Treatment of the elderly patient with acute myeloid leukaemia.

Individuals of 60 years living in western countries generally have a mean life expectancy of 20 years at least. Therefore, when aged individuals present with AML, it is a necessity and a challenge to treat them as efficiently as possible. AML is mainly a disease of the elderly and accounts for more than 50% of its incidence among the general population. The treatment of older individuals with AML has remained difficult and its success is still limited. While in adults with AML of less than 60 years complete responses above 65% and survival rates of 35% are commonly obtained, progress in the treatment of elderly patients has been relatively small. As of today, approximately 50% of older patients may be induced into remission with chemotherapy, and, among these complete responders, only approximately 1 in 10 will survive free of leukaemia beyond 4 years after diagnosis. In fact, on one hand, these results represent the rationale and motivation for offering chemotherapy to the older population. On the other hand, they emphasize that major obstacles to better cure rates still exist. These stumbling blocks apparently relate to the restricted tolerance of older subjects to the exposure of chemotherapy and probably also a greater probability of unresponsiveness of the leukaemia to cytotoxic therapy. The haematopoietic growth factors still hold some promise and may improve outcome, but for the time being there is insufficient direct evidence to indicate a defined and established role. It is evident that new avenues should be pursued and trials specifically designed for elderly people with AML be conducted. These trials would need to address questions related to the choice of chemotherapeutic drugs (e.g. idarubicin versus mitoxantrone), their dose and schedule selection, the use of multidrug resistance modulators (to overcome intrinsic drug non-responsiveness), and the optimal clinical use of haematopoietic growth factors, including thrombopoietin. Since trials addressing specific questions regarding the development of treatment of elderly patients with AML have remained scarce, the initiation of these studies is sorely needed. One may hope that these clinical trials will provide some of the necessary answers and new clues, and will be useful to advance future therapy of elderly AML patients.