Acute myeloid leukemia in the elderly: current therapeutic results and perspectives for clinical research

More than half of acute myeloid leukemia (AML) diagnoses are currently made in patients older than 60 years. Furthermore, even if the age-specific incidence remains stable in the coming years, the incidence of AML in elderly people is expected to consistently increase, given the progressive ageing of the general population. Consequently, the treatment of the disease in aged individuals represents a daily challenge in clinical hematology. Several studies have shown that, in current practice, a high fraction of patients older than 60 years is negatively selected for inclusion in clinical trials that are based on intensive chemotherapy. Apart from performance status and comorbidity at diagnosis, other non-clinical factors can significantly affect therapeutic choice including the distance from hematologic institution, presence of a carer, physician's and patient's attitude, and the scientific interest of the physician in a given therapeutic programme. In daily practice, a combination of these factors results in relevant selection of patients for clinical trials. Clearly, preselection of patients with AML leads to misleading overly optimistic results in some studies. Treatment of AML in the elderly is difficult and well-controlled trials in this group of patients are uncommon. Frequently, higly selected patients are recruited to relatively small phase II unrandomised trials with complete remission (CR) rates ranging from 25 to 70 %. These figures may turn unrealistic in the current practice. The present article reviews results of most relevant studies addressing therapeutic results in elderly patients with AML. Questions to be addressed will include potential selection biases, results with conventional chemotherapy, the therapeutic potential of autologous and allogeneic stem cell transplantation and a critical review of results achieved with newly developed drugs.