Treatment of acute lymphoblastic leukemia in older adults: now and the future

Acute lymphoblastic leukemia (ALL) is an uncommon disease with poor outcomes in older patients. Although intensive chemotherapy can induce complete responses in older patients, the mortality rate is unacceptably high. The 5-year survival rate for patients achieving a remission ranges from 17% to 23%. ALL is usually more aggressive in older patients, and these patients' reduced functional capacity renders them less able to tolerate treatment. The need for less-intensive, more-efficient treatment modalities in this population of frail and high-risk patients is evident. Clinicians should strongly consider treatment in clinical trials for their older patients. If such trials are not available on site, physicians should refer older patients to tertiary centers for possible enrollment in a study. Significant advances have been made in the past decade toward understanding the biology of ALL and in developing novel therapeutic agents. Blinatumomab, inotuzumab ozogamicin, and newer-generation tyrosine kinase inhibitors appear to be promising agents. Clinical studies show remarkable results with these agents, either alone or in combination with low-dose chemotherapy. Now that clinical trials are being designed with less-intensive treatment regimens and broad entry criteria, older age is less likely to be an exclusionary factor. However, clinical trials that enroll older patients with ALL should include detailed documentation of their underlying comorbidities, cognitive function, and performance status.