For patients over 75, I’m usually not going to give induction, but where I struggle sometimes to decide is if I see a really fit, healthy 76- or 77-year-old with FLT3-mutated acute myeloid leukemia (AML) with significant leukocytosis on admission. Particularly if they present with tumor lysis syndrome or disseminated intravascular coagulation (DIC), this is somebody who obviously needs to be in the hospital and needs treatment right away. With the FLT3 mutation, you could use HMA-venetoclax in this patient, but this is someone whom I think that maybe 7+3 and midostaurin would be a good option as well. The RATIFY study that led to approval of midostaurin plus chemotherapy was conducted in patients up to the age of 59,1 but it is approved for adult patients regardless of age.

So that’s someone for whom I might decide to deviate from my stance on 75 and above, but I have also seen some unfortunate outcomes in the past in this setting and have wished I made different treatment decisions. As I said previously, chemotherapy will unmask someone’s age, and can do so very quickly. You can’t undo 7+3 once you’ve given it. You give it, and then you just have to support them through the myelosuppression and wait until they recover and hope that they do. That’s the hard part.

So to me, these are really complex patients for whom it’s difficult to determine the best approach.

Reference:

1. Stone RM, Mandrekar SJ, Sanford BL, et al. Midostaurin plus Chemotherapy for Acute Myeloid Leukemia with a FLT3 Mutation. N Engl J Med. 2017;377(5):454-464.