A New Tool for Comprehensive Geriatric Assessment in Elderly Patients with Acute Myeloid Leukemia: A Pilot Study from China
Acute myeloid leukemia (AML) is a prevalent hematological malignancy among the elderly, with the median age at diagnosis ranging from 68 to 72 years. Approximately one-third of newly diagnosed AML patients are aged 75 years or older. Survival rates in elderly AML patients are notably lower compared to younger patients, emphasizing the need for careful management and tailored treatment strategies. Achieving complete remission (CR) is a critical endpoint for prolonged survival, and intensive induction chemotherapy (IC) has been validated as a superior approach over less-intensive therapies, even in patients aged 80 years or older. However, the clinical outcomes of IC in elderly AML patients are often compromised by comorbid conditions and increased susceptibility to therapy-related toxicities. Therefore, selecting patients who are suitable for intensive IC is crucial to improving clinical outcomes in this population.
Comprehensive geriatric assessment (CGA) has been developed by geriatricians to evaluate elderly patients, including those with cancer. CGA methods have shown promise in predicting clinical outcomes and identifying patients who may benefit from aggressive therapy. However, the tools used for CGA in AML patients are not standardized and can be complex. This study aimed to validate the instrumental activities of daily living (IADL) scales, age, comorbidities (Charlson Comorbidity Index), and albumin (IACA) index as a new tool for CGA in elderly AML patients.
The study included patients aged 60 years or older who had been diagnosed with AML at Beijing Hospital, China, between May 5, 2011, and April 30, 2017. The final follow-up for survival analysis was conducted on May 31, 2018. The decision to treat a patient and the choice of treatment type and intensity were based on the clinical judgment of the attending physician, who was blinded to the IACA index results. Patients received either IC, decitabine as a single drug, or best supportive care (BSC). The IACA index was calculated based on four risk factors: IADL scales, advanced age (>75 years), hypoalbuminemia (<3.4 g/dL), and high burden of clinical comorbidities (Charlson Comorbidity Index score of ≥3). Patients were categorized into low-risk (0 points), intermediate-risk (1–2 points), and high-risk (≥3 points) groups based on their IACA index scores.
A total of 61 patients were included in the study, with 21, 34, and 6 patients categorized into the IACA low-risk, intermediate-risk, and high-risk groups, respectively. The rates of relapse/progression-related mortality were 23.8%, 58.8%, and 100.0% in the low-, intermediate-, and high-risk groups, respectively. The 2-year probabilities of overall survival (OS) were 47.7% and 20.2% in the low- and intermediate-risk groups, respectively, which were significantly higher than those in the high-risk group. In the low-risk group, the 2-year probability of OS in patients receiving IC was significantly higher than in those receiving BSC.
The study also examined toxicities and treatment-related mortality (TRM) in patients who received IC or decitabine. Hematologic toxicities were the most common, followed by infectious, cardiovascular, central nervous system, and gastrointestinal toxicities. The rates of TRM were comparable between the low- and intermediate-risk groups and between the decitabine and IC groups. Among patients receiving therapy after diagnosis, 48.7% achieved CR, with a significantly higher rate in the low-risk group compared to the intermediate-risk group. The rate of relapse/progression-related mortality was highest in the BSC group, followed by the decitabine and IC groups.
In the multivariate analysis, high leukocyte counts at diagnosis, achieving CR, and IACA index were independent factors associated with OS. The study concluded that the IACA index is a simple and effective tool for CGA in elderly AML patients, with low-risk patients potentially benefiting from IC.
The IACA index incorporates essential aspects of a geriatric assessment, including functional status (IADL scale), nutritional status (serum albumin), and comorbidity burden (Charlson Comorbidity Index). The IADL scale is particularly important in assessing the functional abilities of elderly patients, as it provides additional information beyond performance status measures like ECOG and Karnofsky. Comorbidities are a significant factor in treatment decisions for elderly AML patients, with higher comorbidity burdens associated with poorer outcomes. The inclusion of serum albumin levels in the IACA index reflects the importance of nutritional status in predicting survival and treatment tolerance.
The study’s findings suggest that the IACA index can effectively predict clinical outcomes in elderly AML patients and guide treatment decisions. Low-risk patients, as identified by the IACA index, may benefit from intensive induction chemotherapy, while intermediate-risk patients may require careful consideration of treatment options. High-risk patients, who are unlikely to benefit from intensive therapy, may be better suited for supportive care or less-intensive treatments like decitabine.
Despite its promising results, the study has several limitations. The retrospective nature and relatively small sample size, particularly in the high-risk group, may affect the accuracy of the findings. Additionally, the use of different chemotherapy protocols in the IC group may influence the interpretation of results. Future prospective, multicenter studies with larger patient cohorts are needed to further validate the usefulness of the IACA index in geriatric AML patients.
In conclusion, the IACA index is a concise and effective tool for comprehensive geriatric assessment in elderly AML patients. It can help identify patients who are likely to benefit from intensive induction chemotherapy and guide treatment decisions to improve clinical outcomes in this vulnerable population.
doi.org/10.1097/CM9.0000000000000645
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