When Treating Leukemia, the Patient’s Life Is the Blueprint: Tina Bhatnagar, DO

Treating acute leukemias, acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML), requires clinicians to weigh far more than disease biology. From managing comorbidities in older patients to navigating fertility conversations with younger ones, the challenges are as varied as the patients themselves.

In this interview with The American Journal of Managed Care^® (AJMC^®), Bhavana (Tina) Bhatnagar, DO, associate professor of medicine at West Virginia University Cancer Institute at Wheeling Hospital, discusses how she tailors treatment goals to individual patients across age groups. She explains why lower-intensity regimens have transformed conversations with older patients, how treatment strategies for adolescent and young adult (AYA) patients differ from those used in other adult populations, and why addressing life goals—including fertility preservation and caregiver support—is essential to comprehensive leukemia care. She also reflects on how the AML treatment landscape is evolving as molecular profiling reshapes what personalized therapy looks like in practice.

This interview has been lightly edited for clarity.

AJMC: What impact do comorbidities have on outcomes in older patients who have ALL or AML?

Bhatnagar: They definitely contribute. In general, acute leukemias are aggressive and they can be harder to manage in people who have a lot of preexisting medical conditions. Some of the medications that we use to treat AML and ALL can be hard on individuals who struggle with heart issues or kidney problems. Administering some of these drugs that are very active in AML can be a problem as a result of their toxicity profile, particularly for older or more frail patients. It’s just something we always take into mind when we’re trying to select treatments, because ideally, we want to get rid of the disease, but we don’t want to do so at the expense of incurring a lot of unnecessary toxicity.

AJMC: How do treatment goals differ between younger and older patients?

Bhatnagar: Everyone is different, certainly, and I have to be mindful, too, of not imposing what I think somebody wants in their care plan. I think it’s always really important to share what you know about the disease and to let the patient be an active partner with you in those goals. We do know that acute leukemias are aggressive. We do know for older adults that the long-term outcomes are not great still, and hopefully that will change over time.

When I’m speaking to older patients, I hear different answers. Some people want to be very aggressive about their care. Even in the older AML and ALL space, there are some very effective lower-intensity regimens that we can offer our patients to achieve disease control and to lengthen their lifespan. It’s not like the conversations I used to have earlier in my career where there wasn’t anything that you could offer those patients without causing a lot of adverse effects. Oftentimes I find that my older patients, if there’s a palatable option for them that isn’t going to make them very sick, will go for it, and they will try to get whatever time they can get, if possible. Then I do have other patients, too, who don’t want to go through all of the logistical things that come with an acute leukemia diagnosis.

Acute leukemia patients are very high utilizers of the health care system. They’re always here in clinic or in the hospital because of their compromised immune system; they’re at risk for lots of complications. I do have patients who have often turned to me in the middle of an office visit and said, “Thanks, but no thanks to treatment,” and they want to focus on maximizing their quality of life for whatever time they have left and maximizing their time at home and away from the clinic.

For younger patients, it is very unusual for me to see a younger patient who says that they don’t want to receive treatment. Most of them will do just about anything to try to save their life, because they have so much life left to live. They want to reach those milestones that a lot of us want to reach. They want to graduate or get married or have kids. It’s different for different people, but there are goals that they want to achieve, and so for that reason they’re more likely to do more intensive therapies with the goal of being cured from their cancer. That can involve multiple lines of chemotherapy, targeted therapy, immunotherapies, or transplant. Those are all things that we take into account, while also trying to help them juggle their life goals. For example, fertility is something that we have to address frequently in younger AML or ALL patients who are of childbearing age or who are even younger but at some point want to have a family in the future.

Those are all important conversations to have so that once they are through their leukemia diagnosis and once they're cured, we want them to be able not just to survive but to thrive afterwards and achieve their life goals.

AJMC: Does how you approach fertility preservation conversations differ for female and male patients?

Bhatnagar: It’s definitely more straightforward for male patients. It’s easier to sperm bank, just logistically speaking, whereas fertility preservation for women is much more involved. Oftentimes, given the acute nature of a leukemia diagnosis, a female patient can’t afford to wait to consider her fertility options. Normally, we refer them to fertility preservation, but oftentimes, I think the fertility piece of things for women with leukemia or younger females with leukemia gets addressed on the back end once they’re done with all of their treatments and once they’re cured and ready to move on with their lives.

We know up front whether or not our treatments are going to affect their fertility. We know transplant will definitely affect their fertility if they move forward with a stem cell transplant, so we have those discussions. The fertility preservation specialists, too, also know how likely somebody is to get pregnant following their bout of treatment, so we can use all of that to help our patients make the best decision for them as far as family planning goes.

AJMC: What is the typical treatment regimen for younger patients?

Bhatnagar: There are some drugs that we use in both diseases. By and large, the ALL regimens are much more complicated. These are regimens that contain maybe around 10 drugs that a patient may see over a period of 2 to 3 years. For younger patients, the AYA population and pediatric protocols can last about 2 to 3 years if those patients don’t go through transplant. Even the younger adults, who are [aged] between 15 and 39 years, we treat them on pediatric-inspired protocols. That is the standard of care, because we know that for whatever reason, their disease biology seems to mirror the pediatric population more so than it tends to mirror the adult population. Then there are some genetic lesions, too, that we see a lot in the AYA population that we don’t see in the pediatric population. There’s this entity called PH-like ALL, which I won’t get into the weeds about, but it is something that you will see relatively frequently in people who are in that AYA age group. To answer your question, those younger patients are generally treated like a pediatric patient, with multiple drugs over a period of 2 to 3 years.

In the AML space, it is kind of changing. The historical standard for younger patients was this regimen called 7 + 3, and it’s been around since the 1950s. At one time, it was really the only thing that you could really offer somebody with AML. It’s one of the few regimens where you have to hospitalize people for a month in order to get through it, which is different compared with other cancers that are normally treated on the outpatient side. 7 + 3 has sort of been what we’ve used most frequently for younger patients, and that usually involves a 4- to 6-week hospital stay, high infection risk. They stay in the hospital for a long time because the chemotherapy is so intense that it obliterates their blood counts for several weeks, so they need to be monitored closely for infections, bleeding, complications, as well as toxicities of the chemotherapy regimen itself.

The field is evolving, though, as we’ve sort of gotten into the weeds a bit more about the molecular underpinnings of AML. Now you could have a group of 4 AML patients who are young, and they’re all treated differently according to the characteristics of their disease. So, I’ll be curious to see what happens, 5 or 10 years from now, but there are a lot of people who predict that 7 + 3 will be used for only a very limited group of patients with AML.

AJMC: What would you like other clinicians to know about treating younger patients with ALL or AML?

Bhatnagar: Younger patients have a lot of unique challenges, particularly this middle group, the AYA patients, who are not really children, but they’re also younger adults. That stage of life is busy by itself, without having a cancer diagnosis in the mix as well. I would encourage clinicians to be mindful of the rest of this person’s life. What are their long-term goals career-wise? I think that’s important. To take into account their family planning goals, try to choose regimens that really kind of fit in, in some way, with those goals and their other responsibilities. Also, I think it’s always important to take the caregiver into account. Oftentimes for these younger patients, if they’re married, they often have a younger caregiver who’s involved in their life and who helps get them through their cancer diagnosis. So making sure that they’re a partner and an ally as you’re trying to get this person through their diagnosis, I think, is critically important.