Table 3 Challenges in treating older patients with ALL

Clinical factors

 Decreased performance status

 Increased number of comorbidities

 Decreased organ function

 Polypharmacy

 Frequent dose reductions, delays, or omission

 Higher risk of adverse events (infections, neurotoxicity, secondary malignancies)

Biological factors

 Increased incidence of adverse-risk karyotype (e.g., low hypodiploidy/near-triploidy, t(9;22), t(4;11), complex cytogenetics)

 Lower incidence of favorable-risk karyotype (hyperdiploidy, t(12;21), ETV6-RUNX1)

 Higher incidence of adverse risk molecular signatures (Philadelphia chromosome-like, TP53 mutation)

Social factors

 Inadequate caregiver and/or social support

 Transportation/travel difficulties to tertiary centers

Other factors

 Perceived lack of benefit of receiving anti-leukemia therapy rather than supportive/hospice care