Personalizing treatment for older adults with hematologic malignancies is key to ensuring optimal care is provided to patients. Different considerations exist when higher intensity therapies are delivered to elderly patient populations, particularly from the perspective of toxicity. Best practices surrounding the use of these therapies are constantly evolving.
In a review published in Blood, Rebecca L Olin, MD, of the department of medicine at the University of California San Francisco, summarized current literature surrounding best practices related to the use of allogeneic hematopoietic cell transplantation (HCT), autologous HCT, and acute myeloid leukemia (AML) induction chemotherapy in older adults with hematologic cancers. In addition, she reviewed current evidence on the use of chimeric antigen receptor T-cell (CAR-T) therapy in older patients.
Evaluating Candidacy for AML Induction Chemotherapy
Age definitions can differ substantially across various malignancies, with classifications often determined by the specific type of cancer. In general, the definition of an “older patient” is higher in the solid tumor malignancies (older than 70 years) compared with hematologic cancers (older than 60 years).
Several factors need to be considered when choosing optimal therapy for older patients. For example, the administration of high intensity induction chemotherapy often requires extended hospitalization due to prolonged periods of myelosuppression. Other considerations include patient-specific factors, such as the presence of comorbidities, that may require additional supportive care interventions. Current eligibility algorithms for AML induction chemotherapy incorporate multiple parameters, including performance status, cytogenetics, and chronologic age.
Although these tools can be helpful, each algorithm has its own unique limitations. Common examples include an overreliance on cytogenetic data, or the inclusion of nonquantifiable surrogate measures. As a result, widespread adoption of these decision-making tools has not yet occurred. Aside from comorbidities and performance status, physical function, which often measured subjectively through instrumental activities of daily living (IADL) or patient-reported activities of daily living (ADL), is the geriatric domain with the greatest prognostic value for induction chemotherapy.