Rethinking ALL Treatment for Older Adults: Emily K. Curran, MD

Ten years ago, an 82-year-old walking into a hematologist’s office with a new diagnosis of B-cell acute lymphoblastic leukemia (ALL) faced a brutal choice: undergo intensive chemotherapy that might not work and might actually kill them, or forgo treatment altogether. In some studies, up to 1 in 5 older adults died from the treatment itself. The conversation wasn’t really about getting better. It was about how much to endure, explained Emily K. Curran, MD, an associate professor of internal medicine at the University of Cincinnati College of Medicine.

Curran has watched this transformation unfold in real time from the front lines of her own practice. She has been treating patients with ALL since that difficult era, and today she is advocating for the field to update its assumptions. The shift centers on newer immunotherapies that are rewriting what’s possible for older patients with B-cell ALL. These are not just more tolerable alternatives to intensive chemotherapy. As Curran puts it, there are “emerging data that these treatments work as good, if not, in some cases, better than our standard intensive chemo.” She has given these regimens to patients in their 80s, and she no longer views frailty as the disqualifying factor it once was.

But she is also clear-eyed about what “better tolerated” actually means in practice. Inotuzumab means weekly clinic visits, bone marrow biopsies, and likely twice-weekly transfusions. Blinatumomab means being attached to a pump for 4 consecutive weeks. “Just because we can do more intensive and more toxic treatment doesn’t mean we necessarily should,” she says. That same principle applies in reverse: easier is still hard.

In the second part of her recent interview with The American Journal of Managed Care^®, she addressed several important questions: should clinicians update their goals-of-care conversations now that treatment options have expanded? What does frailty mean in this context? And what does she want patients to understand before they walk into their first appointment?