Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011
Comprehensive geriatric assessment: Expert roundtable
RS: Professor Reinhard Stauder (Innsbruck Medical University, Austria)
LB: Professor Lodovico Balducci (Moffitt Cancer Centre, Tampa, Florida, USA)
AC: Professor Antonio Cherubini (Perugia University Medical School, Italy)
LR: Professor Lazzaro Repetto (Istituto Nazionale Ricovero e Cura Anziani, Rome)
MB: Professor Mario Boccadoro (San Giovanni Hospital, Turin, Italy)
RS: Thanks a lot for joining us on the podium. I think it became clear from the questions we gave to the audience that the colleagues are very interested in using this geriatric assessment and many colleagues feel that interaction between geriatricians and haematologists should be improved. So when our colleagues go back to their institutions on Monday, how should they approach these two items? How to integrate geriatric assessment and how to improve the co-operation between geriatricians and haematologists? So we would like to ask that.
LB: First of all I wish to compliment the organisers for this very comprehensive meeting and all the speakers who, in my opinion, did a superb job. As senior in this field, not only because I’ve worked in this field probably more than anybody else but also because of my chronologic age, which is older than Dr McVie, as we have seen, I’m probably the oldest physician here, I take the prerogative to make a couple of comments that I think will summarise what was said today. First of all, I think we all concluded that age is a physiological fact and the physiological assessment of the age should direct the management of the patient. Second, we concluded that the geriatricians have developed a number of instruments that have been used for the assessment of life expectancy and I’m very grateful to Professor Lucio for presenting those data from Lee, from San Francisco, showing how comorbidity and function can be integrated in a very reliable estimate of mortality risk, so that is already there. And also for showing the work done by us, Repetto has shown how the geriatric assessment and especially function, not that much comorbidity, function can indeed predict the risk of complications from chemotherapy. And finally I was very impressed by the communication of Dr Vey from Marseilles that has highlighted what I think should be the conclusion of this meeting, and that should be the conclusion of a co-operation between geriatricians and oncologists or haematologists in the management of older patients with all types of malignancies. I want to congratulate the people in France who have realised that already from a long time ago; they have a fantastic network of geriatric oncology, they will form this year the Société Francophone d'Onco-Gériatrie. They have already established this co-operation so they can really be a model for all the other countries. But in my opinion that should be the main conclusion of the conference today. Thank you.
AC: I cannot not agree with Professor Balducci because of course this is probably the way forward. What I could see from the different presentations is that we have two different issues here that we call under the same umbrella of comprehensive geriatric assessment. One issue is to have screening tools and the other issue is the second part of the comprehensive geriatric assessment which is the management of the complexity of the problems. So in this sense I would think that the screening is only part of the job but then we need to manage and the more successful will be the therapies in prolonging survival of these patients, the more we will need to manage all the complexity of the other problems. Just one example that was very clear in the beginning of the presentation of Professor Balducci, the issue of polypharmacy. It’s a tremendous issue, 15% of older people go to the hospital just for side effects of medicines. The more medicines become available, the more the issue is becoming a problem. So I would think that from Monday what is going to be really useful is to start to make research on how the integration… so the approach that Professor Vey clearly illustrated there already, doing that, but I think it’s the way forward because we have to build this collaboration. We don’t have an established example to do but we need to build that and the best way to build anything is to do research on that and to see which impact will make this collaboration on the outcome of our patients.
RS: Maybe you could comment, there is certainly a difference between a comprehensive geriatric assessment which is certainly a holistic approach and the multi-dimensional geriatric assessment which uses some scores which might be appropriate in a certain situation?
AC: When we speak of comprehensive geriatric assessment, although the expression is somehow misleading because it focuses on the evaluation. But this is really a methodology for the management of the patient in which all the instruments that have been shown are just a way of collecting pieces of information in order to allow the team to prepare and individualise a treatment plan that is then further re-evaluated. So I think that also the last presentation of my Spanish colleague, I don’t remember the name because Michelangelo sounds very similar to the Italian one, but it was clearly pointing out that we need different steps. The screening is a phase, then the complete evaluation for those who need it is another step and I believe the management of the complexity of the haematological and non-haematological problem is a further step and we need to find a way to address all these phases, not just the initial screening.
LR: Can I make a comment starting from your initial question, how to integrate oncology, haematology and geriatrician? I want to start from the conclusion of Professor Boccadoro’s talk, he concluded his presentation saying that we need tools and I want to add that we need specific tools to be validated in the haematological setting. I think this should be the next step. So far we have a lot of data sustaining the validity of the geriatric approach, of the use of comprehensive geriatric assessment in oncology. Now we have to find tools to be validated in specific situations. Of course we cannot imagine that a single tool may be fit for patients, candidates for aggressive treatment like bone marrow transplants, or for less aggressive treatment. This should be the next point to be addressed in clinical trials. My second comment is on the use of screening tools or very comprehensive geriatric assessment. In our practice we administer this screening tool to every patient older than 70 years, just to define patients likely to benefit or not from specific oncologic treatment. For the first group of patients, we used a comprehensive geriatric assessment in order to decide what type of treatment is the best option for individual patients.
MB: May I ask all of you a simple question? The word complexity came out several times; I think that it is even more complex than before because we are not talking about intensive or not intensive treatment for acute leukaemia. High dose RSC, low dose RSC, we are talking about hundreds of new drugs that are really effective and are less toxic than before so the complexity is even more complex. So what are your ideas about the possibility to solve this problem in facing the new agents in myeloma, in CLL? There are several new drugs.
LB: I believe, and you are one of the leaders in that field, that of course in many diseases from acute leukaemia to mainly myeloma or CLL, the molecular profile of the disease may answer the direct treatment and consequently that can give up. For example in CLL, obviously unless you have an 11 Q you really don’t need to use a combination of FC, according to somebody, I’m just giving that as an example. Acute leukaemia is a disease where aging is almost always a marker of poor outcome. But going back to the geriatric assessment, I think that the basic decision of any medical decisions is the one that Lazzaro presented and these always worked out the balance between benefit and risk. Now the new medications may reduce the risk of the treatment so they may allow people who are less fit to be treated but the busy point is always there. The balance is always there, the balance may be changed by the type of treatment that we receive but the question is always that balance. And to know that balance you need to know who is the patient that you are treating and for that reason I mentioned before, Cherubini mentioned it and I am going to mention it again, it’s extremely important to have this co-operation of geriatrician and haematologist and also it’s important to collect the data, to have some vaguely reliable databases so you can continuously update and learn whether the IADL, for example, are a risk factor for chemotherapy related biotoxicity; they may not be risk factors for azacytidine or for lenalidomide or for some of the new targeted treatments. So that’s why it’s so important to keep these databases, you are not going to learn that in randomised control studies, you need to have thousands of patients for doing that. We all present here, we should all feel responsible to be involved in this very important type of population research because that is the only way to learn what we are doing with older patients. I think that in Europe you have a much better system than we have in the United States; you have nationalised health care so you can definitely more easily obtain follow up datayou have a kind of captive population so you can obtain this data much easily.
AC: With cancer I think that we need to work a lot on these two aspects of pharmaco-evaluation. The first one, I agree the clinical trial doesn’t give a lot of answers but still we need to insist that older people are included in them and that there are pharmacokinetic studies that are currently often poorly done. So we need that information and this information we need to combine with the information of large databases. But, of course as Professor Balducci clearly pointed out, the information we’re going to get from the database is clearly dependent on the quality of the database. So even in that the collaboration would be essential; if we can characterise older people with a real comprehensive geriatric assessment and then follow up the treatment of haematological malignancies, we are going to have a lot more information than just collecting the standard clinical information about age, sex and maybe diseases or drugs.
LR: A comment on this. I think that pharmacologic studies are very important and we need phase I, phase II studies in elderly patients before to use in the large practice with new drugs and even older drugs. We have a resolution at the European Parliament asking for a registrative study to evaluate a number of very young people but we don’t have a similar solution asking to evaluate elderly patients and we should have this resolution. A second comment on how to best integrate geriatricians and haematologists and oncologists, in our team we should have at least one physician dedicated to this type of patient. Only with dedicated people we can build knowledge, new studies and implement our practice.
LB: I would like to add to all that, one aspect that we have talked much about and that is extremely important and can also be obtained by the databases and that is the long-term outcome. We have talked a lot about active life expectancy and it’s very important to have this co-operation between geriatricians and haematologists first to manage the patient and make sure that they are maintained in a fit condition while they receive the treatment, but second also to see how badly the treatment may or may not affect these patients. For example, the CR data that are not based on function, are not based on sub-CR data, suggests that chemotherapy causes dementia, other CR data suggests that they do not. So really those data are not adequate to study this problem. Finally, the other issue that I really think needs to be studied together with all the other issues of geriatric oncology is the care giver.
AC: A quick comment. We should be aware that this aging of the population is generating and it is always serving a kind of schizophrenic response. The European Union decided that 2012 will be the year of active aging so that we need to improve two years of active life expectancy and then they, for instance, only now start to do something with a lot of insistence from patients and societies about the evaluation of drugs in older people. But if we cannot guarantee better treatment of chronic diseases, how can you expect to achieve the active aging?
RS: This discussion was very lively, thanks a lot to the specialists; thanks a lot to the speakers. I finish this session. Thanks.