Management of haematological cancer in the elderly

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Published: 29 Mar 2011
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Prof Reinhard Stauder - Innsbruck Medical University, Austria and Prof Mario Boccadoro - San Giovanni Hospital, Turin, Italy
Prof Reinhard Stauder and Prof Mario Boccadoro speak to about a roundtable discussion on the management of haematological cancer in elderly patients, which took place at the Blood Cancer in the Elderly European Expert Forum, Rome 19th-20th March. There are a large number of treatment options available and clinicians must take numerous factors into account before they can decide on the correct choice. Many drugs have produced excellent results in younger patients but have not been as successful in the elderly. Although it is important to assess patients according to physiological and not chronological age, there is a need for more randomised trials to establish the optimal doses of these new drugs when used to treat less fit patients. Profs Stauder and Boccadoro conclude by discussing the importance of a multidiscipline approach to geriatric oncology, the need for new tools to treat blood cancers and the journal of geriatric oncology.

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

Professor Reinhard Stauder (Innsbruck Medical University, Austria) and Professor Mario Boccadoro (San Giovanni Hospital, Turin, Italy)

Management of haematological cancer in the elderly 

Interviewed by Peter Goodwin

PG: now has the opportunity to welcome both Reinhard Stauder from Innsbruck and also Mario Boccadoro from Italy. What are you involved in at the moment? You’ve just come out of this session, a round table discussion aimed at looking at managing elderly haematologic oncology patients. What were the key things that came out of it? First of all, if I may ask you Reinhard about evaluation because that’s the big issue?

RS: It’s an important issue because we have to realise that the majority of our haematological oncology patients are older than 70 years. So in many diseases the median age is around 70 or even 75 years. So we have to evaluate the physiological age; physiological age should form the basis of our decision. So it should not be the passport age, it should be the individualised treatment which is the most important thing in decision making.

PG: And you had contributors at the session talking about all the different malignancies – myeloma, MDS, CLL, lymphomas, AML. Is it the same for all of these?

RS: We realised, one of the conclusions was that it is quite important to include this evaluation of physiological age in all different blood cancers. And we have discussed which is the best approach, which is the best way to establish it, the best way to integrate it. But without any doubt it has to be integrated in all haematological malignancies in the elderly.

PG: Now how does that ring with you, Professor Boccadoro, because you are also interested in the whole process of decision making about therapy for the various haematologic malignancies? First of all you’ve got the evaluation and the fact that the physiological age is now considered to be paramount. What is your thought in terms of decision making?

MB: Before making a decision you have to look at the several possibilities that we have in several haematological malignancies. We are going from allogeneic transplantation to the new drugs to the palliation. The array of possibilities are enormous so we have to take into account the biological characteristics of the disease; we have to decide which is the best treatment but, first of all you have to talk with the geriatrician and we have to establish a collaboration between the geriatrician and the haematologist. This is the only possibility to make the right therapeutic decision for your patient because you have to take into account the response rate but also the toxicity of every drug in every patient.

PG: So one of the special things in elderly patients is that the geriatrician can have quite a big input?

MB: There are at least three new drugs that have been explored in randomised trials that are giving excellent results that we never saw before. But that doesn’t hold true for the elderly myeloma patient where you have a rate of discontinuation of about 40%. So it’s right, it’s obvious that the dose is not the right one, that we have to take into account several other aspects; we have to modify and we need specific trials for these patients.

PG: So how does that ring with you?

RS: That sounds quite well. It became clear to us, we made interactive questions with the audience and the majority of haematologists in Europe believe, or they are fully convinced, that this co-operation between haematologists and geriatricians has to be improved. So this is one of the major points at this conference.

PG: I know that there is this whole thing at the beginning of the conference about what is classified, what is the definition of old age. Do you think that is evolving as the conference progresses?

RS: Yes. I have the feeling that it is evolving because the specialists from the different entities, they start to realise that the median age in CLL in myeloma, in myelodysplastic syndromes, is much higher than they had anticipated before. And an important point was that physiological age is more important than chronological age.

PG: And from what you’re both saying, the co-operation and teamwork and the multi-disciplinary aspect of care seems again to be extremely vital, especially in older patients would you say?

MB: At the end of the session, we had some criticisms from the major experts, saying that we need more support for this. If aging is really the major problem in the European community, we need support because to establish this multi-disciplinary team is more complex than before. So the criticisms were that the European agencies are recognising this problem but probably not yet supporting adequately these new activities. It’s more complex than before.

PG: And there seems to be also a growing awareness that this is a speciality that needs to be named as a speciality – geriatric oncology. What do you both think about that? The conference here has very vigorously supported it, it’s a full house.

MB: There are some areas that need more support. These are the areas where you have the advantages in the therapy for myeloma. For instance, there are some diseases where the survival is unchanged in the last twenty years but where you have big advantages, so you have to establish there the co-operative teams.

RS: I feel that there are two major points which are responsible that colleagues are interested in elderly cancer patients. Point one is that the elderly, in real life, form the majority of our patients so they are just there which means when they go back on Monday to their hospital, these elderly persons will be there waiting for a decision. Secondly, colleagues know that decision-making in the elderly is not as easy as in younger; it’s complex. You have to consider comorbidities, you have to consider cardiac impairment and so on. That’s why they are glad to have a conference where these points are addressed by the specialists.

PG: So could I ask you both finally, what are the practical messages that will help doctors to make these right decisions and do the right evaluation?

MB: My last slide was a big sentence: we need tools. We have to elaborate new tools and to validate new tools so all the doctors can rapidly assess the patient in a multi-disciplinary session. So we have to go in this direction to create new tools.

PG: Reinhard, do you think that doctors are equal to this at the moment? Will they be dismayed by the difficulty of treating older patients with blood cancer or are there definite things that you would recommend doctors to be doing right now?

RS: I would recommend including a multi-dimensional assessment in their evaluation process and one more important point is to develop recommendations and guidelines, particularly for the elderly. So then the colleagues have got a kind of help in their decision-making.

PG: There is a journal of geriatric oncology now, it’s a new publication. What’s the importance and the relevance of that publication in this era where we are now very aware that older patients need a particular category of treatment?

RS: The Journal of Geriatric Oncology is new, it was launched in 2010; it is the official organ of the International Society of Geriatric Oncology and it addresses all questions and items related to elderly cancer patients.

PG: Well that sounds very wise counsel. Thank you both very much, Reinhard and Mario for joining me on