ASCO 2011 Annual Meeting, 3—7 June 2011, Chicago
Importance of geriatric oncology
Professor Hyman Muss – University of North Carolina Medical School, USA
Doctor Muss, thank you for taking time off from your busy schedule at ASCO. You are a medical oncologist with a real passion for making sure that elderly patients get a better deal and get a fair crack of the whip. And you were mentioning that you think that, for once, ASCO has come up to the mark, and has actually produced some really good sessions. Would you like to summarise them for me?
Well I think that ASCO has always been good to us, but I think two things are starting to happen: ASCO is continuing to give the sessions, and people are actually showing up at the meetings. What’s been very special about the sessions this year is a lot of them have been devoted to geriatric assessment - things that really we all need to know, because cancer is a disease of ageing. I know in the UK and US, our average age of cancer now is 66, a lot different from the public perception. So at this meeting, we’ve had a lot of sessions that have focused on how do you assess older patients, how do you figure out, perhaps, who’s frail or vulnerable, not going to tolerate therapy; on the other hand, who is in really great shape, even though they’re older, and should not be low-balled, and should get the best treatment. So there’s been a lot of sessions focused on this, including geriatric assessment, including, perhaps, new molecular markers of ageing that might help in treatment decision and very practical tools that one might be able to use in their office soon, that we hope to get web-based, online, so when you’re seeing a patient it can help you make a treatment decision or estimate side effects.
Now you’re a solid tumour oncologist and ecancer ran a meeting for haematological oncologists in Rome a couple of months ago because it was reckoned that the haematological oncologists were about five or ten years behind the solid tumour oncologists. Is that your impression too?
Well I’m a haematologist also but I don’t like to admit it because I haven’t been able to keep up with all the modern advances. But I think they’re getting involved more and more but I think they still have restrictive protocols and think someone who is 60 is old, where a lot of us would violently disagree for personal and other reasons.
When the median age of some of the haematological oncology malignancies, CML, are up in the 70 mark. You know, myelofibrosis is 70, acute myeloid leukaemia is around 70.
Absolutely, AML I show on slides as a disease of ageing.
And to exclude all these patients from the clinical trials means there’s no evidence base for how to treat these patients, and that means there are also no evidence for withholding treatment from these people, because those things haven’t been tried. There’s an assumption, which is somewhat arrogant and ill-informed by the medical profession, that the date of birth is what matters.
Yes. To follow up on that, we are developing new leukaemia trials in the United States for our co-operative groups, and we actually have trials that are set up for people 60 and older. I still think it’s young but at least in AML there’s a different biology for many of the older patients. And these trials also include geriatric assessments. So we’re going to learn not just about the hard-core outcomes like complete remission and response; we’re going to say what did that treatment do to the function of the patient? Was it worth it, and things. And hopefully those data will either compel, or teach us who not to treat but also provide a lot of information on the fact that older people can do very, very well with modern treatments if they have the right care in the hospital, the right support.
In Rome, we had a presentation from Bavaria which showed that 45% of patients over the age of 70 who had chronic myeloid leukaemia were not given imatinib with the chance of a 90% response rate, then they got hydroxyurea, with a 10% response rate, based on the date of birth. And there is no evidence anywhere in the imatinib literature that there’s a dose age effect.
Yes. I’m not sure if it’s a cost issue, but certainly that seems like a habit we have to change.
I’m intrigued by these tools. Are you saying that I can get a geriatric assessment tool come online, and I just, or I get it on a keystick that comes into my computer, and I see somebody who I’m a little bit concerned about and I’ve not got the skills of a geriatrician, or the experience that I can actually… they can talk me through that?
Right. So we’re working on tools…
Who are ‘we’?
In the United States in our co-operative groups, and we have a consortium of ageing research. And our leader is Dr Arti Hurria who’s been at these meetings. And what we’ve done is we’ve developed… in the United States we have a dramatic shortage of geriatricians, and we’re not going to fix it very quickly. And so how do you work in your office to figure this out? So we’ve developed the mini geriatric assessment that takes about 30 minutes. It’s mostly self-administered to the patient. Many can do it, it includes some professional time, like what we call a ‘get up and go’ test, walking three metres and coming back. It includes cognitive function, which is very important and just a few other measures. So it may take a professional ten minutes’ time at most - a nurse, a physician perhaps, someone in the office. And then it includes all scales, domains, activities of daily living – can you dress yourself, can you use the telephone, can you pay your bills, have you fallen, have you lost weight? All the things that we know are important that a lot of physicians never think of asking, it’s not in the history. The social history is do you smoke or drink; we really want to know who you live with, can you pay your bills, does your daughter have to come and drive you to the doctor all the time, or do you do it? And so these scales now, a lot of them we have on scannable forms and we’re trying to develop them on the web. So you could be sitting in your office, you get scores, and it will tell you this person can’t even dress herself or has bad cognitive function and ideally refer you to a social worker, perhaps a Board-certified geriatrician, to look at all the issues. So we’re hoping to get this online shortly, either through ASCO or our own website that we have for our research group and we think it will be very helpful. It has to be real time.
We can’t have this on ecancer.tv?
You might be able to do this on ecancer.tv.
35,000 oncologists each month are coming in.
So this is exactly the sort of thing I think we should be doing.
My view is it should be public domain. These scales are all public domain, like the, what’s called, Activities of Daily Living. It’s 30 years old. it works. And if you have someone who can’t walk a block to buy their groceries or can’t dress themselves or eat, considering them for intensive chemotherapy is probably not a reasonable option.