There is a lot of evolution in oncology because of targeted treatments. While from years ago mantle cell lymphoma was a fatal disease with a short median survival, with the apparition of new targeted treatments changed the situation very much, that’s now very different and there is some hope for these patients. That changed the way we have to manage these kinds of patients, indeed if we had palliative treatment the new objective is quality of life so that’s not very much difficult. You can decrease the treatment as far as the situation of the patient is keeping not too bad.
If we have a chance to better control the disease for a longer time you have to deal with maintaining the chance of the results of the treatment to the best level with not too much increase in the toxicity and so on. In this case when you are dealing with the elderly you have to use a geriatric oncology approach. Mantle cell lymphoma is really a disease of the elderly because the median age in population based series is about 75 while in clinical trials it’s about 65-70 so there’s the usual selection we observe. So that tells a lot to the geriatric oncologist: first that we have to push a geriatric oncology approach with screening, geriatric assessment and so on. Second, that we have to work with the clinicians on a more daily basis to improve our management. That’s something very much important.
How will new therapies play a part in treatment of mantle cell lymphoma?
The targeted therapies are very much adapted to the elderly because they are supposed to be more specific so the ratio between efficacy and toxicity should be much better, first. That’s positive so that would push the elderly to receive this kind of treatment. Then we still have problems to solve, the first one is that it’s very costly so there is a society decision, it’s not the physician to take this decision but probably to participate in the discussion how far should we push this costly treatment in the elderly. I’m not saying that we shouldn’t treat elderly patients, we should, but we should treat if we have a reasonable chance to get good results. So we have to be cautious with that, we have to work in the elderly population, not in younger patients, we have to work on predictive factors of a good outcome. That’s something we have to take into account.
Could you give some background on your ‘Success in Geriatric Oncology’ session?
That’s very much positive to have a session for young physicians involved in geriatric oncology. We need young physicians to be involved in geriatrics, they are the future so that’s very much positive. I’m very positive about this session also because they were very much active, there were a lot present in the session so that’s just what we have to do and we should help them.
In my presentation I was talking about what to do, it was very much simple. You have to be clear on the topic you are working on, you have to keep on track when you are deciding where you want to go and you have to have a long term objective. That’s very much simple. Then the last thing, you have to be very much structured in your research and you have to implement a strong methodology. Then what I think is very important for these young oncologists is that they remember that they have older geriatric oncologists that may support them and I try to push them to ask for the older to grab the people in the hallways between the sessions then tell them, ‘Well, you don’t know me but I am a young oncologist and I would like to develop this trial, could you help me? I don’t have any methodologies, could you help me? My network is quite limited right now, could you advise me to do something? Can you introduce me to the national representative of SIOG? Could you introduce me with this guy who is an expert in the field and who may help me?’ That’s very important to stress – they have not to remain between young people, they have not to be shy and they get to the older to get some advice. We are here for them.
How does the goal of treatment in younger patients differ in geriatric oncology?
With the older patients the objective is slightly different from the objective of treatment, it’s slightly different from what you have with younger patients. With younger patients your objective is to cure, with older patients you have to cure but you have a qualitative side so that if your patient is alive one year after but in bed that’s not a success, for sure that’s a real failure. So we go to dual endpoints where you have to control disease at least and also to ensure that the patient remains independent with a good quality of life and so on. There is a lot of place for innovation there. Technically they do exist but the experience of clinicians and statisticians is not that good. So we have to work on the endpoints, not only by pushing these different endpoints but also by using a technical methodological approach. For example, I was talking about a specific trial that was performed where the two endpoints were used, one was survival and in this place the treatment was not significant. The other one was a trial but it was overall treatment utility and it was significant there. So in the elderly probably we have to think about that. I don’t know what will be the solution, if it’s overall treatment utility, co-primary endpoints, composite endpoints, I don’t know, that’s not really the important thing. We have to think in these terms and in trials, in specific trials, we have to compare different endpoints to make some progress there.