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SOHO 2024 | Considerations when selecting patients over 70 with AML for transplantation
Charles Craddock, CBE, FRCP, FRCPath, University of Birmingham, Birmingham, UK, discusses how fit and newly diagnosed patients with acute myeloid leukemia (AML) over 70 should always be considered for allogeneic stem cell transplantation (alloSCT). The introduction of reduced-intensity conditioning (RIC) regimens has made transplantation a viable option for elderly patients. However, it is important to note that patients with refractory disease or significant comorbidities face higher transplant-related mortality and should not be considered. This interview took place at the Twelfth Annual Meeting of the Society of Hematologic Oncology (SOHO 2024) congress in Houston, TX.
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Transcript
So, disease relapse remains unfortunately the major cause of treatment failure in adults with acute myeloid leukemia. This is particularly true in older adults, probably because of increased frequency of adverse disease biology. And therefore, we’re mindful of the fact that allogeneic transplant delivers the most effective anti-leukimic payload that we know of in the management of AML, it’s really timely to think how can we deploy such an effective anti-leukimic therapy safely in older patients...
So, disease relapse remains unfortunately the major cause of treatment failure in adults with acute myeloid leukemia. This is particularly true in older adults, probably because of increased frequency of adverse disease biology. And therefore, we’re mindful of the fact that allogeneic transplant delivers the most effective anti-leukimic payload that we know of in the management of AML, it’s really timely to think how can we deploy such an effective anti-leukimic therapy safely in older patients. And the advent of reduced intensity regimens has allowed us to contemplate with some degree of equanimity transplanting patients in their 60s. And really until about 10 years ago that was what we felt to be quite adventurous but the age of transplant has steadily risen and you know many of the patients who come through a routine transplant ward now will be over the age of 60. But in the last 10 years groups have recognized that the most important consideration is not chronology but biology and if a patient is fit there’s now abundant evidence that you can safely take such patients up to the age almost of 75 or in some centers up to 80 safely into a transplant and this is really important because the only alternative therapy for such patients is either intensive chemotherapy, which delivers long-term survival rates of about 15 or 20 percent in that age population, or venetoclax and azacitidine which is not curative.
So the real question is not which patients should proceed to transplant but which patients should not. And the default I think in newly diagnosed fit adults with AML over the age of 70 should be considered taking to them transplant. There should be tissue types of diagnosis and unrelated search started. The patients who you wouldn’t want to think of taking to transplant are patients with refractory disease probably or patients with such significant comorbidities that you can predict a high transplant-related mortality. So the recent CIBMTR data shows a steady increase in transplant activity in this population which I predict will simply pick up pace.
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