SIOG 2015

Advances in treatment options for elderly cancer patients

Dr Ravindran Kanesvaran - National Cancer Centre Singapore, Singapore

Here at the conference you’re reviewing medical oncology but I know particularly you’re interested in lung cancer and there’s quite a lot happening here. Is there a paradigm shift happening? Are we moving forwards to a new era of lung cancer treatment?

Yes we are, absolutely. Compared to how lung cancer was treated maybe even up to five or six years ago it was just chemotherapeutic agents and there were new targeted agents coming in to the market. But now it is pretty much standard of care for all our patients to have their tumours tested for molecular aberrations, especially mutations, so we have patients with EGFR mutations, ALK, MET, ROS, all sorts of mutations whereby we do have therapies that can target these cancer causing mutations. So that is a shift but what has changed has been the advent of immunotherapy in the last years.

But, in fact, not so long ago the big difficulty was getting patients to have their lung cancer really taken seriously with intensive treatment that could be effective. Has that all changed? Are patients being treated adequately now do you think?

Absolutely, at least in my centre. It took quite a bit of time to convince a lot of my colleagues in other fields like respiratory medicine that these patients can have a much longer survival, especially if we are able to identify the specific mutations and treat accordingly. For example in the past with chemotherapy and with the knowledge that we had a lot of patients with lung cancer would survive maybe eight months, a year or a year and a half with some of the newer agents but now with the targeted agents, like in EGFR mutant patients, we’re looking at three years. So this has not only changed the way we have treated them but it has also required a mind-set change amongst my colleagues who now see longer surviving lung cancer patients.

But is this confusing because you have the molecularly targeted agents, you also have the immunotherapies. Can you guide us as to what’s happening and what you think the priorities should be right now?immunotherapies. Can you guide us as to what’s happening and what you think the priorities should be right now?

So up front when a patient gets diagnosed with lung cancer it is essential to have their tumours molecularly tested for these mutations and if they do have the mutant we should treat them first with these targeted agents. Subsequently there is emerging data and these are quite robust phase III data that show that if these patients fail these molecularly targeted drugs we can try immunotherapeutic agents that are on the market, immune checkpoint inhibitors like the PD-1 PD-L1 inhibitors. Unfortunately in terms of assessment of response we have not found a good marker to identify who will respond best. They have used PD-L1 markers to see whether that can be a response tool but it’s not been so effective.

So at the moment your advice, is that to dip a toe in the water to immune checkpoint inhibition right now?

Yes, primarily I would say treat the activating mutation first with the active agents that we have and then subsequently if there are no other alternatives then immune checkpoint inhibitors form a good opportunity to treat these patients.

Can you put this into the domain of older patients? We’re here at a conference specialising in geriatric oncology, why do you favour immune approaches in this group of patients?

Based on the study data that we have at present and also some of my anecdotal experience in using these drugs as part of clinical trials, we find that it’s quite well tolerated and in older patients who have multiple comorbidities and are frail you want to use a therapy that does not have that many side effects whilst not sacrificing efficacy and immune checkpoint inhibitors provide that hope.

So how would you sum up the best advice to clinicians now to get that balance right between getting an effective therapy, whether it’s chemotherapy, molecular targeted therapies or immune approaches and reducing side effects? What’s the crystallising advice?

In summary I think it’s important to assess the patient, do a complete comprehensive geriatric assessment, assess their fitness and then assess their tumour, look at not just the histology, look at molecular cytogenetics and see what are the mutations that we can target. Based on a comprehensive assessment of all these pieces of information we then choose which will be the appropriate first line treatment if we have a target; if we don’t perhaps chemotherapy and then in second line we already have good data with immune checkpoint inhibitors. Finally, if there’s a clinical trial available we should still choose them, even if they’re elderly as long as they’re fit for it.

Of course, that’s in an ideal world, many doctors in many countries may not be able to afford immune checkpoint inhibitors so could you summarise quick advice for them?

Yes, if they have access to a clinical trial using these drugs then I would recommend that, enrolling patients into that. Unfortunately, outside of that, if there’s no early access programme then these drugs are just too expensive.

But the balance then is that chemotherapy properly used can achieve good results though?

Absolutely. Chemotherapy when properly used, or even the targeted therapies, can achieve good results. It’s essential to assess the patient appropriately first and if you choose the right patient they will benefit very well from these drugs.