Allogeneic stem cell transplantation for the elderly and especially for patients who are 65 years or older, or 70 years, or even 75 years of age is becoming more and more relevant because the numbers overall across the world are increasing for these patients due to several reasons: due to better management of these patients, due to better understanding how we actually define elderly. And also because of the demographic shifts, we noticed that people who are elderly are more and more fit than the usual generations in the 1990s or early 2000s...
Allogeneic stem cell transplantation for the elderly and especially for patients who are 65 years or older, or 70 years, or even 75 years of age is becoming more and more relevant because the numbers overall across the world are increasing for these patients due to several reasons: due to better management of these patients, due to better understanding how we actually define elderly. And also because of the demographic shifts, we noticed that people who are elderly are more and more fit than the usual generations in the 1990s or early 2000s. So this is a big improvement on the one hand. On the other hand, this makes us a bit more hesitant and makes the whole procedure, stem cell transplant procedure, which is a very intense time and intensive treatment for patients, this makes the decision for what to choose and when to choose a bit more delicate because age, yes, on the one hand, as a physiologic age may not be that kind of a category of decision making so we tend not to decide because of age, 64 years of age or 65 years of age to give this patient the transplant or not. This is a very, very heterogeneous decision making based on a holistic approach, where we take into account the physiology, but also the comorbidities which in itself is a very, very delicate discussion because certain comorbidities may be a bit more risky than the others.
And this brings us to the conditioning regimens because conditioning before stem cell transplantation is a very important part of the procedure where we try to reduce the risk for relapse. But also try to balance this risk of relapse with the risk of non-relapse mortality after transplant, which is related to the transplantation itself. So this needs to be balanced in a very delicate way. And then the age and the condition of the patient comes into account because certain regimens tend to induce more comorbidities after transplantation, but also have a certain risk profile with regards to relapse or nom-relapse mortality.
So we have myeloablation, which is considered a higher intensity conditioning regimen, which reduces the risk for relapse in most trials, but also increases the risk for non-relapse mortality because of the high intensity. So one would think that patients who are elderly have more risk for non-relapse mortality when they receive higher intensity treatment. And then this needs to be balanced with the risk for relapse, because risk for relapse for a patient who is 75 or 70 years of age, does also seem to be individual. Because when the relapse happens in five, six years, this means a completely different world than a patient who is 40 years, who wants to live 10, 20 years. So risk for relapse of younger patients seems to be a bit more important. So we could think that we can try to identify certain treatments that may be associated with a higher relapse rate, but reduce the risk for non-relapse mortality. And that’s why we use reduced intensity conditioning for many patients with acute myeloid leukemia and MDS. And there, there is particularly one regimen, treosulfan-fludarabine which has shown in a large randomized control trial, very encouraging results for elderly patients. And this is the largest trial with the oldest population so far and the randomized trial comparing certain conditioning regimens. So we, in our practice, we use treosulfan-fludarabine in many, many cases where we need to balance the risk for relapse, the risk for non-relapse mortality and age.
