In 2020 guidelines intended to support patients, clinicians, and other health care professionals and decision-makers, the American Society of Hematology (ASH) provided evidence-based recommendations for older adults with newly diagnosed acute myeloid leukemia (AML).1 The guidelines were developed to help patients from diagnosis through post-remission therapy, and end-of-life and hospice care.
While an average adult aged 75 years living in the United States may live for dozens of more years, with about a 96% chance of being alive in 1 year, an adult of the same age with AML has an average life expectancy measured just in months. Only 1 in 5 older adults with AML will survive after 1 year, and there is less than 4% chance of 3-year survival. For adults aged 65 to 74 years, the prognosis is only slightly superior. “Thus, on average, being diagnosed with AML at age 65 years or older in the United Stated means dying a decade too soon,” the guideline authors wrote.
In the development of these guidelines, the members of the panel mainly focused on helping clinicians with decision-making and treatment alternatives by using 6 critical questions for the management of AML in older adults. Questions involved the pursuit of antileukemic treatment vs best supportive management, therapy intensity, the role and duration of postremission therapy, combination vs monotherapy for induction and beyond, duration of less-intensive therapy, and the role of transfusion support for patients no longer receiving antileukemic therapy.
The following are the questions and recommendations provided by the ASH panel for the treatment of older patients with newly diagnosed AML.
Question 1: Should older adults with newly diagnosed AML who are candidates for antileukemic therapy be offered antileukemic therapy instead of best supportive care only?
Recommendation 1: Based on moderate certainty in the evidence of effects, the ASH guideline panel recommends offering antileukemic therapy over best supportive care to older adults with newly diagnosed AML who are candidates for such therapy.
Question 2: Should older adults with newly diagnosed AML who are considered candidates for antileukemic therapy receive intensive antileukemic therapy vs less-intensive antileukemic therapy?
Recommendation 2: Based on low certainty, the ASH guideline panel conditionally recommends intensive antileukemic therapy over less-intensive antileukemic therapy in this patient population.
Question 3: Should older adults with newly diagnosed AML who achieve remission after at least 1 cycle of intensive antileukemic therapy receive postremission therapy vs no additional therapy?
Recommendation 3: Based on low certainty in the evidence of effects, the panel conditionally recommends postremission therapy over no additional therapy for patients who achieve remission after at least 1 cycle of intensive antileukemic therapy and who are not candidates for allogeneic hematopoietic stem cell transplantation. The guideline authors also noted that in some settings, patients may receive 2 cycles of intensive antileukemic therapy even after achieving remission with the first one. For such cases, they recommend the second cycle of intensive therapy by postremission therapy.