The Impact of Personalised Medicine in Elderly Patients with Cancer
How to assess reserves in elderly cancer patients and specific issues for use of targeted therapy in that population
We met with Matti Aapro of the Institute of Multidisciplinary Oncology in Geneva, Switzerland, to discuss the benefit to elderly patients with cancer from the increased understanding of cancer biology, how to develop and implement a standardised approach to strengthen our ability to assess and tailor treatment plans that optimise treatment outcomes, and the specific issues regarding the use of targeted therapy in this population.
ESMO: Can elderly patients benefit from increased understanding in cancer biology?
Matti Aapro: Today’s advances and understanding in cancer biology are important for all of our patients and, obviously, that includes the elderly patients. We believe that by addressing the mechanism that is underlining the cancer progression, we will avoid some of the side effects related to drugs which are not that specific. This will therefore, for elderly patients, who are more fragile, decrease the risk of having side effects that would be deleterious for the outcome.
ESMO: The geriatric population is frequently excluded from cancer clinical trails. So, can we apply research finding from younger counterparts, or is there something specific to take into consideration with elderly patients?
Matti Aapro: Well unfortunately, elderly patients are not often included in clinical studies. There is still a trend, even if it is not as strict any more, to not include elderly patients because colleagues believe that they will not tolerate the treatment. It is because of the compatibilities that come with age. Elderly patients not being in clinical trials, as often as they should be, means that we will not have the numbers needed to really evaluate what is the interaction between the agents used to treat the cancer, the other drugs that the patients needs for the other diseases they might have, and the elderly have other diseases which can be considerably impacted by the interaction between the drugs, or also can impact on the tolerability of the treatment by the elderly person.
ESMO: How do we develop and implement a standardised approach to strengthen our ability to assess and tailor treatment plans that optimise outcomes for the elderly?
Matti Aapro: In the past we thought that the age limit was determinant. We have realised that this is completely wrong. What is important is to understand who the elderly person is. Geriatricians have told us that we have several types of instruments that can look at the elderly person, assess the elderly person’s reserves, in terms of, for example, diabetes, lung disease, cardiac disease and then determine how frail this person is and depending on the frailty level of the elderly person, we will have to adapt the treatment, or, very often, this frailty can be a reason for a specific geriatric intervention.
ESMO: Now targeted treatments are often in a convenient form of pills. Are there specific issues for elderly patients by taking the treatment in that form?
Matti Aapro: Today’s treatments tend to be, more and more in the oral form. Both cytotoxic agents, or so called ‘targeted agents’ - I always laugh at that because hormonal treatment is targeted therapy and we never use the term 'targeted' for hormonal treatments.
The fact that they are long term treatments means that the patient will start the treatment, and then the patient might experience some side effects and will decide ‘well after all I am not going to take this, but I am not going to tell the doctor either’.
Another thing that can also happen is that some patients tend to forget, this is an issue with elderly patients much more then younger patients. So the management of this long term treatments with oral therapy really needs a different type of approach. We can not simply proscribe and see the patient a few weeks later to see what has happened. We have to establish a way of communication, and depending on the country, depending on the set up of the health system, this could be either through the physician or through the nurse or through the local general practitioner who can be involved in some countries as well. In order to make sure that the patient will come back, ask questions and that we can encourage them to continue with the treatment even if there are some initial side effects.
ESMO: So how important is regular contact between the doctor and an elderly patient in helping to ensure that they continue to take the oral drugs?
Matti Aapro: Doctor-patient contact is of primary importance and the importance in the elderly person is the same as in the younger person, we need a bond between the doctor and not only the doctor - the whole treating team, a bond between the nursing team and the patient because the faith that the patient will have in the outcome is very much dependent in the trust the patient has in their team. Furthermore, what I would like to emphasise for elderly patients is the importance of eliciting their opinion. Elderly patients tend to be less active in giving their opinion, they are a little bit more passive - it has been shown in studies and it is very important to allow them to say what they think, what is their goal besides our goal, and to match the two goals.
Today, the interaction between physicians and the patients has been studied by quite a few groups, and what has been clearly established is that unfortunately, in the medical faculties, we are not taught how to speak to a patient, how to listen to a patient. Now, in some countries, at least in oncology, and I am certain it’s also now reaching other areas, we have specific courses that are given in a postgraduate setting in order for trainees to understand what are the technics of talking to the patient, of reassuring a patient without being paternalistic and also of allowing the patient to voice his or her own opinion.
ESMO: What role can ESMO play in improving the way that elderly patients with cancer are treated?
Matti Aapro: ESMO has embraced the importance of addressing this specific sub-population of the elderly patients very clearly. A couple of years ago, ESMO published a
Handbook for physicians on how to address the elderly cancer patients population.
I am also a member of SIOG (International Society of Geriatric Oncology), and we would like to work very closely with ESMO in the development of the adequate means to better understand the patient, to better treat the patient, and also to address the issues of the patients' families.
ESMO: How important is a collaborative approach for improving the treatment of elderly patients?
Matti Aapro: The collaboration between scientific societies is of paramount importance. There are the larger societies that embrace a whole field, like ESMO embraces the whole area of medical oncology. Then we have specific societies that look at different specialty areas. In the areas that I am interested in, like geriatric oncology, we have SIOG. We have also the supportive care society, called MASCC (Multinational Association of Supportive Care in Cancer) and this is a prime example of the fantastic collaboration between MASCC and ESMO as we now have common guidelines in some areas of supportive care.