2010 American Society of Hematology Annual Meeting 3rd 7th December
Prof Lodovico Balducci - Moffitt Cancer Center, Florida, USA
Senior Adult Oncology Program at Moffitt Cancer Center
LB Ludovico Balducci
We tend to think of cancer as a disease of old age. Now, explain; is it just that?
LB The cancer is definitely a disease of old age. I think developing cancer is a price you have to pay for getting older. It’s the same way as, you know, getting Alzheimer’s disease and many other diseases. Fortunately, cancer is a disease that in the majority of cases is treatable, and the reason why we started this programme, which indeed was the first in the world when it was started in 1993, was to facilitate the treatment of older cancer patients.
IV At the moment, older cancer patients may not be getting treated in a satisfactory way, is that what you thought?
LB I think that was definitely... was the case when we started. I think that the situation has improved dramatically since then. And I think that we have a role in that.
IV What were the issues that you to look at?
LB I would say there are several issues, because age is a multi-dimensional event. But I would say the major issue... main issues were ageism; in other words, prejudice against age, feeling that age was associated with a poor outcome, irrespective of what. Number two, difficulty of access to care, number three, discomfort of many healthcare providers in assessing what ageing is about, and that I think has been the major issue that we have promoted through our programmes.
We explain that age is not a chronological event as much as a physiological event. There are people in their seventies, sometimes in their eighties who run marathons, and do a lot of activities, and if they develop cancer, it would be a big disservice to deny treatment to them.
IV So in your Senior Adult Oncology Programme, what have you been doing?
LB We have been doing a comprehensive assessment of the older person, try to establish what the older person’s life expectancy was without cancer, what the risk of the chemotherapy was, so that the person could make a informed decision. We have also tried to make sure that the other problems of ageing were taken care of, for example, our average patients take ten drugs. Each one of these drugs may have side effects. Some of them are important, some of them maybe not, consequently, we are going to optimise their treatment. Often older patients need to have access to care, they don’t have adequate transportation, they don’t have an adequate care-giver and so we take care of these social problems as well. Older patients may have problems with nutrition, simply because they don’t have adequate access of nutritional... of our patients are indeed interviewed by a nutritionist, by a social worker, taken via pharmacist, to take care of all of these collateral problems that go with ageing.
IV Obviously it’s a many-faceted problem, and also a multi-disciplinary situation that you’re dealing with, but could you pull out of that some of the key things that you think clinicians and carers ought to be holding onto, to keep clear in their mind about how to improve cancer treatment for older patients?
LB I believe that the key issue is to assess the functional age of each person, okay? And that can be done with the geriatric assessment, and hopefully in the near future, we’ll... we will be able to do it with some laboratory tests. For example, the length of leukocyte telomeres is a very promising test for that, the concentration of inflammatory markers is a very important test. The second important issue is to take care of all the other problems that the older has. Remember that we are not just taking care of cancer, but we are taking care of a person who has problems with transportation, who has problems with movements, who has problems with taking maybe too many medications or too much medication or something. And so to optimise all the other aspects of this person...
IV Is there a problem of additional toxicity with older patients?
LB Absolutely, age is associated with an increased risk of some of the chemotherapy-related toxicities, such as depression of the bone marrow, Mucositis, which is an inflammation of the mucosa that can cause dehydration in older people. Peripheral Neuropathy, that may make older people more dependent, more unable to function, and perhaps increase the heart toxicity, whether the chemotherapy affects or not the cognitive function of the patients is still a question, but certainly something that needs to be studied.
So most of these toxicities can be prevented, and that’s one of the things that we are certainly engaged into doing.
IV Age is sometimes an exclusion criterion in randomised control trials. What can be done about that, and are there enough RCT’s being done?
LB Not... age fortunately is not anymore a... as far as I know, at least in the Western countries, a criteria of exclusion from a randomised control trial. And indeed, there have been a number of very important studies done mainly in Europe, on cancer in the elderly. For example, there are four or five important studies coming out of France and Italy, Sweden, the Netherlands over Lymphoma in the elderly. There have been very important studies done here in the United States by Dr Massa, over adjuvant chemotherapy on breast cancer in older people. So these studies are being done, the real problem however, even with these, is that they select in the best possible population of older people.
It’s very important to demonstrate that chronologic age is a not a contra-indication to treatment, but we really would like to see how chronologic... how co-morbidity, how poor function... how poor cognition without definite dementia do influence the treatments and that is what we are engaging to find.
IV And would you like to see less cherry-picking of patients for studies?
LB Absolutely, no it depends what the study is about. I mean, the studies that were done by Dr Coiffier in France, by Dr Zinzani in Italy, by Dr Bjorkom in Sweden were certainly... in Sweden was certainly extremely important in showing that you can treat the Lymphoma, a curable disease, even in patients who are very old. So that principle was demonstrated. What we need to know now is, in which of these patients, on which older patients this treatment is indeed beneficial? And this is what we are here for.
IV And you’ve been leading the way here in Florida, at the Moffitt in Tampa, but this is now beginning to happen all over the world.
LB I would say that I’m... you know, our programme was the first in the world, that I know, and in 1993, there was very little written. My book was the first book of geriatric oncology published at that time. Since then, there have been some major programmes established in the United States, but I have to pay particular respect to what was done in France. France I think is really the model of... and I have been a consultant for the initial Institute of France... for the National Cancer Institute of France for about four years. And they have created a network of work on cancer in the ageing, where oncologists and geriatricians work together, and all older patients proactive throughout France, are properly evaluated and studied. I think that has been a fantastic model to be developed in all the world.
In the United Kingdom, we have Dr Aldizium in Bristol, who has done... probably has been the first surgeon really to study the influence of age on the surgical risk. He has done a fantastic, he has developed a number of very important models, is new incoming President of the International Society of Geriatric Oncology. And in many other countries, Switzerland, Italy, Spain there has been a lot of movement for that, and right now, even in Brazil, I just was in Brazil a couple of weeks ago, there is a movement. In fact, I know several people who trained with me. Throughout Latin America there is this interest. I would Brazil and Chile are probably the countries that are more ahead on that respect.
IV And finally, what word of encouragement or idea would you like to leave clinicians with?
LB I would like to leave the clinicians with the idea that they need to become comfortable in examining older people, in recognising what functional age is, and in giving to these people the best possible treatment to maintain not only their life, but mainly their function, which is the most important aspect. If I can leave you with a key word, that is active life expectancy. Active life expectancy means how long the older person is going to be independent, and that is the most important thing that we need to produce through treatment of cancer and... Well, treatment of all diseases in the ageing. And cancer is probably... right now is a major threat to this active life expectancy.
IV Ludovico, thank you very much for joining us here in Orlando.
LB Thank you.
IV So it’s goodbye from e-Cancer TV just for a few moments, from the Convention Centre in Orlando.