Diagnose and treat leukemia in the elderly

There are four main types of leukemia. The types are based on whether the leukemia spreads slowly (chronic leukemias) or rapidly (acute leukemias) and where the leukemia begins.

The four main types are:

• Acute lymphoblastic leukemia (ALL). ALL are formed in immature lymphocytes, a type of white blood cell found in the bone marrow. ALL tends to grow and spread quickly. It is relatively rare and mainly affects children.
• Acute myeloid leukemia (AML). AML begins in the bone marrow in non-lymphocytic white blood cells. It grows often and spreads quickly. AML is a common type of leukemia in older people, but it is relatively rare compared to other forms of cancer. The average age of diagnosis is around 68, and people under 45 are very rarely diagnosed with AML.
• Chronic lymphoid leukemia (CLL). CLL starts in lymphocytes and usually progresses slowly over time. It is the most common type of leukemia in adults. CLL is usually diagnosed in people around the age of 70 and is very rarely diagnosed in people under the age of 40.
• Chronic myelogenous leukemia (CML). CML occurs when your bone marrow makes too many myeloid white blood cells. CML is growing slowly. The average age at diagnosis is 64, and about half of the cases are people 65 and over.

AML is more common in older people because it is often caused by genetic mutations. These mutations may not cause cancer at first, but they can build up over time and lead to acute leukemia.

Chronic leukemias are more commonly diagnosed in older people, mainly because they often do not cause symptoms at an early stage. They are also slow growing, and cancer cells usually build up gradually over time as people get older. Therefore, people tend to be older when they are diagnosed with chronic leukemia.

Some of the more common symptoms of leukemia in older people include:

Again, it’s important to remember that chronic leukemia may not show symptoms until much later in the course of the disease.

A healthcare professional may be able to identify leukemia with a blood test called a blood count. This is a routine test, so they can identify a problem even before you have symptoms. In this case, the test will show too many white blood cells or cells that are out of the ordinary.

If your doctor suspects that you have leukemia, they may recommend some of these additional tests:

• physical exam to see if your lymph nodes, liver, or spleen are swollen (enlarged)
• bone marrow biopsy, in which tissue is taken from the bone marrow in your hip to see if there are leukemia cells in your bone marrow and to determine what type of leukemia you may have
• pulmonary radiography
• PET to determine the stage of leukemia, which means knowing how far the cancer has spread and progressed
• chest computed tomography
• cytogenetics, which examines chromosomes in blood or bone marrow samples and may indicate the type of leukemia you have
• lumbar puncture, which checks cerebrospinal fluid for leukemia cells

Some of these tests can also help your doctor, often a hematologist or oncologist, determine what stage your leukemia is at. Different types of leukemia are classified in different ways:

• ALL does not have stages like other types of cancer, but your doctor will take your type of ALL (B or T cells) into account when considering treatment options.
• AML is classified into subtypes, rather than symptoms, using the French-American-British classification system. It includes eight subtypes based on certain characteristics of blood cells, such as the number of leukemia cells and the type of genetic mutations.
• In the United States, LLC is typically staged using the Rai system, which includes steps 0 through IV. The stages are based on the amount of lymphocytes in your blood and bone marrow, as well as the spleen, lymph nodes, and liver damage.
• CML has three stages: chronic, accelerated, and explosive. These steps are based on:
  • symptoms
  • number of blood cells
  • the number of blast cells you have

The type of treatment you receive will depend on several factors, including your general health, the type of leukemia, and your age.

Leukemia in the elderly is often more difficult to treat than leukemia in young people. This is due to the fact:

• Older people tend to have more comorbidities or coexisting conditions.
• Higher doses of chemotherapy are too harsh for the elderly.
• People become more prone to infections as they age.
• Older people have more cell mutations.

However, leukemia in the elderly can still be successfully treated and even cured. Treatment options are discussed in the following sections.

Watch and wait

If you have a type of chronic leukemia and are in relatively good health, your doctor may recommend that you watch and wait before starting treatment. Since some treatments can be harmful to older people, this helps to ensure that you are not treated until you need it.

Chemotherapy

Chemotherapy is a common treatment for leukemia in people of all ages. If you are otherwise healthy and have the necessary social support, your doctor may recommend intensive chemotherapy, which is more likely to cure your leukemia. However, low-intensity chemotherapy can also work very well and can be used if you have other health concerns.

Stem cell transplant

Stem cell transplants may not often be offered to older people, but they can prevent leukemia from relapsing very well. A relapse occurs when your leukemia comes back after the treatment is finished. You need to be generally healthy (in addition to leukemia) to have a stem cell transplant.

In many cases, stem cell transplants are used for people whose cancer is caused by many genetic mutations. This is because cancers with fewer mutations or with other causes are more likely to respond well to chemotherapy, which is generally less risky.

Medications

There are several types of drugs available to treat leukemia, including immunotherapies and kinase inhibitors. Immunotherapies help your immune system kill cancer cells, while kinase inhibitors help stop cancer growth.

The outlook for people with leukemia depends on many factors, including:

• the stage at which you are diagnosed
• your age
• the type of leukemia you have
• other health problems you have

Acute leukaemias

For people aged 70 and over, the median overall survival rate for ALL is 4 months and the survival rate for AML is 6 to 12 months.

Targeted therapies such as immunotherapies can increase survival rates for people with acute leukemia. While some research suggests that targeted therapies may increase survival rates to around 10 months after diagnosis, these therapies are new so less is known about them.

Different types of drugs are approved for different types of leukemia. Because these drugs work on specific pathways in your body, they may be safer than other therapies. Your doctor may also recommend adding medication to chemotherapy for better results.

Chronic leukemia

For chronic leukemia, treatment is typically used to control the spread of cancer and manage your symptoms. It is not usually expected to cure leukemia, although you can live with chronic leukemia for many years. If you go into remission after treatment, a stem cell transplant can further increase your survival rate.

Here is an age breakdown of the 5-year survival rates for people with CLL, according to the Cancer Research UK advocacy group:

• 60 to 69 years old: almost 90%
• 70 to 79: over 80%
• 80 years and over: around 65%

The 5-year survival rate for CML is about 40 percent for people aged 65 and older.

Leukemia is more often diagnosed in older people than in adults of other ages. Your doctor will take your general health, type of leukemia, age, and other factors into consideration when developing a treatment plan.

While the median survival rate for acute leukemia can be intimidating, new treatments being tested could improve survival rates. People with chronic leukemia can live with this disease for many years and successfully manage their symptoms. Talk to your doctor about your treatment goals to find the options that are best for you.