ASH issues new guidelines on treatment of AML for older adults
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New guidelines issued by ASH and published in Blood Advances aim to support patients, clinicians and other health care professionals in their decisions about treatment for older adults with acute myeloid leukemia.
“This is a particularly vulnerable population, given their poor outcomes with even the most aggressive therapies and mitigating circumstances that may affect treatment choices and outcomes, including other serious medical conditions, adverse risk factors that make treatment less effective, and goals of therapy,” Mikkael A. Sekeres, MD, MS, director of the leukemia program in the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute, told Healio. “These are the first set of treatment guidelines for older adults with AML that focus deliberately on patient decision-making and goals, and take both patients and their health care providers through the real-time steps in decisions patients have to make about their treatment.”
ASH, with support of the McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre, assigned a task force to address critical questions that mirror real-time practitioner-patient conversations in the management of adults aged 55 years or older with AML. These critical questions included use of antileukemic treatment vs. best supportive management, indications for treatment intensity, the role and duration of post-remission therapy, combination therapy vs. monotherapy for induction treatment and beyond, the duration of less-intensive therapy and the role of blood transfusion for patients no longer receiving antileukemic therapy.
The task force strongly recommended antileukemic therapy vs. best supportive care for older adults with newly diagnosed leukemia who are candidates for such therapy. It recommended intensive antileukemic therapy, rather than less-intensive antileukemic therapy, for patients who can tolerate it.
The task force advised post-remission therapy vs. no additional therapy for patients who achieve remission after at least one cycle of intensive antileukemic therapy and are not candidates for allogeneic hematopoietic stem cell transplantation. The guidelines recommended two cycles of intensive antileukemic therapy even if patients achieve remission after the first cycle — the task force considers the second cycle of intensive therapy as post-remission therapy.
For patients eligible for antileukemic therapy but not intensive antileukemic therapy, the task force recommended monotherapy with either a hypomethylating agent or low-dose cytarabine. Those who respond may continue this less-intensive therapy rather than discontinuing therapy at the time of response, according to the guidelines. However, the task force acknowledged that combination therapy, including low-dose cytarabine plus glasdegib (Daurismo, Pfizer) or hypomethylating agents or low-dose cytarabine plus venetoclax (Venclexta; AbbVie, Genentech), has demonstrated efficacy, and that this recommendation may change based upon upcoming results of randomized trials.
The final recommendation suggested red blood cell transfusions as a standard of care that should be given when patients transition to palliative care or hospice.
“These guidelines are structured to assist clinicians in the conversations they have with patients at every step of treatment consideration, and encourage ongoing discussions about patient goals of care,” Sekeres told Healio. “As only approximately half of older adults with AML are offered any treatment at all, the guidelines encourage practitioners to at least have a discussion about treatment options with their patients, and continue to support patients with blood transfusion through palliative care and hospice settings.”
For more information:
Mikkael A. Sekeres, MD, can be reached at Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195; email: sekerem@ccf.org.
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