Transplantation for Older Patients with Hematologic Malignancies in 2021: Uncertainty and Ethics in Decision-Making

Hematological malignancies such as acute myeloid leukemia or myelodysplastic syndrome occur predominantly in older individuals. For many of these patients, hematopoietic cell transplantation is currently the only treatment modality with curative potential. However, older age tends to be associated with increasing co-morbidities, rendering patients more susceptible to toxicities associated with the transplantation procedure. Further, transplantation carries the risk of inducing graft-versus-host disease, the clinical result of the immunological attack of donor cells against the patient's body, even if the donor is matched (for human leukocyte antigen) with the patient. These complications affect quality of life and may prove fatal. More conventional chemotherapy does not carry the risk of these complications; however, in most patients, it does not cure the disease. Therefore, multiple patient and disease characteristics are being considered in the decision-making process regarding the two treatment strategies, and the decision is generally based on statistics from previous studies. Of course, those statistics do not consider individual patient personalities nor physician attitudes, which clearly affect patient decisions. Thus, these discussions involve considerable uncertainty and ethical considerations as to the greatest benefit at the lowest "cost" for the patient.