Acute myeloid leukemia (AML) generally develops in patients who fall into the “baby boomer” category, a group that is increasingly living longer than ever before. “The treatment of older adults with AML is extraordinarily complex because of the spectrum of treatments and varying patient care goals,” explains Mikkael A. Sekeres, MD, MS. “The intensity of treatment can range from supportive or palliative care to cytotoxic chemotherapy that necessitates a 4-to-6-week hospitalization. Patient care should focus on the goals of therapy and other factors, such as comorbidities and a balance of safety and efficacy, that go into treatment decisions.”
The American Society of Hematology (ASH) recently published guidelines for treating newly diagnosed AML in older adults. Developed in partnership with the McMaster GRADE Centre and published in Blood Advances, the guidelines offer recommendations for this vulnerable population based on systematic reviews of all available evidence (Table). They are intended to help with critical care decision making, including if and how to proceed with cancer treatment and the need for blood transfusions for those in hospice care.
“While guidelines for AML have been published by other groups, these recommendations are the first to keep the goals of care for patients front and center,” says Dr. Sekeres, who chaired of the ASH guideline panel. “They guide healthcare providers and patients through the many decisions that must be made about treatment in real time, from diagnosis until treatment is complete.” He adds that the guidelines are one of the few to be developed through a rigorous process of vetting the evidence underlying the recommendations.
According to Dr. Sekeres, the ASH panel was comprised of experts in leukemia, geriatric oncology, guideline development, epidemiology, frailty, and quality of life, representing a wide range of considerations in older adults with AML. “We initially identified about 20 questions that we felt were important to answer but winnowed these to the 6 most critical questions to guide treatment recommendations,” he says. “This included determining if an older adult with AML should be treated at all while also considering the different intensities of initial and subsequent therapies and palliative care or hospice considerations.”
If deemed appropriate based on a patient’s treatment plan, the ASH guidelines recommend chemotherapy or other treatments over supportive care. They also recommend more intensive over less intensive treatment when tolerable. Of note, the guidelines also described the clinical benefit of palliative red blood cell (RBC) transfusions for those who are no longer receiving therapy for leukemia, including those in hospice care.
“One recommendation that may seem intuitive is that older adults with AML should be offered some chemotherapy over none, if it aligns with patient goals of care,” Dr. Sekeres says. “As incredible as it may seem, about 50% of older adults with AML in the United States are never offered any chemotherapy. Another recommendation that is particularly important is that patients in a palliative care or hospice should receive RBC transfusions to improve quality of life. This should be considered standard supportive care rather than an extraordinary measure. Many hospices will not allow patients to receive any RBC transfusions, but the ASH guidelines clearly state that such practices are wrong and inappropriate.”
Weighing Risks & Benefits
The guidelines note that discussions between patients and physicians are instrumental to personalizing treatment plans in AML. They recommend collaboration to establish patient goals and wishes, paying attention to factors like side effects and risks of chemotherapy and time in the hospital. These issues must be weighed against potential benefits like remission and extended life. Such efforts can ensure that patients make appropriate treatment decisions that are consistent with their goals.
Clinicians are encouraged to visit www.hematology.org/AMLguidelines to access the complete guidelines and find more information and resources. In the meantime, Dr. Sekeres says additional research is necessary to further inform healthcare providers on the most appropriate strategies for treating newly diagnosed AML in older adults. “We need more rigorous clinical trials to compare less and more intensive treatment approaches,” he says. “We also need to define the value and precise duration of post-remission treatment in older adults with AML.”
Sekeres MA, Guyatt G, Abel G, et al. American Society of Hematology 2020 guidelines for treating newly diagnosed acute myeloid leukemia in older adults. Blood Adv. 2020;4(15):3528-3549. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7422124/.
Sekeres MA, Stone RM, Zahrieh D, et al. Decision-making and quality of life in older adults with acute myeloid leukemia or advanced myelodysplastic syndrome. Leukemia. 2004;18(4):809-816.
Grimwade D, Walker H, Harrison G, et al; Medical Research Council Adult Leukemia Working Party. The predictive value of hierarchical cytogenetic classification in older adults with acute myeloid leukemia (AML): analysis of 1065 patients entered into the United Kingdom Medical Research Council AML11 trial. Blood. 2001;98(5):1312-1320.
Pulte D, Gondos A, Brenner H. Improvements in survival of adults diagnosed with acute myeloblastic leukemia in the early 21st century. Haematologica. 2008;93(4):594-600.