Different options for elderly CLL patients

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Published: 29 Mar 2011
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Prof Robin Foà - Sapienza University of Rome, Italy and Prof Michael Hallek - University of Cologne, Germany
As the average life expectancy increases in western nations, the issue of how to treat cancer in the elderly is becoming an increasingly important issue. The most common leukaemia in the western world is CLL (chronic lymphocytic leukaemia); Prof Robin Foà and Prof Michael Hallek outline the different therapies available and discuss the factors which influence clinicians’ choice of CLL treatment. There is a need for more clinical trials to develop drugs with lower toxicity profiles which can be tolerated by less fit elderly patients. Profs Foà and Hallek speak about the low toxicity and potential role of kinase inhibitors and antibodies, the necessity to adjust treatment for different patient subgroups and the need for a standard measure to define patient fitness.

Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011

Professor Robin Foà (Sapienza University of Rome, Italy) and Professor Michael Hallek (University of Cologne, Germany)

Different options for elderly CLL patients

Interviewed by Peter Goodwin

PG: ecancer.tv is now pleased to welcome Michael Hallek from Cologne, a big centre for haem-onc, and Robin Foà from Rome, La Sapienza University. Robin, you opened the session, can I ask you first, I want the two of you to tell me about the CLL session and some of the round table discussions, the exciting ones you’ve just been having. But to begin with, you’ve got some demographic points to make, haven’t you?

RF: Yes. I was asked to make an introductory comment on the congress, a) because we’re in Rome and b) also as the AHA President and that’s something that they asked me to comment upon. The congress is extremely timely because of the demographics. We’re in general living much longer so the definition of elderly is changing considerably. To give you some figures, we’re living in Italy and in Italy the median life expectancy overall is about 82-83 years with females over 80 and males 79. This is more or less the same figure in central Europe but it’s not the same around the whole world. If you go to Russia it’s ten years or fifteen years younger; if you go to Turkey it’s about ten years younger; if you go to Africa we’re talking about forty or fifty years of median age. So it’s extremely important the fact that we are living longer but it’s not the same around the world so demographics at the time of treatment of the elderly is a key point.

PG: But it’s a growing problem in many parts of the world that far more, a greater proportion, of the population, are older.

RF: Older and, we should add, not only older but fitter because there’s also the issue of anagraphic age and biologic age so we’re growing older and often we are in much better conditions.

PG: Now fitness, Michael, is one of the key topics that was discussed at the session. What are your views about, first of all, the definition of fitness because it does affect what treatment you can give your elderly patient with blood cancer.

MH: Absolutely. I think physical fitness is now becoming the key discriminator between treatment allocation actually, allocations of our more aggressive treatment versus a milder treatment or more gentle treatment. There is a problem already: we don’t have a common, generally accepted definition of a physically fit patient versus a non-fit patient. So for the future development of this very important area, I think one of the major developments that now have to take place is that we have some kind of a common sense or a common definition of how we define fit versus non-fit patients. We have made some attempts in the German group to do that but that’s just out of the positive data that we have developed a score or used a score but there’s plenty of other algorithms to do this and I think the challenge is to come up with a generally accepted thing.

PG: So let me get this right, if the patient is fit then there is a whole range of treatments which can be used?

MH: So if the patient with CLL is physically fit, you can give him chemo-immunotherapy, so triple combinations and in a less fit patient that’s not the case.

PG: And some countries are different from other countries because I heard it say that in the United States of America, cancer doctors don’t know how to spell chlorambucil.

MH: Absolutely. Well that’s another thing, there are not only age differences but also cultural differences, which I like to call it, or national differences or transatlantic differences in treatment since a few drugs, like chlorambucil, are widely used in Europe. I think we had a survey here at the meeting where physicians were responding, 60-70% were using chlorambucil as a first line in the elderly while this drug is unknown to many centres in the US.

PG:  But Professor Foà, what do you urge clinicians to be doing from this CLL, chronic lymphocytic leukaemia, session that you’ve just been attending?

RF: One of the main messages that came up from what has been developed so far is that the elderly, which as we said earlier are now preponderant. I come from a country, Italy, where a third of the population is over the age of 65. With the decline in fertility, in Europe at least, we are becoming not only old in age but becoming an older population. So we have to focus much more our attention on the elderly which, for certain haematological diseases, are a very important proportion of patients. So this came out very clear. Clinical trials must be designed, also for less fit elderly patients which are today an unmet clinical need. Bearing also in mind that if you reach a certain age you’re prone to live longer; if you’re 70, you haven’t died earlier, your life expectations in Europe would be probably almost another 15-20 years. This is extremely important.

PG: Chronic lymphocytic leukaemia is a disease of older patients and many of those patients over the age of 70 have been excluded, or simply not included, in randomised controlled trials. Now we need treatments specifically for them, what about the gentle treatments that you’ve been discussing about this, Michael?

MH: Well the hope is that we would have, and already have, a couple of drugs that are mild in their toxicity so we could use chlorambucil which already is a little milder than the combinations. Antibodies usually, especially rituximab used in CLL as a single agent for activity but very low toxicity, therefore frequently used in the US, less so in Europe. Then there are new drugs coming which is our hope also in a few years we might treat CLL with kinase inhibitors and they are extremely non-toxic, they barely have any toxicity. And in the future, and I would say future means in five years from now, we could use combinations of antibodies plus kinase inhibitors and that’s a suitable treatment for less fit patients, of course.

PG: Could I get both of you to discuss what you think are the practical messages coming over for the busy oncologist?

LB: Referring to CLL, let’s remember that a) it’s the most frequent leukaemia in the Western world and it’s something we haven’t said. It might be different in other parts of the world, for instance it’s rare in Asia; in Japan it’s a very rare disease but in Europe, in the Western world, it’s the most frequent leukaemia, accounting for about 30% of all leukaemias. So we need to diagnose them very accurately and we need to have different algorithms of treatment according to different subgroups of patients – elderly, fitness, and we haven’t discussed prognostic markers. That, I think, is what we have to devise further and innovative treatment strategies.

MH: Which means, in practical terms, and just expanding what Robin has said, a physically fit patient with positive genetic prognostic markers, meaning good prognosis, usually is treated with FCR if the patient needs treatment. A patient with reduced physical fitness, usually in Europe, should be treated first line with chlorambucil and we should also emphasise again the vast majority of all patients are diagnosed at a stage where we don’t do any treatment at all. So early stage CLL doesn’t need any treatment and that’s the key messages.

PG: Well there’s much more to be said about this very fascinating and important subject in such a common cancer but Michael and Robin, thank you very much for joining us here on ecancer.tv.