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Comparing front-line therapies in older AML patients
overall survival.11 It should be noted that, despite these survival differences, the SEER registries lacked functional and cytogenetic data, thus limiting applicability of these results. In our analysis, 79.3% of patients had an ECOG performance status of 0 or 1, and only 13.4% of patients had a high CCI of ≥3. The fact that most of our patients had good performance status or low CCI could account for the increased tolerability to induction chemotherapy, therefore conferring an additional survival advantage to treatment compared with supportive care or low-intensity treatment. On the other hand, Juliusson et al. demonstrat- ed in a leukemia registry that even older patients with poor performance status seemed to benefit from chemotherapy compared with best supportive care.20
Although the need for quality of life (QOL) assessments before and after treatment are well recognized in AML, and may represent an important outcome measure, cur- rently, clinical trials mainly focus on quantitative assess- ments of life rather than qualitative. Geriatric assessments in combination with conventional clinical and disease- specific factors can accurately predict vulnerability to treatment toxicity; however, such assessment models spe- cific to AML are lacking.39 Oliva et al. reported a study on elderly AML patients in which QOL physical functioning was of prognostic relevance; however, these results did not correlate with physician-assessed ECOG performance status.40 As shown previously, even hematologic improve- ments from reduction in transfusions can lead to improved
QOL.41,42 Although QOL is an important measure of treat- ment outcomes, our study did not capture such informa- tion, posing a limitation regarding the effects of treatment options on QOL. Therefore, prospective studies regarding whether HMA treatment versus intensive chemotherapy can improve QOL are warranted to assess this vital com- ponent of AML care.
In conclusion, as shown in our analysis of a large patient cohort, patients over the age of 70 years with AML had a significant survival benefit with HMA or high-intensity therapy compared with supportive care or low-intensity therapy. Moreover, patients who were treated with HMA showed a striking survival advantage over those who received traditional high-intensity therapy. Because of the present lack of a clear decision model to allow for compar- ing treatments more objectively, elderly patients with AML may receive suboptimal treatment. The results pre- sented here contribute to an ongoing effort to design a comprehensive decision analysis model comparing treat- ment effectiveness to baseline characteristics in elderly patients with AML.
Funding
This work was supported by National Institutes of Cancer grant 5R01CA168677-02 (PI – Martine Extermann, MD, PhD) and in part by the Biostatistics Core Facility at the Moffitt Cancer Center & Research Institute, a National Cancer Institute-designat- ed Comprehensive Cancer Center (P30CA076292-16).
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