Chapter 95: Hematologic Malignancies (Leukemia/Lymphoma) and Plasma Cell Disorders

Learning Objectives

• Recognize presentation, workup, and management of common hematologic malignancies in older adults.

• Recognize the value of geriatric assessment to personalize care for older adults with hematologic malignancies.

• Recognize treatment approaches for older adults diagnosed with common hematologic malignancies.

Key Clinical Points

1. Older adults make up a large proportion of incident and prevalent hematologic disorders, as well as those dying from these conditions.

2. The response rates and cure rates for older patients with hematologic disorders have lagged behind those of young adults for a number of reasons: more resistant tumor biology, presence of multiple chronic conditions, and functional impairments that decrease treatment tolerance. Underrepresentation of older adults in clinical trials remains a limitation as well.

3. Myelodysplastic syndromes can be indolent or progress rapidly to bone marrow failure; treatment should be risk-adapted based on disease and patient characteristics.

4. Antileukemic therapy improves survival for most older adults with acute myeloid leukemia.

5. Oral tyrosine kinase inhibitors provide long-term disease control for older adults with chronic myelogenous leukemia.

6. Chronic lymphocytic leukemia (CLL) is the most common leukemia in the Western Hemisphere and may be expected to be encountered in a geriatric practice. Older symptomatic patients with and without comorbidity can benefit from targeted therapy regimens.

7. Modern classification systems for lymphomas are evolving rapidly and incorporate immunophenotyping and genetics.

8. Comorbidity and frailty are strong modifiers of prognosis and must be incorporated into treatment planning.

9. Immunotherapies play an increasing role in treatment of some lymphomas; consider life expectancy and potential toxicity when planning treatment.

10. Plasma cell disorders (PCDs) are among the few neoplasms where routine laboratory testing other than by tissue biopsy can detect a clonal population by detection of monoclonal protein in the serum or urine.

11. Male gender and African-American race are risk factors for all PCDs.

12. All patients with PCDs require evaluation for associated abnormalities, that is, “CRAB” criteria: hypercalcemia, renal insufficiency, anemia, or bone lesions.

13. Prevention of complications in those with multiple myeloma includes intravenous bisphosphonates to reduce the risk of pathologic fractures or painful lytic lesions requiring radiation; and infection prophylaxis with pneumococcal vaccine, annual influenza vaccine, and, for patients receiving certain treatments, herpes zoster prophylaxis with acyclovir or valacyclovir.