Research in context
Evidence before this study
We searched PubMed before submission (final search on March 8, 2015) for original research articles published since 2001 about reduced-intensity conditioning allogeneic haemopoietic stem cell transplantation (HSCT) versus chemotherapy in patients aged 60 years and older with acute myeloid leukaemia in first complete remission, using the search terms “acute myeloid leukaemia”, “allogeneic”, “reduced intensity”, and “elderly” or “60 years”. Although several studies showed the feasibility of allogeneic HSCT following reduced-intensity conditioning in elderly patients with acute myeloid leukaemia in first complete remission, no prospective randomised trials comparing allogeneic HSCT versus chemotherapy have been reported in these elderly patients with acute myeloid leukaemia. We identified two comparative retrospective trials that included patients with acute myeloid leukaemia aged 60 years and older and compared allogeneic HSCT with chemotherapeutic post-remission therapy. Both studies suggested improved outcome by allogeneic HSCT compared with other post-remission treatments, which was mostly present in intermediate-risk and adverse-risk subgroups of acute myeloid leukaemia. Similarly, in patients younger than 60 years of age with acute myeloid leukaemia in first complete remission, we and others have reported improved survival with allogeneic HSCT compared with chemotherapeutic post-remission therapy, especially in patients with intermediate-risk and adverse-risk acute myeloid leukaemias.
Added value of this study
Our study included a large number of patients with long follow-up who all received induction treatment for acute myeloid leukaemia in prospective phase 2 and 3 trials. Our results of a time-dependent analysis show that, in patients 60 years of age or older with acute myeloid leukaemia in first complete remission, allogeneic HSCT might provide improved outcome compared with a non-allogeneic HSCT post-remission therapy approach, especially in patients with intermediate-risk and adverse-risk acute myeloid leukaemias.
Implications of all the available evidence
As outlined recently, tailoring of post-remission therapy in elderly patients depends not only on disease-related risk factors, such as the underlying cytogenetic or molecular risk of the acute myeloid leukaemia, but also on patient risk factors, including comorbidity status and performance status. Outcome of post-remission therapy in patients with acute myeloid leukaemia, especially those aged 60 years and older, might benefit from a personalised treatment approach that takes into account both patient and disease factors, with the assessment of acute myeloid leukaemia risk status, comorbidities, and performance status. Although allogeneic HSCT might improve outcome in subgroups of elderly patients with acute myeloid leukaemia, these results need to be confirmed in a prospective trial, which is currently ongoing (NCT00766779).