Older adults: should the paradigm shift from standard therapy?

For older adults (ie, those age 60 and above) with acute myelogenous leukemia, patient and clinician have three choices: standard therapy, ie, a "3+7" regimen or low-dose ara-C, investigational therapy, or palliative care. Investigational treatments sponsored by pharmaceutical companies tend to exclude the 10-20% of older patients who have a poor performance status (Zubrod >2), an increased bilirubin, or creatinine (>1.9 mg/ml) and who are thereby unlikely to do well with standard therapy. However, even excluding such patients, standard treatment offers little obvious benefit for most older patients. Nonetheless, these older patients are not uniform and can be stratified to receive investigational therapy, which is mandatory for most, or standard therapy, which is not inappropriate for some.