1016/j.jgo.2022.11.005] [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: 05/06/2022] [Revised: 10/23/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022]
Abstract
Acute myeloid leukemia (AML) is associated with poor outcomes in older adults. A major goal of treatment is to balance quality of life and functional independence with disease control. With the approval of new, more tolerable regimens, more older adults are able to receive AML-directed therapy. Among these options are hypomethylating agents (HMAs), specifically azacitidine and decitabine. HMAs have become an integral part of AML therapy over the last two decades. These agents are used either as monotherapy or nowadays more commonly in combination with other agents such as the Bcl-2 inhibitor venetoclax. Biological AML characteristics, such as molecular and cytogenetic risk factors, play crucial roles in guiding treatment decisions. In patients with high-risk AML, HMAs are increasingly used rather than intensive chemotherapy, although further trials based on a risk-adapted approach using patient- and disease-related factors are needed. Here, we review trials and evidence for the use of HMA monotherapy and combination therapy in the management of older adults with AML. Furthermore, we discuss the use of HMAs and HMA combination therapies in AML, mechanisms of action, their incorporation into hematopoietic stem cell transplantation strategies, and their use in patients with comorbidities and reduced organ function.
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Affiliation(s)
- Nina Rosa Neuendorff
- Clinic for Hematology and Stem-Cell Transplantation, University Hospital Essen, Hufelandstrasse 55, D-45147 Essen, Germany.
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Surbhi Singhal
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Shelby Meckstroth
- Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Vincent Thibaud
- Department of Hematology, Hôpital Saint-Vincent, Université Catholique de Lille, 59000 Lille, France
| | - Yue Zhao
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Nabiel Mir
- Section of Geriatrics and Palliative Medicine, The University of Chicago Medical Center, Chicago, USA
| | - Yung-Yu Shih
- Department of Hematology and Oncology, Clinic Favoriten Vienna, Austria
| | - Danielle M C Amaro
- Department of Oncology and Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Mukul Roy
- Department of Radiation Oncology, Jaslok Hospital, Mumbai, India
| | - Joseph Lombardo
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Lars Klingen Gjærde
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
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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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