Is outcome of older people with acute myeloid leukemia improving with new therapeutic approaches and stem cell transplantation?

ABSTRACT

Introduction: The clinical outcome of older patients with acute myeloid leukemia (AML) is still poor, especially for those who are unfit to treatments aimed at altering the natural course of the disease. Hypomethylating agents (HMA) offer an important therapeutic opportunity to a consistent number of patients, but long-term results are largely unsatisfactory.

Area covered: Recently, a number of new agents have been registered for AML, some of which selectively available for older patient population, with promising results in terms of response rate and survival. Furthermore, the upper age limit for allogeneic stem cell transplantation is constantly increasing, so that this procedure is offered and actually given to an increasing number of older patients with AML. A literature review was conducted of the PubMed database for articles published in English as well as for abstracts from most important and recent hematology meetings on AML in older patients.

Expert opinion: Appropriate selection among different options on the basis of clinical fitness and molecular findings at diagnosis as well as at relapse would result in improvement of therapeutic results, sparing unnecessary toxicity and optimizing health systems resources.

KEYWORDS:

• Acute myeloid leukemia
• older patients
• new drugs
• allogeneic stem cell transplantation
• geriatric assessment

Article highlights

• The clinical outcome of older patients with AML remains poor, particularly in patients presenting with unfavorable genetic and molecular findings at presentation or in those judged as unfit to receive intensive chemotherapy.

• Currently, older patients with AML have more treatment options than ever before, either at diagnosis or relapse, following introduction in the daily practice of new genomically and non-genomically oriented new agents.

• Impressive results have been reported following combinations of venetoclax plus HMA and, at less extent, of ven plus LDAC, so that ven/HMA is coming to represent the new standard of care for older unfit patients with AML.

• The upper age limit for eligibility to allo-SCT is continuously increasing, and the procedure is currently offered up to 75 years. Comparable long-term outcome after allo-SCT from sibling and matched unrelated donors in patients older than 50 years have been recently reported; in addition, availability of haploidentical donors is expected to broad the number of potential donors.

• Research on maintenance treatment after chemotherapy or allo-SCT is actively ongoing and CC-486, an oral formulation of azacytidine has been already demonstrated as able to prolong relapse free and OS in older patients with AML.

• The emergence of immunotherapy as a powerful weapon to treat other hematologic malignancies has spurred the exploration of the immune landscape of AML to apply new immunotherapeutic approaches.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.