AML in the elderly: a different entity, a different treatment.

Professor Gert Ossenkoppele an expert in acute myeloid leukemia (AML) started his presentation by confirming that patients with this type of cancer have a median age of 70. With regard to overall survival in elderly patients, age is a bad prognostic factor and very little improvement has been seen over the last 30 years. Many clinicians are wary about using intensive chemotherapy in elderly AML patients it is toxic. However improvements in supportive care have not really changed the outcomes for patients with AML over age 65.

Intensive induction chemotherapy with conventional or with myelosuppressive novel therapy is more likely to induce remission than low-dose therapies

He went on to explain that the biology of AML in an elderly patient is quite different from that of a young individual. In fact the data from microarray-based assays, used to uncover the molecular distinctions between AML subtypes, demonstrated that there are clear differences between AML presenting in an elderly patient compared to a younger one (chromosome abnormalities, deletions, Multi-Drug Resistance etc). These molecular signatures will form the basis of diagnosis, prognostication and treatment in AML patients and especially in elderly patients.

The different biology and clinical behaviors of AML at older age pose some crucial questions about the most appropriate clinical management of this disease. First, should AML in elderly patients be treated with intensive or less intensive therapy? In most clinical studies the CR rate in patients treated with intensive therapy has been similar, around 65% which is a very good response rate. In one Swedish study it was shown that intensive therapy actually increased overall survival. “Of course this depends on other prognostic factors such as karyotype and performance score” said Professor Gert Ossenkoppele, “ the more negative prognostic factors presenting the worst it is”

So in summary Professor Gert Ossenkoppele made the following recommendations:

1. Avoid therapeutic nihilism
2. Intensive therapy should be offered even to patients of an older age
3. Reduced Intensity Conditioning RIC allogeneic stem cell transplantation (allo-SCT) is a feasible and potential therapy that should be considered
4. Put elderly patients into trials
5. If unfit for intensive therapy opt for:
   1. Supportive care
   2. Phase I/II studies (new drugs)