Early mortality and survival in older adults with acute myeloid leukemia

The influence of hospital volume and physician volume on early mortality in acute promyelocytic leukemia patients

Acute promyelocytic leukemia (APL) is a highly curable hematologic malignancy in the era of all-trans retinoic acid (ATRA) combination treatment. However, only a modest change in early mortality rate has been observed despite the wide availability of ATRA. In addition to the clinical characteristics of APL patients, studies on the hospital volume-outcome relationship and the physician volume-outcome relationship remained limited. We aim to evaluate the association between hospital and physician volume and the early mortality rate among APL patients. The patients were collected from Taiwan's National Health Insurance Research Database (NHIRD). Early mortality is defined as death within 30 days of diagnosis. Patients were categorized into four groups according to individual cumulative hospital and physician volume. The risk of all-cause mortality in APL patients with different cumulative volume groups was compared using a Cox proportional hazard model. The probability of overall survival was estimated using the Kaplan-Meier method. All 741 patients were divided into four quartile volume groups. In the multivariate analysis, only physician volume was significantly associated with early mortality rate. The physician volume of the highest quartile was a protective factor for early mortality compared with the physician volume of the lowest quartile (HR 0.10, 95% CI 0.02-0.65). Hospital characteristics were not associated with early mortality. In the sensitivity analyses, the results remained consistent using two other different definitions of early mortality. Higher physician volume was independently associated with lower early mortality, while hospital volume was not. Enhancing the clinical expertise of low-volume physicians may ensure better outcomes.

Application of iron oxide nanoparticles in the diagnosis and treatment of leukemia

Leukemia is a malignancy initiated by uncontrolled proliferation of hematopoietic stem cell from the B and T lineages, resulting in destruction of hematopoietic system. The conventional leukemia treatments induce severe toxic and a long series of unwanted side-effects which are caused by lack of specificity of anti-leukemic drugs. Recently, nanotechnology have shown tremendous application and clinical impact with respect to diagnosis and treatment of leukemia. According to considerable researches in the context of finding new nanotechnological platform, iron oxide nanoparticles have been gained increasing attention for the leukemia patients use. In this review, a short introduction of leukemia is described followed by the evaluation of the current approaches of iron oxide nanoparticles applied in the leukemia detection and treatment. The enormous advantages of iron oxide nanoparticles for leukemia have been discussed, which consist of the detection of magnetic resonance imaging (MRI) as efficient contrast agents, magnetic biosensors and targeted delivery of anti-leukemia drugs by coating different targeting moieties. In addition, this paper will briefly describe the application of iron oxide nanoparticles in the combined treatment of leukemia. Finally, the shortcomings of the current applications of iron-based nanoparticles in leukemia diagnosis and treatment will be discussed in particular.

Preferences of adults with cancer for systemic cancer treatment: do preferences differ based on age?

Background: We used the Therapy Preference Scale, a 30-item questionnaire, to determine cancer treatment preferences of adults with cancer. Methods: We used Wilcoxon's rank sum test and Fisher's exact test to compare the preferences of younger (<60 years) versus older adults (≥60 years). Results: While 56% of patients would accept treatment offering increased life expectancy at an expense of short-term side effects, 75% preferred maintenance of cognition, functional ability and quality of life to quantity of days. Oral instead of intravenous treatment (p = 0.003), shorter hospital stay (p = 0.03), preservation of cognitive function (p = 0.01) and avoidance of pain (p = 0.02) were more important to older patients compared with younger patients. Conclusion: Many patients prioritized maintenance of cognition, functional ability and quality of life; older patients valued oral treatment, shorter hospital stay, preservation of cognitive function and avoidance of pain.

Determination of fitness and therapeutic options in older patients with acute myeloid leukemia

Treatment of older patients with AML remains challenging. Although age, performance status, and comorbidities are commonly employed to determine fitness for intensive treatment, several studies have demonstrated improved outcomes with treatment in older and classically unfit patients, highlighting the importance of other disease-related and patient-related factors that have prognostic value for treatment outcome in AML. However, consistent and objective assessments for fitness are lacking. Multi-parameter geriatric assessment tools offer more comprehensive evaluation, but are limited by the required resources and lack of standardization and consensus regarding prognostic value. These assessments are particularly important considering the emerging new AML therapies that represent a spectrum of intensities. Patients should therefore be evaluated holistically for fitness to receive a specific treatment, with the aim of providing individualized care, and such definitions of fitness should also consistently be applied to clinical trials. This review will examine evolving criteria for the determination of fitness among AML patients and discuss treatment options for older and/or unfit patients with AML.

Usefulness of Charlson Comorbidity Index to Predict Early Mortality and Overall Survival in Older Patients With Acute Myeloid Leukemia

INTRODUCTION

Older adults with acute myeloid leukemia (AML) often have significant comorbidities. We hypothesized that greater comorbidity burden predicts worse 1-month mortality and overall survival (OS) in patients ≥60 years with AML.

MATERIALS AND METHODS

We included 50,668 patients ≥60 years diagnosed between 2004 and 2014 from the National Cancer Database; patients were divided into 3 groups with Charlson comorbidity index (CCI) 0, 1, and ≥2. Chi-square tests were used to examine the association between CCI and different variables. We used logistic regression and Cox proportional hazard models to determine predictors of 1-month mortality and OS, respectively.

RESULTS

Among the entire cohort, 65% had CCI 0, 24% had CCI 1, and 11% had CCI ≥2. Thirty-four percent did not receive chemotherapy. Patients with CCI 0 were more likely to receive chemotherapy, especially multiagent chemotherapy and undergo upfront hematopoietic cell transplantation. In multivariate analyses, 1-month mortality and OS were significantly worse with CCI 1 or ≥2, compared with CCI 0 in the entire cohort, as the subgroup of only those patients who received chemotherapy. Younger age, male gender, higher annual income, academic facility, longer travel distance, and acute promyelocytic leukemia were associated with improved OS.

CONCLUSION

In one of the largest real-world studies of older adults with AML, we demonstrated that greater comorbidity, measured by higher CCI, independently predicted worse early mortality and OS in older patients with AML. Higher CCI was more common with increasing age and correlated with lower likelihood of receiving chemotherapy and hematopoietic cell transplantation. Whether optimal comorbidity management and supportive care may improve outcomes needs to be studied further.

Ivosidenib – Another Feather in the Hat of Treatment for Acute Myeloid Leukemia

The treatment of acute myeloid leukemia has undergone a paradigm shift in the past few years. Multiple new targeted and nontargeted agents have been approved in the recent past. Isocitrate dehydrogenase (IDH) mutation is one such target that has been identified, and two new drugs, ivosidenib and enasidenib have been approved. The former is an IDH1 inhibitor, and the latter is an IDH2 inhibitor. The mechanism of action, key trials, adverse events, and monitoring of ivosidenib has been discussed in this article.