Many doctors who treat leukemia are perplexed about the designation of patients as “elderly” at age 60 or 65. This is not infrequently the age of their doctor, who might not like to imagine himself or herself in a higher-risk category or kept from curative therapy.
The median age of developing acute myeloid leukemia (AML) is around 67, when cardiac, pulmonary, renal, and every other function may be compromised and potential contributors to morbidity, or not. Doctors who’ve seen durable remission in patients over 70 and far too many deaths in teens and young adults, wonder if a birthdate may triage new patients away from optimal care.
Several recently published articles should interest doctors seeking help in making treatment decisions with the older AML patient. Even before I point to the scholarly reviews, interesting data that provide real-life context come from analysis of Medicare claims for 2013 by Dr Michael Thompson and colleagues.1 These researchers found that 90% of beneficiaries over 65 with AML were seen in low-volume hospitals (fewer than 8 cases per year) and only 7.3% in high- or highest-volume ones (8-129 cases per year).
Mortality at 30 days and 1 year were significantly lower in high-volume hospitals, though still appreciable, at 28% and 70%. Chemotherapy was given to only 14% of patients in low-volume hospitals. These data presumably exclude many patients transferred after diagnosis to higher-volume centers for treatment. Such data highlight that triage patterns, hospital experience, and transfer delays should be considered among the many variables that may affect success of treatment.
An article by Dr Elihu Estey (with CME credit available) reviews the contributions of molecular characteristics, including mutations on outcomes in older adults and reported results of intensive treatments including transplants.2 These data come from large institutions or cooperative protocol studies where extensive genetic evaluation is possible.
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For the patient considered unfit for intensive treatment, an excellent thorough review of options by Dr Harry Erba was published last year, available open access.3 The expertise of Doctors Estey and Erba, like those at major “large-volume” cancer centers, is accessible to any doctor with a phone or email in need of additional help when making the difficult decisions for patients of or above the median age of AML.
- Thompson MP, Waters TM, Kaplan EK, McKillop CN, Martin MG. Hospital volume and acute myeloid leukemia mortality in Medicare beneficiaries aged 65 and older. Blood. 2016 Jun 29. doi: 10.1182/blood-2016-05-716662 [Epub ahead of print]
- Estey E. Acute myeloid leukemia: 2016 Update on risk-stratification and management. Am J Hematol. 2016;91(8):824-46. doi: 10.1002/ajh.24439
- Erba HP. Finding the optimal combination therapy for the treatment of newly diagnosed AML in older patients unfit for intensive therapy. Leuk Res. 2015;39(2):183-91. doi: 10.1016/j.leukres.2014.11.027