Diagnosis and Management in the Elderly

Deirdre A. Jenkins, MD
Richard C. Woodman, MD
Division of Hematology and Hematological Malignancies,
University of Calgary and Tom Baker Cancer Centre, Calgary, AB.

Introduction
Chronic lymphocytic leukemia (CLL) is a monoclonal disorder of long-lived, mature lymphocytes. It is the most common leukemia in North America with an incidence of 2.7 cases per 100,000. CLL is primarily a disease of the elderly, with a median age of 70 at diagnosis and a slight male predominance. In patients older than 85 years, the incidence rises to 30.6 per 100,000.¹ There are no clear hereditary patterns; however, increased incidence is noted in families with other lymphoproliferative disorders. The etiology is unknown, and typical risk factors for other cancers (like viruses, radiation and chemicals) have no clear role in CLL. The importance of understanding the diagnosis and treatment of this disorder lies in the chronic nature of the disease, as patients may live years to decades after diagnosis. Knowing your treatment goals, and anticipating complications are fundamental for managing patients with CLL.

Diagnosis
While there has been a growing number of patients serendipitously diagnosed on routine blood tests, the majority of patients will present with symptoms referable to their disease (Table 1).

M.D. Minden, M.D., Ph.D., FRCPC
Princess Margaret Hospital
University Health Network
Toronto, ON

Introduction
Leukemias are malignancies of the blood and bone marrow and are classified as either acute or chronic malignancies of the myeloid--red blood cell, granulocyte, platelet lineage--or lymphoid--T or B lymphocyte. In this article we will focus on acute myeloblastic leukemias (AML) and recent advances in their classification and therapy.

In the United States, approximately 10,100 cases of AML are diagnosed each year and the yearly mortality rate from this disease is approximately 6,900 individuals. The incidence of AML is low in children (<1/100,000) and increases with age, such that by the time a person reaches the age of 80 the incidence is approximately 15/100,000 (Figure 1).¹ Over 60% of patients are 55 years of age or older, making this a significant problem in the aging population.

AML develops as the result of genetic changes in hematopoietic stem cells of the bone marrow.² These changes block the ability of the cell to undergo normal differentiation resulting in a blast-like morphology. In some cases, the patient may have large numbers of circulating leukemic blast cells compromising blood flow to vital organs.

Dr. Tabo Sikaneta, MD
Clinical and Research Fellow
Massachusetts General Hospital
Harvard Medical School

Chronic myeloid leukemia (CML) and chronic lymphocytic leukemia (CLL) are malignant hematologic disorders that predominantly affect the middle-aged and elderly. Although they share certain features in their clinical presentations, these two neoplasms differ significantly with regard to epidemiology, pathogenesis, prognosis, and management issues. This article will compare and contrast CML with CLL in order to highlight these important clinical differences. Particular attention will be given to the treatment issues faced by elderly patients with these chronic leukemias, and to the role that primary care physicians may play in the management of these diseases.

Definition and Epidemiology
CML is the clonal proliferation of hematopoietic stem cells. CLL is the clonal proliferation of small, long-lived, mature B lymphocytes. CML is less common, with an annual incidence of 1-2 per 100,000 members of the general US population. It has an equal distribution among both sexes.¹ Both CML and CLL affect whites more than blacks, are not familial, and are not related to a history of known carcinogenic agent exposure.² Although the median age of onset of CML is 53, a sizeable minority (10-30%) contract CML after age 60.