Michael Lübbert, MD, from the University of Freiburg Medical Center, Freiburg, Germany, discusses the treatment landscape for elderly acute myeloid leukemia (AML) patients at the International Symposium on Acute Leukemias (ISAL) 2017 in Munich, Germany. He describes the Decider trial (NCT00867672), which assessed the synergistic effects of hypomethylating agents together with all-trans retinoic acid or valproic acid. While the science behind this choice is complex, from a patient perspective the most important point is that both of these show moderate side effects alone. Prof. Lübbert explains that the aim of the trial was to combine either all-trans retinoic acid or valproic acid with hypomethylating agents to achieve better survival and better clinical results. While no benefit was seen with the addition of valproic acid, surprisingly good results were seen when hypomethylating agent therapy was combined with all-trans-retinoic acid, showing an increase in overall survival (OS) from 5 months to 8 months, which was not accompanied by increased toxicity. This will now be confirmed in a randomized placebo-controlled trial. Prof. Lübbert highlights that for elderly AML patients over 60 years of age, the determining factor in treatment choice is whether they are fit enough for chemotherapy or not. If patients are not fit enough for chemotherapy, they will be treated with hypomethylating agents, however this is not curative and resistance quickly builds up. For these patients, the goal is to increase the time to resistance without increasing toxicity. On the other hand, patients fit enough for chemotherapy are led towards a cure mediated by an allogenic stem cell transplant, and the question is which treatment is best to lead them to this transplant. Prof. Lübbert outlines the work of a consortium currently assessing whether milder treatment, such as with hypomethylating agents, is comparable to aggressive chemotherapy in leading patients to transplant.

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