Outcomes of Elderly Patients with AML in the Hamilton Area: How Are We Doing?
Authors: Kukaswadia Sadiya , Hsu Tina , Wasi Parveen 
Published: April 2020

Acute myeloid leukemia (AML) is the most common form of leukemia amongst adults. Elderly patients (i.e. over the age of 60) with AML consistently have poorer outcomes than their younger counterparts and very few guidelines exist on the optimal management of AML in this population. A retrospective chart review of patients 60 years of age or older diagnosed with AML was conducted to better define this population, identify biological and patient characteristics that predict outcomes with treatment, and determine factors influencing management decisions. A total of 142 patients diagnosed with AML between April 2002 and April 2007 were included. Patients were analyzed together, as well as in pre-specified age groups (60–65, 66–75, and &gt;75 years). Patients ranged from 60 to 92 years old, with a median of 70 years. Very few patients had a favorable cytogenetic profile (3.5%) at the time of diagnosis (Table 1). In addition, 41.5% of patients had a preceding hematologic diagnosis. Of these, 61.0% had pre-existing myelodysplastic syndrome and 16.9% had chronic myeloid leukemia. The proportion of patients with secondary transformation increased with age (age 60–65 −25%; 65–75 −39%; &gt;75 – 51.3%). Over 60% of patients were induced, with younger patients opting for induction more often (age 60–65 − 88.6%; 65–75 − 66.1%; &gt;75 – 20.5%). The most commonly cited reasons for not treating were the presence of comorbidities (32.1%), patient preference (26.8%), age (17.9%), and preceding hematological conditions (16.1%). Only 25% of those treated were able to complete the entire course of treatment. Despite this, more than half (58.1%) of patients were able to attain remission. As expected, overall survival was dismal across all age groups with 10.6% surviving to one year. Median survival was 2 months with survival decreasing with increasing age (Table 2). With treatment one year survival increased to 15.1% with a median survival of 3.75 months (treated vs. untreated - 15.1% vs. 3.6%, p &lt;0.005). This result was largely driven by survival in the 60–65 year age group, in whom those treated did significantly better than those who were not (1 year survival 20.5% vs. 0%, p &lt;0.005; median 6 vs. 0.18 months). In terms of economic resources, patients who were induced had significantly more outpatient appointments (22.2 vs. 6.4, p &lt;0.0001), hospital days (58.8 vs. 11.6, p &lt;0.0001), and used more blood products (65.7 vs. 12.1, p &lt;0.001), presumably due to increased survival in those who were treated. This dramatic difference between those treated and those who were palliated was seen both in patients age 60–65 and 66–75, but was markedly attenuated in patients older than 75. Our findings are consistent with previous studies. Elderly patients with AML do poorly, with worsening outcomes with increasing age, and survival that is measured in months. This may be due to the increasing prevalence of patients with preceding hematological disorders and secondary transformation with age, as well as poor cytogenetic profiles of this population. In addition, as age and comorbidities increase, more patients opt out of induction chemotherapy. Further research is needed to establish optimal management and improve outcomes of elderly patients with AML.

Table 1: Cytogenetics

All patients (n; % of patients) Age 60–65 years (n; % of patients) Age 66–75 years (n; % of patients) Age 76 years and greater (n; % of patients) No of Patients 142 44 59 39 Cytogenetics Unknown 40 (28.2%) 10 (22.7%) 11 (18.6%) 19 (48.7%) Favourable 5 (3.5%) 1 (2.3%) 2 (3.5%) 2 (5.1%) 12 Intermediate 59 (41.5%) 23 (52.3%) 24 (40.7%) (30.8%) 6 Unfavourable 38 (26.8%) 10 (22.7%) 22(37.3%) (15.4%)

Table 2: Survival Rates

All patients (n; % of patients) Age 60–65 years (n; % of patients) Age 66–75 years (n; % of patients) Age 76 years and greater (n; % of patients 1 year survival 15 (10.6%) 8 (18.2%) 5 (8.5%) 2 (5.1%) All 2/56 (3.6%) 0/5 (0%) 1/20 (5.0%) 1/31 (3.2%) Untreated 13/86 (15.1%) 8/39 (20.5%) 4/39 (10.3%) 1/8 (12.5%) Treated (p = 0.004) (p = 0.003) (p = 0.41) (p = 0.23) Median survival (months) 2 3 2 1 All 1 5.5 days 1.5 1 Untreated 3.75 2 6 2.9 Treated Lost to Follow Up 52 (36.3%) 17 (38.6%) 24 (40.7%) 11 (28.2%)