An Analysis of Treatment Choices for Acute Myeloid Leukemia in Patients 60 Years and Older from the University of Duesseldorf AML/MDS Database.
Authors: Klaerner Viola , Kuendgen Andrea , De Porre Peter , Hildebrandt Barbara , Haas Rainer , Gattermann Norbert , Germing Ulrich 
Published: October 2019

Abstract
Treatment choices for elderly patients (pts) with acute myeloid leukemia (AML) were assessed through a retrospective analysis of 705 pts aged ≥ 60 years (yrs), diagnosed between January 1986 and December 2005. The treatments administered to pts were grouped into three categories: best supportive care (BSC), combination induction chemotherapies including high dose ara-C (HDT), and low-intensity single-agent therapies (LDT; approx. 50% were low-dose ara-C, others included valproic acid, thalidomide, lenalidomide, decitabine, 5-azacytadine, gemcitabine and etoposide). The reviewed AML population consisted of 57% of pts aged 60–69 yrs, 17% 70–74 yrs and 26% ≥75 yrs; median age at baseline was 70 yrs. Overall, 41% of pts had antecedent MDS, and 75% had a bone marrow (BM) blast count of 20–30% at baseline. Of the 705 pts 56.5% who received BSC, 33.2% were treated with HDT and 10.4% with LDT. Age was shown to strongly influence the choice of treatment. The use of HDT dropped significantly from 57.6% for pts <65 yrs old to 24.2% for patient 70 to 74 yrs. At ≥75 yrs, 89.2% of the pts received BSC, only 4.3% received HDT, and 6.5% received LDT. Antecedent MDS was another important factor influencing treatment choices. In the age group 60 to 69 yrs, HDT treatments dropped from 67.1% in pts with no prior history of MDS to 28.9% in pts with a history of MDS. For pts ≥70 yrs, there was a clear drop in administration of HDT from 21.8% to 2.1% respectively. A third factor impacting on treatment choice was BM blast percentage. The majority of pts with a baseline BM blast count of over 30% were treated with HDT regardless of age, but the proportion decreased from 86.4% in pts <70 yrs of age to 54.2% in the age group ≥70 yrs, with a corresponding increase in BSC treatment. In contrast, 84.2% of pts 70 yrs and older with a blast count of 20–30% were treated with BSC. An unfavorable karyotype is also considered to be an adverse prognostic variable. However, karyotype exhibited an influence on treatment choice only in the group of pts 70 yrs and older, where 41.3% of pts with not unfavourable karyotype vs 19.6% with unfavourable karyotype received intensive chemotherapy. The median overall survival based upon treatment type, age or prior MDS shows that pts receiving either HDT(<70 yrs 9.93 month (mth); ≥70 yrs 7.9 mth; prior MDS 5.54 mth) or LDT (<70 yrs 10.62 mth; ≥70 yrs 6.39 mth; prior MDS 6.1 mth) survived significantly longer than those treated with BSC only (<70 yrs 4.03 mth; ≥70 yrs 2.56 mth; prior MDS 1.21 mth). Interestingly the analysis showed not much difference in median overall survival for pts treated with HDT (9.67 mth) vs LDT (9.54 mth). However, the number of pts for LDT is too small to make statistically relevant conclusions. One reason for the extremely poor outcome in pts treated with BSC might be a worse performance status compared with pts treated with chemotherapies. In summary, treatment choices are affected by age, BM blast count and a history of prior MDS. In the future, according to newer data from several groups, karyotype will presumably gain more importance for the selection of treatment. The analysis indicated that BSC was a major treatment option for elderly AML pts. However results show very poor overall survival for untreated AML pts, justifying the use of new agents to improve outcome in this subgroup.