Impairment in functional status and survival in patients with acute myeloid leukaemia

Wedding, Ulrich; Röhrig, Bernd; Klippstein, Almuth; Fricke, Hans-Joerg; Sayer, Herbert G.; Höffken, K.

doi:10.1007/s00432-006-0115-7

Cited by 85 publications

(60 citation statements)

References 20 publications

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“…[13][14][15][16] Wedding et al found that impairment of instrumental activities of daily living was the single most predictive variable of survival in their sample of AML patients ages 19-85 years (median 61.1). 13 The ability to perform tasks necessary to live independently in the community, that is, shopping, food preparation, housekeeping, laundry, transportation, handling finances and medication bears most importantly on the survival of older adults. Muffly et al 15 found that the presence of slow walking speed and low mental health before transplant also have prognostic value for poorer survival.…”

Section: Functional Considerationsmentioning

confidence: 99%

Process of allogeneic hematopoietic cell transplantation decision making for older adults

Randall

Keven

Atlı

et al. 2015

Bone Marrow Transplant

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Allogeneic hematopoietic cell transplantation (alloHCT) may be the only curative option for some older adults with hematologic malignancies, and its associated risks of significant morbidity and mortality warrant a clear, informed decision-making process. As older adults have not been transplanted routinely until recent years, younger people have been the prototypical group around whom the current process has developed. Yet, this process is applied to older adults who have different considerations than younger patients when making their transplant decision. Older adults do not have the open-ended lives of younger patients and are entitled to consider how to spend their remaining time. They also possess maturity and experience, and with proper knowledge, they can make informed choices rather than moving forward in the transplant process unaware. Notably, older patients face similar problems with the informed decision-making process in nephrology. Strategies such as providing education about alloHCT gradually and repeatedly during induction, presenting recent knowledge from the literature in plain language, and utilizing a team approach to patient education may help older adults make the best decision about transplant in light of their situation and values. Understanding when and how older adults decide on alloHCT is an important first step to further exploring this problem.

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Section: Functional Considerationsmentioning

confidence: 99%

Process of allogeneic hematopoietic cell transplantation decision making for older adults

Randall

Keven

Atlı

et al. 2015

Bone Marrow Transplant

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“…Reported studies indicate that although age is important, performance status, associated comorbidities and impairment of functional status have a greater impact on survival. 12,13 Instrumental activities of daily living (IADL) was used for analyzing the functional status of 63 AML patients (median age 61.1, with a range of 19-85 years). 12 IADL was the single most predictive variable (hazard ratio (HR): 4.3, 95% confidence interval (CI) 1.7-10.5, P ¼ 0.001) on survival.…”

Section: Induction Therapymentioning

confidence: 99%

“…12,13 Instrumental activities of daily living (IADL) was used for analyzing the functional status of 63 AML patients (median age 61.1, with a range of 19-85 years). 12 IADL was the single most predictive variable (hazard ratio (HR): 4.3, 95% confidence interval (CI) 1.7-10.5, P ¼ 0.001) on survival. Although Karnofsky performance status (PS) (HR: 4.8, 95% CI 1.9-12.3, P ¼ 0.001) and an unfavorable cytogenetic risk group (HR:6.0, 95% CI 2.5-14.3, Po0.001) were significantly associated with survival, age did not independently affect survival.…”

Section: Induction Therapymentioning

confidence: 99%

“…15 Higher HCT-CI scores are associated with higher mortality. 12,[16][17][18][19] An MDACC study in 177 elderly AML patients (age 460) showed that early date rates were 3%, 11%, and 29% in patients with HCT-CI scores of 0 (n ¼ 39), 1-2 (n ¼ 53) and X3 (n ¼ 85) (Po0.001), respectively. Median OS was inversely affected by higher HCT-CI scores (median OS was 45, 31 and 19 weeks in these three groups, P ¼ 0.04).…”

Section: Induction Therapymentioning

confidence: 99%

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To transplant or not: a dilemma for treatment of elderly AML patients in the twenty-first century

Üstün

Lazarus

Weisdorf

2013

Bone Marrow Transplant

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AML treatment presents significant challenges in the elderly, who more often have poor risk cytogenetic and molecular markers, comorbidities and compromised performance status. Although population-based studies indicate that treated patients' survival is better than those who are not treated, there is an understandable reluctance of physicians to choose aggressive therapy. Even in this older population 40-60% CR rates are achievable. Several scoring systems and web-based programs help to predict TRM and CR rates. These sources can assist physicians in the difficult decision-making process of aggressive therapy in an individual patient. Clofarabine and hypomethylating agents are reasonable options and can induce CR in patients who cannot receive standard induction with anthracyclines and cytarabine. Despite encouraging CR rates, median survival remains short (o12 months) in elderly AML patients. Even those patients achieving CR have limited long-term survival (B20% at 3 years) without allogeneic hematopoietic cell transplantation (alloHCT). AlloHCT is feasible and can provide approximately 40% survival at 2 years in appropriately selected patients. Although increased age is associated with poorer survival, higher comorbidities and poor performance status have more negative impact than age per se. The short duration of CR demands that leukemia and transplant physicians collaborate immediately after diagnosis to move quickly toward alloHCT. This collaboration is also essential to choosing the right individuals to transplant and to bridging post-remission therapy (intermediate-dose cytarabine, a hypomethylating agent or FLT-3 inhibitor) in this sometimes frail population. Future studies should be designed not only to address who should receive alloHCT, but also to improve our understanding of AML biology and the process of its cure.

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“…22 In another study, patients who reported needing assistance with instrumental activities of daily living at diagnosis had decreased survival, independent of age and KPS. 23 These data suggest that simple standardized measures to assess functional status can enhance the pretreatment evaluation for older adults. Further details on functional assessment will be described in the section on geriatric assessment (GA).…”

Section: Performance Status Strengths and Limitationsmentioning

confidence: 99%

Geriatric perspective: how to assess fitness for chemotherapy in acute myeloid leukemia

Klepin

2014

Hematology

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Characterizing "fitness" in the context of therapeutic decisions for older adults with acute myeloid leukemia (AML) is challenging. Available evidence is strongest in identifying those older adults who are frail at the time of diagnosis by characterizing performance status and comorbidity burden. However, many older adults with adequate performance status and absence of major comorbidity are "vulnerable" and may experience clinical and functional decline when stressed with intensive therapies. More refined assessments are needed to differentiate between fit and vulnerable older adults regardless of chronologic age. Geriatric assessment has been shown to add information to routine oncology assessment and improve risk stratification for older adults with AML. This review highlights available evidence for assessment of "fitness" among older adults diagnosed with AML and discusses future treatment and research implications. Learning Objective• To recognize patient characteristics that influence treatment tolerance for older adults receiving chemotherapy for AMLThe majority of patients with acute myeloid leukemia (AML) are age 65 or older, with approximately one-third of patients Ն75 years of age at diagnosis. 1 Despite this, the optimal treatment for older patients remains unclear. Compared with middle-aged patients, older adults (typically defined as Ն60 or 65 years) experience shortened survival and increased treatment-associated morbidity. [1][2][3] For example, population-based data from the United States (Surveillance Epidemiology End Results, SEER) highlight the age-related survival disparity. Rates of 5-year survival from time of diagnosis decline from 39% to 8.5% to Ͻ2% for people Ͻ65, 65-74, and Ն75 years of age, respectively. 1 Older adults are more likely to experience treatment-related death than younger patients, ranging from 10% to 30% in many clinical trials. [2][3][4] Chronologic age, however, is a surrogate measure for both changes in tumor biology (conferring treatment resistance) and patient characteristics (affecting treatment tolerance). Both tumor biology and physiologic reserve vary widely among older adults of similar chronologic age, necessitating individualized assessment strategies. Controversy of intensive therapy for older adults with AMLConcerns regarding efficacy and toxicity of standard treatments have resulted in Ͻ40% of older adults receiving chemotherapy for AML in the United States. 5 Despite poor outcomes for older adults in aggregate, clinical trial and observational data show that chemotherapy can improve survival for selected patients, even those Ͼ80 years of age. 4-7 A landmark study comparing intensive induction in a randomized fashion to supportive care demonstrated a small but measurable survival advantage for patients 65 years of age and older. 4 Survival has improved over time in both observational data and clinical trials, although the magnitude of improvement declines with increased age. 1,5,[8][9][10][11] Observational data also suggest that the effect of induction th...

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Impairment in functional status and survival in patients with acute myeloid leukaemia

Cited by 85 publications

References 20 publications

Process of allogeneic hematopoietic cell transplantation decision making for older adults

Process of allogeneic hematopoietic cell transplantation decision making for older adults

To transplant or not: a dilemma for treatment of elderly AML patients in the twenty-first century

Geriatric perspective: how to assess fitness for chemotherapy in acute myeloid leukemia

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