Deschler Barbara, de Witte Theo, Mertelsmann Roland, Lübbert Michael
Department of Hematology Oncology, University of Freiburg Hugstetterstr. 55, D-79106 Freiburg, Germany.
Haematologica. 2006 Nov;91(11):1513-22.
High-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are mainly diseases of patients over the age of 60 years. In these patients, intensive chemotherapy and/or allogeneic blood stem cell transplantation are the only curative treatment approaches, while non-curative options include low-dose chemotherapy or best supportive care alone. The basis for treatment decision-making in this clinically and biologically heterogeneous group is not well defined.
In order to investigate treatment stratification patterns and outcomes in this population, we performed a systematic literature search in MedLine for relevant clinical reports published between 1989 and 2006. Only large population-based investigations and publications of clinical trials with more than 40 patients were analyzed.
In 36 AML studies involving a total of 12,370 patients (median age 70 years) median overall survival approached 30 weeks for intensively treated patients. In patients receiving best supportive care alone, or best supportive care plus non-intensive treatment, median overall survival was 7.5 and 12 weeks, respectively. The complete remission rate after induction was 44%, and in those patients who achieved complete remission age no longer influenced prognosis. In 18 large studies approximately 50% of AML patients received induction therapy, 30% non-intensive chemotherapy and 20% supportive care only.
Due to the scarcity of randomized AML/MDS trials in which older patients are assigned to either induction or less intense therapy, predictors to identify older patients most likely to benefit from intensive therapy and novel tools to optimize (or even standardize) recommendations are needed. We propose that in this patient population in the future, geriatric assessment instruments and comorbidity scoring are implemented in treatment decision-making.
高危骨髓增生异常综合征（MDS）和急性髓系白血病（AML）主要是60岁以上患者的疾病。对于这些患者，强化化疗和/或异基因造血干细胞移植是仅有的治愈性治疗方法，而姑息性治疗选择包括小剂量化疗或单纯最佳支持治疗。在这个临床和生物学特征各异的群体中，治疗决策的依据尚不明确。
为了研究该人群的治疗分层模式和结果，我们在MedLine中对1989年至2006年间发表的相关临床报告进行了系统的文献检索。仅分析了基于大样本人群的调查以及患者超过40例的临床试验出版物。
在36项AML研究中，共纳入12370例患者（中位年龄70岁），接受强化治疗的患者中位总生存期接近30周。仅接受最佳支持治疗或接受最佳支持治疗加非强化治疗的患者，中位总生存期分别为7.5周和12周。诱导缓解后的完全缓解率为44%，对于达到完全缓解的患者，年龄不再影响预后。在18项大型研究中，约50%的AML患者接受诱导治疗，30%接受非强化化疗，20%仅接受支持治疗。
由于将老年患者分配至诱导治疗或强度较低治疗的随机AML/MDS试验较少，因此需要预测指标来识别最有可能从强化治疗中获益的老年患者，以及优化（甚至标准化）治疗建议的新工具。我们建议，在未来针对这一患者群体的治疗决策中，应采用老年评估工具和合并症评分。
