Geriatric oncology

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Published: 20 Jul 2010
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Prof Matti Aapro - Clinique de Genolier in Genolier, Switzerland
Prof Aapro speaks about the difficulties of treating cancer in elderly patients. When treating elderly cancer patients clinicians must consider a number of factors such as creatinine clearance, nutritional status and gastric acidity. Although treatments can be very effective in fit elderly cancer patients, there are other factors that must be taken into account. These include the loss of independence and other diseases that the patient may already have.
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ASCO 2010 Annual Meeting, 4—8 June 2010, Chicago

Interview with Professor Matti Aapro (Clinique de Genolier, Switzerland)

Geriatric oncology

What are your guidelines for patients with common cancers such as lymphomas and chronic myeloid leukaemia who are elderly ? How do you approach the position of age?

I think that one of the biggest mistakes that we can make is ask the patient’s age.  It doesn’t matter how old you are, it depends on who you are.  It depends whether you have co-morbidities, it depends whether you have had a past history of treatment which means that your bone marrow will already have been touched by chemotherapy, will not be as resistant to the new chemotherapies.  If you go beyond 80 years old it starts to play a role because it hides things we cannot calculate very easily but up to that age it seems that it really doesn’t play any major influence.  It’s really who you are, what are the other diseases that you might have that will influence your tolerance to treatment and also your prognosis because you might very well die from  infection rather than from your cancer so it might be futile to give adjuvant treatment; you already have a history of three MIs and there’s nothing the cardiologist can do about that.

Are there screening rules for people over the age of 70 before you give chemotherapy, baseline things you would want to do?

Baseline things that we would like to do have not been well qualified until now but it seems that it’s important to look at creatinine clearance.  One of the big mistakes we have done in the past has been to look at creatinine value in the serum which doesn’t reflect kidney function at all.   There is a big debate now about one formula or the other, MDLD seems to be the formula that people like.  Besides that it’s important to look at the patient’s nutritional status.  Albumin levels seem to be quite important but we don’t really know yet for which drug they are important.

What about the issue of oral versus IV chemotherapy?

The issue with oral chemotherapy can be that elderly patients like many patients  will tend to forget to take the treatment, will forget how to take the treatment.  With IV at least you are certain of what you have given.  On the other hand, it’s the hassle of coming to the cancer centre for the treatment so it depends on who the patient is. Another caveat about all treatment is that some elderly patients, especially above the age of 80 might have decreased gastric acidity and that could change the uptake of some oral drugs.

Are you quite happy with fairly aggressive treatment provided functional things are okay such as baseline creatinine clearance?

The data we have shows that patients who are fit will benefit from standard chemotherapies. Again it depends on which setting we are working on.  It’s very important to realise that if you have advanced disease that is really going to kill you, your thinking is getting different from applying somewhat aggressive adjuvant chemotherapy for colon cancer, breast cancer, in someone who might be dying from something else .The most important thing for the elderly patients is that we take into account the fact that some of the treatment can transform an independent elderly person into someone who starts to depend on the environment, on everyone around them and that can be a social disaster because we have to be very careful with those choices because you can treat someone from cancer, prolong life for a few months but transform them from someone who was happy and independent to someone who has to be in a home for elderly, very unhappy, so I don’t know whether that patient would be actually thank us for that.

Is withholding treatment not an option assuming the patient’s fit and is compliant and agrees that they want treatment?

There is no reason whatsoever to withhold treatment from a patient who accepts the risk of some side effects as in a younger patient.  Some elderly patients will say look, if this treatment has this amount of potential side effects, is not going to cure me and you can tell me that you’re going to help me so that I don’t die with pain etc, I don’t need a few months more so I have to respect that.