Physician Resources
Despite advanced age, some patients are able to withstand aggressive, curative treatment for AML. We have developed online assessment tools that help predict the best course of treatment for older, more infirm AML patients.
Case Study
This case study presents an example of assessing a patient’s health state using comorbidities and other assessments to allow for more informed decision making than using age alone.
A 79.5 year old man in remission of AML presented with his first relapse. He was assessed on disease state, comorbidities, and functional status and found to be a good candidate for HCT, for which he would normally be excluded simply due to his advanced age. The assessment included a number of factors determined by his physician as well as through a self-administered survey he completed before his appointment.
After assessment, the patient was found to be in very good physical, social, psychological, nutritional health. He had borderline cognitive health, which may have been caused by a low hemoglobin value at the time. He had one identified comorbidity for malignancy on the HCT-CI score. He was therefore placed in the favorable risk group for tolerating non-myeloablative conditioning and allogeneic transplant. The patient went through with the HCT has no evidence of recurrent disease at over two years post-transplant.
Disease History
The 79 year old male patient started complaining of increasing fatigue and was seen by a hematologist where a complete blood count was done, showing a white blood cell count of 16,000 with 62% lymphs, absolute lymphocyte count of 10,000, ANC of about 300, hemoglobin of 11.8, hematocrit of 34.1, and platelets of 145,000. A bone marrow completed a month later showed 80% myeloblasts. The patient had normal cytogenetics and a normal FISH analysis. A previous note indicated a NPM1 positive mutation.
The patient was treated with induction chemotherapy of standard 3+7 (idarubicin 12 mg/m square times 3 doses, Ara-C 100 mg/m square times 7 doses). His day 28 bone marrow was normal by morphology, flow cytometry and molecular studies indicating first complete remission. He was then given 2 cycles of post remission chemotherapy using single-agent high-dose Ara-C.
3 months after his post-remission therapy, the patient was found to have a low platelet count of 98,000 and flow cytometry showed blasts of 87% of total white blood cell. The patient was re-inducted with the same initial chemotherapy regimen of standard 3+7. Bone marrow biopsy conducted 18 days after the start of chemotherapy indicated a second complete remission with minimal residual disease. The findings were white blood cell count of 34,000, hemoglobin of 9.3, platelet count of 10,000, and blasts of 1%. The patient then went through additional therapy of 2+5 with idarubicin and Ara-C.
At this point the patient was thoroughly assessed for suitability for going through hematopoietic stem cell transplant, as outlined below.
Assessments for Transplant
Physician conducted
- HCT-CI: Determined to have a score of 3 due to a previous malignancy. The score was calculated using medical records, pulmonary function test and labs.
- Disease status: The patient had a long duration between his first CR and relapse, which studies have shown demonstrates better outcomes after HCT. His cytogenetics were normal, which is also favorable for a better outcome after allogeneic transplant. The fact that he was in CR2 was favorable, and would be more so if he became MRD negative before transplantation.
- Gait Speed: His gait speed was measured by timing how long it took him to walk 4 meters. His speed of 1.3 meters per second was good, suggesting a 10 year survival rate of about 70%. (Studenski S. et al JAMA of 2011 volume 305, page 50)
- Up and Go: This assessment measured how long it took the patient to move from a seated position in a chair to an area marked 3 meters in front of the chair, turn around and sit back down in the chair. The patient performed at average pace.
- Cognition Test: Scored intermediately using a mini cognitive assessment instrument.
Patient answered survey assessment
- Treatment preferences: Chance of cure was ranked as his first priority, followed by quality of life and length of life.
- Quality of life (FACT scoring system): For social life and physical activity he scored the highest possible score indicating no impairment. He scored favorably for functional status, and had some limitations in emotional health due to concern over the transplant and availability of donor.
- Social support (ESSI): He scored the highest possible score for social support and scored high on social activity, as well as being above the mean for risk and limitation of social activity.
- Cancer and treatment distress (CTXD): He scored well on this scale, indicating limited distress from treatment or cancer.
- Depression (PHQ-90): He scored in the lowest risk group for depression.
- Basic activities of daily living (BADL) and Instrumental activities of living (IADL): He had the highest possible scores on these scales, which is very favorable in predicting tolerance to treatment.
- Fraility index (FRIED): He scored the lowest possible value on this scale indicating that he is not frail. He was negative for exhaustion, had good nutrition and physical activity.
- Vision, hearing and falls: He scored at low risk for falls, was not found to be hearing handicapped or vision impaired.
Links to Tools and Calculators
Publications
Read about the tool in The JAMA Network | JAMA Oncology | September 7, 2017
Development and Validation of a Novel Acute Myeloid Leukemia-Composite Model to Estimate Risks of Mortality.