Clinical Practice Guidelines Now Available for Older Adults with Acute Myeloid Leukemia

The American Society of Hematology (ASH) recently published 2020 Guidelines for Treating Newly Diagnosed Acute Myeloid Leukemia (AML) in Older Adults. Mikkael Sekeres, MD, chair of the ASH AML guideline panel and director of Cleveland Clinic Cancer Center’s Leukemia Program, shares his insights on the evidence-based guidelines.

What prompted the development of these guidelines?

Dr. Sekeres: The average age of someone diagnosed with AML is 68, and the average age in the United States is increasing as our baby boomer generation ages. Older patients have specific needs related to quality of life, comorbidities and palliative and hospice care, so we brought together an incredible team of specialists in these areas.

These were also part of a larger initiative at ASH to develop or update clinical guidelines for a range of hematologic conditions.

Could you give us a brief overview of the guidelines?

Dr. Sekeres: We centered their development around six critical questions that arise in real-time, in conversations that occur between doctor and patient: deciding on treatment versus supportive management, the intensity of therapy, what role postremission therapy should play, less-intensive combination therapies versus less-intensive monotherapy, how long any less-intensive therapy should continue, and what role transfusions should play for patients who have entered a palliative or hospice mode.

We used the McMaster Grading of Recommendations Assessment, Development and Evaluation, or GRADE, Centre Evidence-to-Decision framework to develop these questions, perform systematic reviews and make recommendations. This is about as rigorous as it gets when it comes to guideline development.

The guidelines recommend treatment over supportive management as well as more intensive therapy when it can be tolerated. We also suggest that giving postremission therapy and less-intensive monotherapies are superior options for patients, while acknowledging that some combinations may not truly be less intensive. Importantly, we make a clear statement that red blood cell transfusions should be considered standard supportive care for patients in palliative or hospice settings. But the main principle we want to emphasize is that optimal care can only come from ongoing conversations between clinicians and patients that continually reassess care goals and risks.

Tell us more about these conversations.

Dr. Sekeres: I think this is where the guidelines the team developed really shine. They take providers step-by-step through the conversations they need to have with newly diagnosed patients to help create a personalized treatment plan. We put a heavy emphasis on patient goals and wishes. Those should be the center of the conversation, especially since the average life expectancy of a 75-year-old patient diagnosed with AML is months and the chance of cure is vanishingly small. So while the guidelines do recommend intensive treatment, it’s ultimately up to the patient whether that is the best option for him or her, and it’s the clinician’s job to help that person understand the benefits and risks.

Can you tell us more about the role of transfusions in older patients?

Dr. Sekeres: Our final recommendation within the published guidelines suggests that red blood cell and platelet transfusions be made available to older patients with AML who aren’t receiving antileukemic therapy, including those who are in hospice or on palliative care. It should be considered a standard, whereas many hospice organizations refuse to allow transfusions, largely for economic reasons. We only had low-quality evidence to support this recommendation, but the panel also found that the likelihood of harm was small. We need more research in this area, but overall, this is something that is likely to be of net benefit to patients, of course in the context of their wishes and any clinician concerns.

While we are confident that the panel made the best choices given the evidence available, we also believe these guidelines are a call to action for more research on this population. Our hope is that by the time these guidelines are updated, we’ll have higher levels of evidence to better guide decision making.