Sekeres Mikkael A, Guyatt Gordon, Abel Gregory, Alibhai Shabbir, Altman Jessica K, Buckstein Rena, Choe Hannah, Desai Pinkal, Erba Harry, Hourigan Christopher S, LeBlanc Thomas W, Litzow Mark, MacEachern Janet, Michaelis Laura C, Mukherjee Sudipto, O'Dwyer Kristen, Rosko Ashley, Stone Richard, Agarwal Arnav, Colunga-Lozano L E, Chang Yaping, Hao QiuKui, Brignardello-Petersen Romina
Leukemia Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH.
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
Blood Adv. 2020 Aug 11;4(15):3528-3549. doi: 10.1182/bloodadvances.2020001920.
Older adults with acute myeloid leukemia (AML) represent a vulnerable population in whom disease-based and clinical risk factors, patient goals, prognosis, and practitioner- and patient-perceived treatment risks and benefits influence treatment recommendations.
These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about management of AML in older adults.
ASH formed a multidisciplinary guideline panel that included specialists in myeloid leukemia, geriatric oncology, patient-reported outcomes and decision-making, frailty, epidemiology, and methodology, as well as patients. The McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline-development process, including performing systematic evidence reviews (up to 24 May 2019). The panel prioritized clinical questions and outcomes according to their importance to patients, as judged by the panel. The panel used the GRADE approach, including GRADE's Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment.
The panel agreed on 6 critical questions in managing older adults with AML, mirroring real-time practitioner-patient conversations: the decision to pursue antileukemic treatment vs best supportive management, the intensity of therapy, the role and duration of postremission therapy, combination vs monotherapy for induction and beyond, duration of less-intensive therapy, and the role of transfusion support for patients no longer receiving antileukemic therapy.
Treatment is recommended over best supportive management. More-intensive therapy is recommended over less-intensive therapy when deemed tolerable. However, these recommendations are guided by the principle that throughout a patient's disease course, optimal care involves ongoing discussions between clinicians and patients, continuously addressing goals of care and the relative risk-benefit balance of treatment.
患有急性髓系白血病（AML）的老年人是一个脆弱群体，其中基于疾病和临床的风险因素、患者目标、预后以及医生和患者感知到的治疗风险与益处会影响治疗建议。
美国血液学会（ASH）的这些循证指南旨在支持患者、临床医生及其他医疗保健专业人员在老年人AML管理决策方面的工作。
ASH组建了一个多学科指南小组，成员包括髓系白血病专家、老年肿瘤学专家、患者报告结局及决策制定专家、虚弱评估专家、流行病学专家和方法学专家，还有患者。麦克马斯特推荐分级评估、制定与评价（GRADE）中心支持指南制定过程，包括进行系统的证据审查（截至2019年5月24日）。小组根据其对患者的重要性对临床问题和结局进行优先排序，由小组进行判断。小组采用GRADE方法，包括GRADE的证据到决策框架，来评估证据并提出建议，这些建议会接受公众评议。
小组就管理老年AML患者的6个关键问题达成一致，反映了临床医生与患者的实时对话：选择抗白血病治疗还是最佳支持治疗、治疗强度、缓解后治疗的作用和持续时间、诱导及后续治疗采用联合治疗还是单药治疗、低强度治疗的持续时间，以及不再接受抗白血病治疗患者的输血支持作用。
推荐进行治疗而非最佳支持治疗。在认为可耐受的情况下，推荐采用高强度治疗而非低强度治疗。然而，这些建议遵循的原则是，在患者的整个病程中，最佳治疗需要临床医生与患者持续讨论，不断明确治疗目标以及治疗的相对风险效益平衡。
