Allogeneic transplantation in the elderly
The ability to escalate therapy and then salvage with stem cells from a donor has been a boon for patients with many types of cancer and hematologic malignancies, making possible a chance of cures in previously hopeless situations. In addition to the ability to markedly escalate the aggressiveness of chemotherapy that can be salvaged with transplanted stem cells, these outside donor cells, if properly managed, can provide an anticancer or anti- leukemia effect without provoking a full-scale debilitating graft versus host reaction. However, allogeneic transplantation remains a difficult, costly and toxic treatment. Taking into account toxicity and complications of high-dose chemotherapy and development of graft versus host disease, as well as infectious complications, unrelated donor transplantation can be deadly for the elderly. The recent (2011) controversy about heart transplantation for the 71-year-old former Vice-President of the United States Dick Cheney brought this issue (as well as the ethical quandaries of allocating scarce organs) to public attention. Elderly patients, even those without chronic medical problems have lower reserves to tolerate or surmount toxicity.
The maximum age for allogeneic transplantation has been increasing as methods of transplantation and supportive care have advanced. Most centers are now considering unrelated donor transplantation for patients at around seventy year mark. Unfortunately this remains an ongoing source of controversy because the literature is contradictory and confusing, owing primarily to the lack of phase 3 studies, which, however, would be very difficult to do. This remains a matter for discussion between patient and physician and an individualized decision between them. The age of around 75 years is now being routinely approached in major centers.