Fit vs Curable in AML: Psychosocial Burden and Older-Patient Treatment Decisions

In "Fit vs Curable in AML: Psychosocial Burden and Older-Patient Treatment Decisions," our experts turn to the human side of fitness and the difficult calls it creates in older adults.

Dr. Zeidan addresses the psychosocial and quality-of-life burdens facing patients with AML, particularly those considered unfit. He notes that therapies once reserved for fit or unfit groups now apply across the spectrum, so the distinction is rarely straightforward. He describes a 72-year-old patient with NPM1-mutated AML, a body mass index above 35, hypertension, and arthritis. Instead of asking whether the patient is fit, he asks whether intensive chemotherapy could cure the patient without transplant. Fitness determines whether chemotherapy can be given, but not whether it should be. If transplant is planned anyway, he notes that azacitidine plus venetoclax may be a reasonable path to get there.

With a median age at diagnosis of 68, most patients carry comorbidities and many face social limitations. A spouse may be disabled, or children may live out of state. Some patients are hospitalized simply because they lack support to travel to visits, even for regimens that could be delivered as outpatients. Dr. Zeidan stresses that psychosocial assessment matters throughout therapy and becomes even more critical before transplant. He calls for a multidisciplinary team that includes social workers alongside physicians, pharmacists, nurses, and nurse practitioners.

Dr. Stein explains that disease biology tends to worsen with age, so adverse-risk ELN categories cluster in older patients. He shares a similar case of a woman in her 60s with NPM1- and IDH1-mutated AML and obesity. He chose intensive chemotherapy, hoping to cure her without transplant. Instead, she was intubated in the ICU for three and a half weeks before recovering. He now questions whether azacitidine plus venetoclax followed by transplant would have been wiser. Dr. Stein suggests clinicians perhaps should not be so afraid of allogeneic stem cell transplant. Dr. Mahmoudjafari agrees that without a crystal ball, these decisions must rest on the information available that day.

Up next, in "Frailty, Comorbidity, and Social Determinants of Health in AML Treatment," Dr. Murthy reviews practical frailty tools and Dr. Zeidan examines how social determinants of health shape treatment.