Abstract
INTRODUCTION: Quality-of-life (QOL) is a patient-related outcome of increasing interest in onco-haematological setting. However, there are very few reports on QOL in elderly patients with Acute Myeloid Leukemia (AML). Prognosis of AML in elderly patients is still poor with a median survival of 9–12 months and less than 20% survival at 5 years. This is due to age-related factors and also to a higher incidence of poor-risk cytogenetics, multi-drug resistance and treatment-related mortality. The measurement of QOL at diagnosis may provide useful information regarding patient preferences and prognosis while followup measurements may indicate acceptance, adaptation and adverse effects of disease and therapy.
METHODS: From 2/2003 and 2/2007, we included 113 elderly AML patients in a multicenter Italian 12-month observational study to evaluate the association of baseline QOL scores and their changes with disease factors, therapy and survival. Patients aged > 60 years (M/F 58/55, mean age 71.7 ± 5.9 yrs) from 4 Institutions with “de novo” AML according to WHO classification were evaluated from diagnosis prospectively up to 12 months. Two different questionnaires were employed: the EORTC QLQ-C30 and the QOL-E v.2. Therapeutic choice was not restricted by protocol and was given freely by the individual center.
RESULTS: Forty-eight patients (43%) received intensive chemotherapy and 65 (57%) lowdose therapy or supportive care. Both age > 70 years (p=0.007) and concomitant diseases (p=0.031) had a significative impact on medical decision for palliative approaches. At diagnosis, general QOL was affected (median QOL-E standardized score 54, IQ range 47– 68, median EORTC global score 50, IQ range 42–67), loss of appetite was perceived by 75% of patients and QOL-E fatigue scores were low, indicating poorer QOL (median 45, IQ range 32–53). There was a significant correlation between fatigue and age, Hb levels and the duration of fever. In a multivariate regression model, both Hb and age indipendently predicted fatigue (linear R2 0.114, p=0.001, and linear R2 0.066, p=0,010). Most patients were given a good ECOG Performance Status (< 2) that, interestingly, did not correlate with the perception of QOL, in particular physical and functional scores. QOL scores worsened after 1 month from diagnosis but patients surviving thereafter perceived an improvement in the following months. When correcting for the effects of age, concomitant diseases and changes in Hb values, fatigue improved in patients undergoing aggressive chemotherapy while it worsened in those on standard or supportive-care (p=0.004). Median overall survival was 49 weeks (95% CI 35–63). Patients receiving aggressive therapy had a longer survival with the median not reached at 60 weeks and 72% of patients surviving versus patients receiving palliative care (median 39 weeks, 95% CI 16–63, p<0.0001). At multivariate analysis, palliative approaches (HR 2.8, 95% CI 1.4 – 5.6, p=0.003), age > 70 yrs (HR 2.4, 95%CI 1.2 – 5.0, p=0.02) and concomitant diseases (HR 2.0, 95% CI 1.1 – 3.8, p=0.044) had an independent negative prognostic impact on survival, as previously reported in many other studies. However, in order to evaluate the predictive value of QOL at diagnosis for survival, in a multivariate model corrected for age, concomitant diseases and treatment option, QOL measures that independently predicted survival were fatigue (p=0.003), global QOL (p = 0.004), physical QOL (p = 0.006) and functional QOL (p = 0.002).
CONCLUSION, QOL seems to have an important role also in the elderly AML setting: though QOL is a highly subjective measurable value, we outline the role of QOL measures at diagnosis as a prognostic factor for overall survival and, thus, as a potential factor for treatment decision.
Supportive Care in Elderly Patients
