Page 2618 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 161 Hematology in Aging 2331

REFERENCES
Assessment of Older Adults With Hematologic Malignancies
Optimal treatment for a hematologic condition in an older patient 1. Cruz M, et al: Predicting 10-year mortality for older adults. JAMA
must be measured in terms of both efficacy and anticipated toxicity. 309(9):874–876, 2013.
Assessing the patient’s reserve before treatment promotes tailoring 2. World Health Organization: Nutritional anemias. Report of a WHO
treatment and provides an objective baseline assessment. scientific group. World Health Organ Tech Rep Ser 405:5–37, 1968.
For all adults over 60 years, we screen for age-associated vulner- 3. Beutler E, Waalen J: The definition of anemia: what is the lower limit
abilities. Cataloging comorbid conditions and assessing performance of normal of the blood hemoglobin concentration? Blood 107(5):1747–
status (PS) plays a central role. PS alone provides only a crude estimate 1750, 2006.
of tolerance to treatment. We find insufficient data to recommend a
specific comorbidity tool or index. However, the Charlson comorbidity 4. Ferrucci L, et al: Unexplained anaemia in older persons is characterised
index or hematopoietic cell transplantation–comorbidity index have by low erythropoietin and low levels of pro-inflammatory markers. Br J
been validated in the context of certain diseases and their treatments, Haematol 136(6):849–855, 2007.
and thus may be invaluable in specific situations. 5. Guralnik JM, et al: Prevalence of anemia in persons 65 years and older
The PS and comorbidity index should be complemented by screening in the United States: evidence for a high rate of unexplained anemia.
for other vulnerabilities, particularly in those older patients for whom Blood 104(8):2263–2268, 2004.
intensive therapy is under consideration. Limitations in the following 6. Ishine M, et al: No positive correlation between anemia and disability in
domains also suggest vulnerability: older people in Japan. J Am Geriatr Soc 53(4):733–734, 2005.
• Instrumental activities of daily living, which are the skills required 7. Segal JB, Molterno AR: Platelet counts vary by ethnicity, sex, and age:
to live independently in the community (e.g., transportation,
paying bills, shopping) analysis of NHANES III data. Blood Abstract 3937, 2004.
• Poor caregiver support 8. Nilsson-Ehle H, et al: Haematological abnormalities and reference
• Cognition intervals in the elderly. A cross-sectional comparative study of three
• Age 70 years and older urban Swedish population samples aged 70, 75 and 81 years. Acta Med
One should directly question patients about perceived problems for Scand 224(6):595–604, 1988.
the recommended treatment. Patients will often relay difficulties not 9. Biino G, et al: Analysis of 12,517 inhabitants of a Sardinian geographic
recognized by a standard medical examination (e.g., caring for an isolate reveals that predispositions to thrombocytopenia and thrombo-
ill spouse, limited prescription coverage, and poor perceived health). cytosis are inherited traits. Haematologica 96(1):96–101, 2011.
More formal screening instruments are available and useful if familiarity 10. Beerman I, et al: Functionally distinct hematopoietic stem cells modulate
can be achieved (e.g., Vulnerable Elders Survey-13).
Knowledge of disease response rates for older adults allows further hematopoietic lineage potential during aging by a mechanism of clonal
individualization of treatment decisions. Responses to imatinib for expansion. Proc Natl Acad Sci USA 107(12):5465–5470, 2010.
chronic-phase chronic myeloid leukemia do not differ substantially 11. Jan M, et al: Clonal evolution of preleukemic hematopoietic stem cells
by age, whereas acute myeloid leukemia induction results in lower precedes human acute myeloid leukemia. Sci Transl Med 4(149):149ra118,
responses, shorter disease-free survival, and greater toxicity relative 2012.
to younger adults. 12. Shlush LI, et al: Identification of pre-leukaemic haematopoietic stem
Although disease-based therapy exists along a spectrum, we gener- cells in acute leukaemia. Nature 506(7488):328–333, 2014.
ally divide therapy into low-intensity, intermediate-intensity, or high- 13. Busque L, et al: Recurrent somatic TET2 mutations in normal elderly
intensity therapy. High-intensity treatment entails strategies such as individuals with clonal hematopoiesis. Nat Genet 44(11):1179–1181,
AML induction and allogeneic hematopoietic stem cell transplantation
owing to high rates of early death for patients with health limita- 2012.
tions. We typically reserve high-intensity therapy for patients with a 14. Xie M, et al: Age-related mutations associated with clonal hematopoietic
preserved PS and controlled comorbid conditions. We recommend expansion and malignancies. Nat Med 20(12):1472–1478, 2014.
that a patient with any vulnerability on screening undergo a more 15. Genovese G, et al: Clonal hematopoiesis and blood-cancer risk inferred
comprehensive geriatric assessment, if available, before curative-intent from blood DNA sequence. N Engl J Med 371(26):2477–2487, 2014.
intensive therapy. Clinics focusing on issues and research in geriatric 16. Jaiswal S, et al: Age-related clonal hematopoiesis associated with adverse
oncology are becoming available, and identifying experts (physician outcomes. N Engl J Med 371(26):2488–2498, 2014.
and nonphysician) in aging with an interest in oncology is invaluable. 17. Artz AS, Thirman MJ: Unexplained Anemia Predominates Despite an
They often can connect patients with resources for specific problems Intensive Evaluation in a Racially Diverse Cohort of Older Adults From
(e.g., home care, transportation, financial help, assisted living).
Intermediate-intensity therapy such as CHOP (cyclophosphamide, a Referral Anemia Clinic. J Gerontol A Biol Sci Med Sci 66(8):925–932,
hydroxydaunomycin, vincristine [Oncovin], and prednisone)-like 2011.
regimens and fludarabine plus cyclophosphamide may produce 18. Price EA, et al: Anemia in older persons: etiology and evaluation. Blood
manageable toxicity-related morbidity in older patients, but they Cells Mol Dis 46(2):159–165, 2011.
remain efficacious and can be administered safely to those with a 19. Ershler WB, et al: Serum erythropoietin and aging: a longitudinal
PS of 2 or better. Demethylating agents span the gap between low- analysis. J Am Geriatr Soc 53(8):1360–1365, 2005.
and intermediate-intensity therapy. Low-intensity therapies, such as 20. Klastersky J, et al: The Multinational Association for Supportive Care in
imatinib or supportive care alone, generally require only a reasonable Cancer risk index: a multinational scoring system for identifying low-risk
nondisease life expectancy of more than a couple of months and can febrile neutropenic cancer patients. J Clin Oncol 18(16):3038–3051,
be given with an ECOG PS of 3 or less.
We strongly encourage a family meeting before initiating treatment at 2000.
which goals and expectations are clearly discussed and support from 21. Cortelazzo S, et al: High risk of severe bleeding in aged patients with
all available caregivers enlisted. Not only will insights be gained into chronic idiopathic thrombocytopenic purpura. Blood 77(1):31–33,
the available support system, but communicating to the entire team 1991.
harmonizes goals for providers and patients alike. Standard guidelines 22. Cohen YC, et al: The bleeding risk and natural history of idiopathic
for infectious disease prophylaxis and growth factor support should thrombocytopenic purpura in patients with persistent low platelet
be supplemented with plans to address limitations found in the initial counts. Arch Intern Med 160(11):1630–1638, 2000.
assessment.