In today’s podcast, Dr. William Tew and Dr. Andrew Artz explain new research presented at the 2016 ASCO Annual Meeting on older adults with cancer. They discuss why it’s important to include older adults in cancer research and what to consider when older adults receive treatment.
ASCO: You're listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology known as ASCO, the world's leading professional organization for doctors who care for people with cancer.
In today's podcast, Dr. William Tew and Dr. Andrew Artz explain new research presented at the 2016 ASCO annual meeting on older adults with cancer. They discuss why it's important to include older adults in cancer research and what to consider when older adults receive treatment. Dr. Tew is a medical oncologist in the gynecologic medical oncology service at Memorial Sloan Kettering Cancer Center and associate professor of medicine at Weill Cornell Medical College. Dr. Artz is a hematologist oncologist and associate professor of medicine at the University of Chicago Medicine.
The ASCO Annual Meeting is the premier educational and scientific event where physicians, researchers, and other healthcare professionals gather to discuss the latest in cancer care and treatment. This Cancer.Net podcast helps put new research findings into context and explains what they mean for patients. ASCO would like to thank Dr. Tew and Dr. Artz for summarizing this research.
Dr. Tew: Well, good afternoon. My name is Dr. William Tew. I'm a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, and I'm a specialist in geriatric oncology, which is an emerging field that is looking at the effects of cancer and its treatment on older adults. And I'm here with my colleague, Dr. Artz. Dr. Artz, did you want to introduce yourself?
Dr. Artz: Great, thank you. My name is Andy Artz, and I'm a hematologist oncologist at the University of Chicago, and likewise, I'm interested in the field of aging with a focus on blood cancers.
Dr. Tew: Terrific. So for this podcast, we are focusing on the research and topics in aging research that were presented at the ASCO 2016 Annual Meeting in Chicago. And I'm happy to say we had a very strong presence at ASCO this year with multiple educational sessions focusing on older adults with cancer, ranging from immunotherapy, precision medicine, to geriatric principles, as well as focusing on specific cancer types such as focusing on patients with endometrial cancer, prostate cancer, bladder cancer, and many more.
What we thought would be most useful today is to discuss some emerging research that was presented at the clinical science symposium as well as the Annual Meeting's plenary session, which all focused on older adults with cancer. The first studies that I wanted to discuss was two large studies that looked at older patients receiving immunotherapy. These studies are most particularly interesting because of the emerging role of immunotherapy in the treatment of cancer. We've seen major breakthroughs for patients with melanoma, kidney cancer, and lung cancer with the use of these new active agents. Moreover, there's been a larger discussion within the United States after President Jimmy Carter publicly disclosed his success with immunotherapy treatment in treating his melanoma that metastasized to the brain. For a 90-year-old president to do so well was really inspiring to us.
So the studies that I want to discuss were two studies. One was a look at the experience at Memorial Sloan Kettering of different immunotherapy agents, including ipilimumab, as well as two checkpoint inhibitors, pembrolizumab and nivolumab, as well as a combination of these agents. This data was presented by Dr. Claire Friedman, and what she looked at was the experience of 74 patients at MSK that received these immunotherapy drugs. The remarkable thing is that all of these patients were age 80 or older, and what she described was how did the patients respond to treatment, and how did they tolerate it. And what was very reassuring from her data was that, although toxicity was seen - side effects were seen, such as diarrhea, effects on the liver, and rash - the percentage of patients that had these types of side effects were very similar to what was described in prior studies with younger patients. So this is very reassuring news for us that age in itself shouldn't be a criteria as far as whether someone's going to be able to tolerate these newer immunotherapy drugs.
The other thing that was important to note was that in older patients, we just have to be a little bit more careful. And older patients are much more likely to have other medical problems, and so if you do have a side effect from an immunotherapy agent, you often have to start steroids or immunosuppressant type of medications. And this could have significant impact on other medical issues such as diabetes, risks of fall, causing delirium or changes in mental status, so we have to be really careful when using these agents in our older patients.
Dr. Artz: Can I ask, what are the special precautions you might take clinically if you're treating an older patient with one of these agents? Do you take any special precautions, or should patients do anything differently if they're older?
Dr. Tew: Well, I think for sure what Dr. Friedman's experience showed was that we be very careful in keeping track of all the potential toxicities, such as the diarrhea, the effects on the organs like the liver and skin. And I think what an older patient who's going to be starting this medications may want to do is, review, first and foremost, all the medical issues that one has, such as diabetes or if they have any bowel issues, to keep their primary care doctor or geriatrician in the loop, in case that one of the side effects develop and affects their other medical issues. And then I think the third is, really if one of these issues were to arise, to quickly reach out to their oncologist, because the supportive medications, the steroids, the hydration, can really improve the tolerability of the drugs. But again, very reassuring that the side effects were manageable in this very old patient population, greater than 80 years of age.
Dr. Artz: Great.
Dr. Tew: Yeah. And, Andy, the other study that was presented alongside Dr. Friedman's study was an even larger study of over a thousand patients from the FDA, which is the regulatory organization in the United States. And what Dr. Singh looked at - and Dr. Singh is a physician affiliated with the FDA - she presented all of the data for patients who had received an immunotherapy agent called nivolumab. And this is the results of studies that led to the approval of nivolumab for kidney cancer, melanoma, and lung cancer. And what she did was look back at how patients did on the treatment as far as side effects and outcomes based on age. So she looked at the younger patients, which she defined as less than 65 and the older patients, which she defined as greater than 65 years of age. And then in the older patient population, she also looked very closely at individual groups like patients in their 60s, 70s, 80s, and so forth. And her findings also came to similar conclusions as the study that I just discussed before, which was that, the immunotherapy agent nivolumab has similar side effects whether you're younger than 65 or older than 65 and that the outcomes also were very similar. So again, very reassuring findings from the FDA.
Dr. Artz: That sounds like great news for the older patients that these options would be available to them, and at least they're treatments they can consider.
Dr. Tew: Absolutely. And I think what this data really highlights is, one, the lack of knowledge that we have for older patients, and the problem with many of the clinical trials that are done in the United States is that they typically enroll younger patients or patients with less medical problems. And often we don't know how well they're going to do with these treatments. So this at least provides a little bit more light and focus on the older patient. And again, very reassuring information for our patients and oncologists.
Dr. Artz: Great.
Dr. Tew: Yeah.
Dr. Artz: Maybe with that I should also discuss a similar issue related to surgery for patients with colon cancer for older adults. Again, with the theme that we often don't know in older patients how they do because studies and a lot of information initially provided tends to be in younger patients. And I liked the study because it was very large and the author, Dr. Aquina, looked at all the colon cancer surgeries done for colon cancer in New York State. And colon cancer surgery is very important part of the initial treatment for colon cancer that's anything more than a very small nodule. And usually, it's with the removal of at least part of the colon called a colectomy or partial removal, a hemi-colectomy. And that's a pretty significant surgery though, and what they found when they looked at how well the older patients did - and they looked at it for one year after surgery - and a lot of the surgical studies had only looked at the first 30 days after the procedure about complication rate, and what they found was that older patients - especially those 75 years and older, where colon cancer is still a common problem - had higher rates of complication and were less likely to be alive one year after the surgery relative to the younger patients. They also showed that one of the main problems were related to cardiac events presumably heart attacks or heart failure that caused people to have a serious event that prevented them from being alive one year later.
I think the message from this is that the older patients need to be evaluated more closely before surgery and while surgery still is often going to be recommended, just has to be done with more caution and probably with more attention before the surgery and even after the surgery with issues that older patients may have, such as heart problems. I don't think, though, the message is not to do surgery because a lot of times this is really important to prevent subsequent problems but just to do it in a safer fashion or in a fashion in where we really think about the needs of older patients, since they may have other medical conditions such as heart problems.
Dr. Tew: Yeah, and that really highlights another topic that was brought in during the clinical symposium on Saturday at ASCO, which was looking at individualizing the care of older patients. And one of the lectures during that symposium was really focusing on the surgical patient and the need of developing better assessment tools before surgery to determine who's at the highest risk. Because we know that chronologic age isn't a very good predictor as far as who is going to have major complications from surgery.
Dr. Artz: Yeah, I think that's a great point, and I think that presentation by Dr. Audisio was a really nice review of older patients undergoing surgery, and I liked some aspects of the talk where he highlighted, first having a really informed discussion, because there are advantages to surgery and preventing problems and there may be downsides as well and just letting the patient know in advance, and the family members, obviously is important. And also I thought the discussion about ways investigators are now looking, and I know you are doing this yourself and at your center and others as well at our center, looking at ways to strengthen people before surgery if time permits, often called prehabilitation, or working on function or other aspects.
Dr. Tew: That's right, so first finding what components of the geriatric assessment that would make a patient vulnerable to a complication from surgery and then intervening before that complication happens. So I think this idea of well, if someone isn't strong enough physically to recover from the effects of surgery, well we should really be focusing our energy on trying to improve the strength of the patient before bringing them to the operating room. Like you mentioned, the prehab type of model. And the key thing is finding which patients would benefit the most and how to incorporate these types of interventions with surgery before or after.
Dr. Artz: Yeah, and you know the last point that I thought was really important was he discussed briefly how you can tailor a surgery a bit to the patient and their different methods of even of how you care for someone having a surgery. And it really seemed like a perfect opportunity to use the assessments beforehand and working with the geriatrician, internist, or medical oncologist to work together as a team to recognize where there may be problems. And perhaps surgeons can modify the approach a bit to make it more tolerable based on the person's needs, if some people may have less adequate nutrition before surgery, some may have more of a history of bowel problems, some people may have been confused or had delirium, and there may be ways after surgery to work together as a team. And even family members, I would think, if they're in with the informed discussion to help prevent some of these complications.
Dr. Tew: That's right. I think this idea of a team approach - particularly in the surgical patient - is the right approach. And I think this is where patients and their families can really act as advocates and encourage a preoperative evaluation, potentially with a physician who has a background in older patients, such as a geriatrician. And with a geriatric evaluation, one could get a better assessment to see if there is any need to reduce the risk of surgical morbidity. And like you mention, the nutrition and physical therapy aspects seem to be the highest of them all.
Dr. Artz: So I guess putting them all together, it sounds like older patients are often able to be offered these newer therapies or approaches. Just has to be done in a more careful manner and perhaps with a planned team approach.
Dr. Tew: Exactly. And I think recognizing that our older patients are going to have more medical problems, they're going to be on more medications, they may have more complicated social support systems, and that they're a little bit more vulnerable to the side effects of treatment, whether it's chemotherapy, radiation, or surgery.
Dr. Artz: Great.
Dr. Tew: I think that one last thing that I wanted to bring up before we're over is the plenary talk. The plenary abstracts presented at ASCO are the best of the best. And so typically, these are three to five abstracts that are selected amongst the thousands that are received to be reviewed and presented in front of the entire conference. And what's exciting this year, in 2016, was that there was a trial that was presented by Dr. Perry and his group, which was focused completely on patients older than the age of 65. And what Dr. Perry and his group presented was the use of adding chemotherapy to radiation in patients who were newly diagnosed with a type of brain cancer called glioblastoma.
I think what's most exiting for this study is one, it shows that we can do studies that focus just on an older patient population and learn really important information. So what they did was they enrolled patients throughout the world. It's an international cooperative group study. And they enrolled patients who were older than 65. The standard approach was typically to do surgery, followed by six weeks of radiation and chemotherapy with a drug called temozolomide. The problem though is that this type of approach to the treatment of this type of brain cancer has never been studied in patient's older than 70. The study that proved that this surgery, chemoradiation approach was effective was limited to patients who were younger than 70.
What Dr. Perry did was, realizing that the vast majority of patients who get glioblastoma are older than 65 - the mean age is 64 in this disease - he focused the study just on older patients and really found some interesting results. Rather than focusing on surgery, he focused on using radiation with or without chemotherapy, so trying to reduce the more significant morbidity of brain surgery in this older patient population. And what they found was using the combination of radiation plus chemotherapy, the drug called temozolomide, greatly improved the outcome of patients without additional added side-effects or long-term complications. It also improved the patient's quality of life. So what they showed was basically that patients lived about two months longer with the addition of the chemotherapy but there were much higher rates of patients that had longer-term control of their disease with the addition of this treatment.
Dr. Artz: So it seems that the patients previously may not have received as aggressive treatment as younger patients in the past when they had these types of brain cancers. Is that true, you believe?
Dr. Tew: Yeah. No, absolutely. What has been studied in the past for an older patient population was just using radiation alone or chemotherapy alone. And what this study showed that it's safe, and it's more effective, actually, to combine both of them, the radiation and the chemotherapy. That patients did better and tolerated the treatment just as well, whether they received single-agent therapies instead. So it's a really great example of when we focus a trial on a specific age population and ask some real-life questions about what confronts us in clinics, how to offer options to our patients and give them real results, real data, as far as what to expect with this treatment. So I thought it was a really great study and hopefully, we'll be seeing more studies like this focusing on this older under-represented age population.
Dr. Artz: And it also seems like the older patients - it was a very large trial, as you said, across different countries - and that older patients will participate in trials when given an opportunity, and it sounds like if we just have the right study and the right question, we can offer older patients clinical trials and the opportunity to benefit from newer treatments or different regimens.
Dr. Tew: Absolutely. Yeah, they enrolled over 500 patients onto this study and found some really meaningful results. Well, we're about at the end of our time here. Any last minute thoughts you had, Dr. Artz?
Dr. Artz: No, I think again this shows that for our older patients, therapies don't need to be withheld simply due to age but sometimes some extra caution should be exhibited, but otherwise, it looks like things are looking better each year for all of our patients and for our older patients. How about you? Do you have any last minute thoughts?
Dr. Tew: I agree. It's so inspiring to see this work being presented and highlighted at ASCO. It's a field that really has emerged over the last decade. And, as you know, our population of older adults here in the United States will only continue to increase. So I look forward to next year's conference and updating you all again about the results in the field.
Dr. Artz: Thank you very much.
Dr. Tew: All right, take care.
ASCO: Thank you, Dr. Tew and Dr. Artz. To learn more about the science presented at the 2016 ASCO Annual Meeting, visit www.cancer.net/ascoannualmeeting. If you have questions about whether new research may affect your care, be sure to talk with your doctor.
Cancer.Net is supported by the Conquer Cancer Foundation, which is working to create a world free from the fear of cancer by funding breakthrough research, sharing knowledge with physicians and patients worldwide, and supporting initiatives to ensure that all people have access to high-quality cancer care. Thank you for listening to this cancer.net podcast.