How I treat older patients with ALL

Abstract

The treatment of older patients with acute lymphoblastic leukemia (ALL) is an unmet medical need. In Western countries, the population is aging, which means there will be an increasing number of older patients. However, in the past few decades, there has been little improvement in treating them, and few clinical trials specifically designed for older patients with ALL have been reported. Older patients with ALL have a significantly lower complete response rate, higher early mortality, higher relapse rate, and poorer survival compared with younger patients. This is partly explained by a higher incidence of poor prognostic factors. Most importantly, intensive chemotherapy with or without stem cell transplantation, both of which are successful in younger patients, is less well tolerated in older patients. For the future, the most promising approaches are optimized supportive care, targeted therapies, moderately intensified consolidation, and reduced-intensity stem cell transplantation. One of the most important challenges for physicians is to differentiate between fit and unfit older patients in order to offer both groups optimal treatment regarding toxicity and mortality risks, quality of life, and long-term outcome. Prospective trials for older patients with ALL are urgently needed.

Allogeneic transplantation is not superior to chemotherapy in most patients over 40 years of age with Philadelphia‐negative acute lymphoblastic leukemia in first remission

“…MRD after induction therapy is regarded as an independent predictor for survival in younger adults with ALL [32,33] and seems to be a powerful predictor for outcome in older adults [4]. Furthermore, Bassan and colleagues previously demonstrated that MRD status can assist in allocating adult patients in remission to maintenance or HSCT [34].…”

“…1 and 2; P value nonsignificant for both comparisons). The 3-year CIR and NRM were 61% [41-76] and 9% [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] for the chemotherapy-only group and 28% and 32% for the transplant group (Table II; Fig. 3; P 5 0.011 for CIR and P 5 0.014 for NRM).…”

“…The reasons for an inferior outcome in the older age group are multifactorial. Performance status and comorbidities affect patient eligibility for curative therapy and are associated with higher treatment-related mortality in those that are treated [4]. While more intensive, pediatricinspired approaches seem to have had a favorable impact on survival of young adults with ALL [5], these intense regimens cannot be safely applied in the majority of older patients [6].…”

Process of allogeneic hematopoietic cell transplantation decision making for older adults

“…These likely evolve over time and/or differ with phases of treatment, so tracking the progression of the sample over time would be important. Two key questions arise: (1) what is the patient's process; and (2) when do they decide. The answers guide the presentation of information by the HCT team and may inform novel solutions to improve the current system.…”

“…[1][2][3][4][5] For these cancers, treatment options that can be used to prolong their lives include allogeneic hematopoietic cell transplantation (alloHCT). AlloHCT may be the only curative option and its associated risks of significant morbidity and mortality warrant a clear, informed decision-making process.…”