ASH releases guidelines on Acute Myeloid Leukemia in Older Adults

Written By : Dr. Kamal Kant Kohli Published On 2020-08-07T08:15:37+05:30 | Updated On 7 Aug 2020 12:11 PM IST

WASHINGTON--The American Society of Hematology has released 2020 Guidelines for Treating Newly Diagnosed Acute Myeloid Leukemia in Older Adults.The guidelines are intended to help older adults with acute myeloid leukemia (AML) and their health care providers make critical care decisions, including if and how to proceed with cancer treatment and the need for blood transfusions for those in hospice care. The guidelines have been published in the journal Blood Advances.

Each year, nearly 20,000 people receive a diagnosis of AML. The disease generally develops in older people; the median age of diagnosis is 68. AML prognosis in older adults is poor. In fact, on average, a 75-year-old diagnosed with AML usually has a life expectancy measured in just months.

The American Society of Hematology 2020 Guidelines are guided by the principle that throughout a patient's disease course, optimal care involves ongoing discussions between clinicians and patients, continuously addressing goals of care and the relative risk-benefit balance of treatment.

"These guidelines take providers through the conversations they have with newly diagnosed patients, almost in real-time," said Mikkael Sekeres, MD, chair of the ASH AML guideline panel and director of the Leukemia Program at Cleveland Clinic Taussig Cancer Institute. "A discussion between patient and physician is instrumental to creating a personalized treatment plan, and these guidelines are unique in that they keep a patient's goals and wishes front and center in that conversation."

In addition to the paucity of curative treatment options and high prevalence of comorbidities complicating treatment in this patient population, some providers may be reluctant to recommend intensive therapies, or any therapy at all, because they fear toxicities in older patients. And some patients may not wish to spend their valuable remaining time in the hospital.

"We recognize the serious issues that patients face, including the side effects and risks of chemotherapy and time in the hospital. Weighing these issues against possible benefits, including remission and extended life, patients can decide what treatment is consistent with their goals," said Dr. Sekeres.

Many hospice organizations will not allow patients to receive blood product transfusions, often for economic reasons. For AML patients in end-of-life and hospice care, the guidelines recommend that blood transfusions should be considered standard supportive care, as they can address palliative needs related to breathlessness, bleeding, and profound fatigue, as well as improve overall quality of life. This guidance supports an ASH policy statement in support of ensuring Medicare hospice beneficiaries can access palliative transfusions.

Main Recommendations are

1.For older adults with newly diagnosed AML who are candidates for such therapy, the American Society of Hematology (ASH) guideline panel recommends offering antileukemic therapy over best supportive care (strong recommendation based on moderate certainty in the evidence of effects ⊕⊕⊕◯).

2.For older adults with newly diagnosed AML considered candidates for intensive antileukemic therapy, the ASH guideline panel
suggests intensive antileukemic therapy over less-intensive antileukemic therapy (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯).

3.For older adults with AML who achieve remission after at least a single cycle of intensive antileukemic therapy and who are not candidates for allogeneic hematopoietic stem cell transplantation (HSCT; allo-HSCT), the ASH guideline panel
suggests postremission therapy over no additional therapy (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯).

4(a) For older adults with AML considered appropriate for antileukemic therapy but not for intensive antileukemic therapy, the ASH guideline panel suggests using either of the options when choosing between hypomethylating-agent monotherapy and low-dose-cytarabine monotherapy (conditional recommendation based on moderate certainty in the evidence of effects ⊕⊕⊕◯).

4(b) For older adults with AML considered appropriate for antileukemic therapy (such as hypomethylating agents [azacitidine and decitabine] or low-dose cytarabine) but not for intensive antileukemic therapy, the ASH guideline panel suggests using monotherapy with 1 of these drugs over a combination of 1 of these drugs with other agents (conditional recommendation based on low certainty in the evidence of effects

5.For older adults with AML who achieve a response after receiving less-intensive therapy, the ASH guideline panel suggests continuing therapy indefinitely until progression or unacceptable toxicity over stopping therapy (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).

6. For older adults with AML who are no longer receiving antileukemic therapy (including those receiving end-of-life care or hospice care), the ASH guideline panel
suggests having red blood cell (RBC) transfusions be available over not having transfusions be available (conditional recommendation based on very low certainty in the evidence of effects). There may be rare instances where platelet transfusions may be of benefit in the event of bleeding, but there are even less data to support this practice and it is anticipated that platelet transfusions will have little or no role in end-of-life or hospice care (⊕◯◯◯).

The AML guidelines are the most recent product of a larger guideline development initiative for ASH, which includes a commitment to the timely update of existing guidelines and the development of new ones on a range of hematologic conditions. In the coming months, resources to aid in the implementation of the guidelines will be added to the ASH website.

For further reference log on to:

Blood Adv (2020) 4 (15): 3528–3549.

American Society of HematologyBlood AdvancesAcute Myeloid LeukemiaASH guidelines

Source : American Society of Hematology

Dr. Kamal Kant Kohli

Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751