title: The challenges of managing older patients with acute lymphoblastic leukemia.
abstract: Acute lymphoblastic leukemia (ALL), predominantly a disease of children, has a second incidence peak in older adults. Patients older than age 50 but younger than age 65 may be included in trials of intensive treatment with curative intent, but their outcome is poor with high nonrelapse mortality (NRM), high relapse rates, and low overall survival. Using limited published data from the United Kingdom ALL XII and HOVON trials, this manuscript explores the reasons for the high transplant-related mortality (TRM) and presents early data from the United Kingdom ALL 60+ and United Kingdom ALL XIV studies. Factors affecting therapeutic decisions for older patients are discussed. A case study illustrates some of the issues involved in managing these patients and the need to individualize therapy and consider all options. There may be a role for reduced intensity allografting in selected, fitter patients older than age 50; this article presents preliminary transplant data from United Kingdom ALL XIV that prospectively assesses this therapeutic modality. Detailed discussion of tyrosine kinase inhibitors and the potential place of novel targeted antibodies and immune T-cell therapies will be not discussed in detail. Finally, there is a description of the major outstanding issues and the trials that are needed to inform decision making and improve outcome in this challenging group of patients.
authors.affiliation: From the University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom.
authors.forename: David I
authors.initials: DI
authors.lastname: Marks
mesh_terms: D017677:Age Distribution; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use; D001424:Bacterial Infections / Q000188:drug therapy; D005260:Female; D005544:Forecasting; D015577:Geriatric Assessment / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D018365:Neoplasm, Residual; D010347:Patient Care Planning; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000401:mortality / Q000628:therapy*; D015363:Quinolones / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D051437:Renal Insufficiency / Q000150:complications / Q000401:mortality; D017678:Sex Distribution; D016019:Survival Analysis; D014182:Transplantation, Autologous / Q000401:mortality; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D000970:Antineoplastic Agents; D015363:Quinolones