PARIS – Impaired physical and cognitive abilities are predictive of worse overall survival in elderly patients with acute myeloid leukemia, according to prospective study findings.
In a 74-patient trial, scores of less than 9 out of 12 on the Short Physical Performance Battery (SPPB) and less than 77 out of 100 on a Modified Mini-Mental State (3MS) exam were associated with a threefold increase in risk of death, compared with scores in patients who had no physical or cognitive difficulties.
The study’s findings could ultimately help determine which elderly patients with acute myeloid leukemia (AML) are fit enough to receive standard chemotherapy regimens for the disease, and which may require a different therapeutic approach. The results should currently be viewed as a "signal" of a possible worse prognosis, however, until further validation.
Dr. Heidi Klepin
"Acute leukemia is probably one of the most dramatic examples of age-related outcome disparity in oncology," said study author Dr. Heidi D. Klepin, of Wake Forest University, Winston-Salem, N.C.
"Older patients consistently do much worse when diagnosed with disease than [do] young patients," Dr. Klepin said on Nov. 4 in an interview at the annual meeting of the International Society for Geriatric Oncology (also known as Société Internationale d’Oncologie Gériatrique).
While much research has focused on examining tumor biology in older and younger patients with AML, few studies have looked at differences in the capabilities of the patients themselves, such as increasing vulnerability or frailty in the geriatric population.
"There has been so little done in geriatric assessment in the leukemia population," Dr. Stuart M. Lichtman said in a separate interview.
Dr. Lichtman of Memorial-Sloan–Kettering Cancer Center, N.Y., who was not involved in the study and served as scientific committee chair of the meeting, said the findings were important because they suggest that general and relatively simple-to-measure parameters could provide valuable information to help clinical decision-making. The SPPB includes asking patients to perform a 4-meter timed walk, stand after being in a seated position, and show how well they balance while standing.
The objective of the study was to assess whether performing a geriatric assessment at the patient’s bedside could predict patient’s likely overall survival. All of the patients included in the trial were about to start induction chemotherapy for AML.
The geriatric assessment consisted of multiple tests to examine cognition (3MS), emotion (Center for Epidemiological Studies Depression Scale, Distress Thermometer), self-reported disability (Pepper Assessment Tool for Disability) and objective (SPPB) physical function, grip strength, and the Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI).
The mean age of patients included in the study was 70 years, 56% was male and 78% had an Eastern Cooperative Group Oncology Performance Status (ECOG PS) score of 0-1. The majority (95%) had an intermediate or poor cytogenic profile. The median follow-up was 7.4 months.
At baseline, 30% of patients were identified as having some form of cognitive impairment, 39% had depressive symptoms, 42% were distressed, 41% had reduced instrumental activities of daily living (IADL), 50% had reduced objective physical function, and 42% had comorbidities.
After researchers adjusted for a host of potentially confounding factors, including age, gender, ECOG PS, and cytogenic risk group, among others, hazard ratios for overall survival were 3.4 for SPPB score less than 9 (P =.03) and 3.0 for a 3MS score less than 77 (P = .008).
"There has been so little done in geriatric assessment in the leukemia population."
Reduced self-reported IADL was also associated with worse overall survival (HR, 2.6), but only after adjusting for confounding factors. SPPB and 3MS were also predictive on univariate analysis.
These data suggest that a better assessment of physical function could provide valuable information about a patient’s likely outcome, "even in clinical practice right now," Dr. Klepin said.
"I think we can use this to improve how patients do with standard treatments, by just paying attention [to baseline parameters] and changing how we manage people," she said. "If we are aware of a problem, can we do things that would prevent that problem from putting a patient in the ICU?"
Dr. Klepin also noted that the information provided by the geriatric assessment could be used to inform and to help patents decide whether they want to be treated with standard chemotherapy or perhaps enter into an appropriate clinical trial of novel agents.
Preliminary data from the trial have been published in the Journal of the American Geriatrics Society (2011;59:1837-46).
The study was supported by the American Society of Hematology, Atlantic Philanthropies, the John A. Hartford Association, the Association of Specialty Professors, and the Pepper Center at Wake Forest University. Dr. Klepin and Dr. Lichtman did not report any conflicts of interest.