Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011

Professor Fernando Ramos (Leon Hospital, Spain)

Acute myeloid leukaemia: the challenges

The session on acute myeloid leukaemia has just finished here in Rome at the Blood Cancer in the Elderly conference and I’m very lucky to have Fernando Ramos from Hospital de Leon in Spain. Fernando what, for you, is the reason for taking such an interest in AML in the context of older patients?

This disease is upsetting for our patients and also for us because it has a very outstanding mortality rate. Overall survival is very, very low and much less than 10% of our patients are alive after a year.

And how much difference does the age of a patient make to AML? How much difference does it make if you have an older patient?

First of all, he is elderly and that is absolutely different because many of the elderly people don’t have the opportunity to receive high dose in chemotherapy; that is now one of the main weapons we have for fighting against cancer. On the other way, some of them don’t want to receive this sort of chemotherapy because it compromises quality of life.

Do you think that as a community we are concerned enough about treatment for elderly patients with AML?

No, absolutely not. Sometimes people have some caveats regarding even the economics that has to do with elderly populations. Discrimination regarding age sometimes also has to do with economics - who is the best population to spend our money on? Obviously if you have a life expectancy of 40-50 years, probably a lot of people would think at the beginning that the best thing would be to give our resources for the young instead of the elderly but that’s the sort of discrimination we must fight against.

You are suggesting, though, that intensive chemotherapy potentially bringing benefits or intensive therapies bringing benefits might not be used in a number of older patients. How do you decide which patients intensive therapies could be used in?

That’s our difficulty at the present time. We don’t have the appropriate tools for making these decisions. Probably there is wide clinical practice and variability among the different hospitals and different doctors and that’s not good at all. What we should do is to have what is called CGA, the comprehensive geriatric assessment, and that’s something that takes time, you need a lot of resources, we need to work probably in an engaged multi-disciplinary team and that’s something we don’t have everywhere or in every hospital.

Now at the session that you’ve just taken part in there was talk about cytogenetics, there’s talk about adverse cytogenetics – a particular sub-group of patients who are going to do poorly. You also were discussing how AML may be different entities within the same disease, what came up?

Since the WHO changed the AML classification a relevant proportion of what was earlier called MDS has moved into the AML world, let’s say. So now there is a relevant proportion of AML patients that have low blast counts and many of them, most of them, are elderly patients with poor risk cytogenetics. These people do not benefit from intensive chemotherapy and we must look for alternative pathways for them.

What sort of good things do you see coming along?

We now have low dose, low intensity chemotherapy and that’s good news. Now we have some data that low dose chemotherapy does benefit patients with AML with a low blast count. What we don’t know so far and we are trying to get the data for translating that into clinical practice is whether these sorts of therapies might also help those patients having more than 30% bone marrow blast cells. It seems, because according to the French compassionate use programme, the bone marrow blast cut-off of 30% is not a key issue regarding its activity.

And how much hope should we hold out for the effectiveness of some of the more gentle therapies, some of the more targeted therapies, in the future?

Obviously it expands the opportunity to give something not very aggressive to sometimes frail patients. So it has been a huge change. The problem is we need some additional time and a lot of additional data to try and see what patients would benefit more.

So what would you say to doctors who are faced with elderly patients with AML, perhaps those who might have been categorised as MDS in the past, who may be frail or may be fit? What should clinicians be thinking about now, finally?

In the survey we took during the session we could see that just a very, very tiny proportion of the doctors in the session chose intensive chemotherapy for these AML patients. Probably it’s not something that we have discussed a lot but we have the feeling that we must change something in these sorts of patients, that we must try another different pathway, a different pathway from the classical one that is always just to choose between just supportive care and intensive chemotherapy. That dichotomy is terrible for the patients because most of them cannot receive intensive chemotherapy and there is a third pathway. The new way should be just to try and test the low dose chemotherapy.

Fernando, thank you very much for joining us here on ecancer.tv.

It’s my pleasure to come here.