Acute myeloid leukemia in the elderly

The optimal management of acute myeloid leukemia in patients over 60 years-of-age remains a controversial issue. The complete remission rates after conventional induction chemotherapy progressively decreases after the age of 60. This is explained by host-related factors and by differences in the biology of leukemia. The incidence of adverse prognostic factors (trilineage myelodysplasia, unfavorable karyotype, mdr1-positive phenotype) is higher in elderly patients. Three strategies are currently offered to older adults with acute myeloid leukemia: intensive chemotherapy, palliative treatment and attenuated dose chemotherapy. Currently, complete remission rates achieved with conventional chemotherapy range from 40-65% according to inclusion criteria. In the past few years, two approaches have been tested in order to improve the results of induction chemotherapy: modifications of chemotherapy regimens with new intercalating agents (idarubicin, mitoxantrone) and the use of myeloid growth factors. Myeloid growth factors have been administered with two objectives: to reduce the duration of neutropenia and the toxic death rate when given after induction chemotherapy, and to prime leukemic blasts when given during chemotherapy. The results of published placebo-controlled studies are discussed. The issues of palliative treatment and of attenuated dose chemotherapy are also addressed in the review, with special emphasis on the role of oral idarubicin.