Discussion: Geriatric Assessments
NOW FOR AN ORIGINAL PAPER ASSIGNMENT:Discussion: Geriatric Assessments
Characterizing fitness in the adult population is important when deciding treatment strategy. In particular, appropriate therapy in the elderly AML patient should be determined based on “patient-specific fitness” using geriatric assessments to determine fitness, vulnerable and frail status regardless of age [70]. In older adults, deemed not fit for intensive induction therapy especially harboring complex karyotype without NPM1 mutations, the use of hypomethylating agents including decitabine and azacitidine has shown to be beneficial [70,71,72]. Both agents, commonly used to treat myelodisplasia, have activity in AML as initial induction therapy and in the relapsed setting. Several phase II and III studies using azacitadine and decitabine have been conducted [71,72,73]. A study of 82 patients with AML, median age of 72 years, who received azacitidine
as part of a compassionate use program showed CR/incomplete CR in 11 of the 35 untreated patients (31%). The median overall response duration was 13 months with the one-year and two-years overall survival rates of 58% and 24%, respectively [73]. Blum et al. showed an even higher complete remission rate of 47% and overall response rate of 64% with 10 days of low-dose decitabine at 20 mg/m2 intravenous over 1 h [72]. This treatment was well tolerated with CR achieved in 52% of subjects presenting with CN-AML and in 50% of those with complex karyotypes [72]. Older patients receiving induction decitabine usually require a median of two to four cycles of therapy to have an optimal response.
Patients with suspected acute promyelocytic leukemia (APL) should be treated with all-trans retinoic acid (ATRA) even before the diagnosis is confirmed. Early use of ATRA decreases the risk of APL induced coagulopathy, development of disseminated intravascular coagulation (DIC) and mortality. For patients with low-to-intermediate-risk APL (WBC ≤ 10 × 109/L) outcomes are excellent with the use of ATRA with arsenic (ATO) [74]. In this non-inferiority study, the ATO-ATRA combination showed CR rates in all 77 patients (100%) and in 75 of 79 patients (95%) in the ATRA-idarubicin group.
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