Dr. Richard Lin is an advanced fellow in the adult Bone Marrow Transplant Service at Memorial Sloan Kettering Cancer Center. He has extensive clinical and research experience in geriatric oncology and palliative medicine. His overarching clinical and research goals are to improve outcomes and quality of life for older patients with blood cancer undergoing transplantation and cellular therapy.
“Doc, is this treatment too risky at my age?”
I get asked this question often when I evaluate an older patient for bone marrow transplantation (also called stem cell transplantation), which is used to treat various types of blood cancers. With baby boomers’ aging, it’s going to be asked more and more. That’s because most blood cancers, including acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), multiple myeloma, and non-Hodgkin lymphoma, are typically diagnosed in adults in their late 60s and early 70s.
Bone marrow transplants were introduced in the 1970s as a high-risk treatment intended to cure certain cancers. They’ve mostly been performed in younger patients because of the harmful effects, or toxicities, to the body that come with the full-dose conditioning chemotherapy that’s needed before the transplant itself. In recent years, however, bone marrow transplantation has been increasingly used for patients older than 60 thanks to lower-intensity conditioning chemotherapy that has fewer side effects, improved supportive care methods, and better ways of deciding which older adults will benefit best from this treatment.
A successful bone marrow transplant for an older adult means preserving the patient’s ability to function during daily life without assistance (called functional independence), improving quality of life, and of course, prolonging life. For patients who are considering this treatment, the key is to balance your life goals against the risks of your disease worsening and harmful treatment side effects.
Here are 3 critical questions to ask yourself and your doctor as you consider this treatment:
1. What are the risks and benefits of a transplant for me?
Different diagnoses require different treatments, and people will need to weigh the pros and cons for the personal situation. For example, older patients with multiple myeloma might benefit from a type of transplant that uses cells from the patient’s own body called an autologous transplant, even though it won’t cure the myeloma. The risk of death is low, and many patients live many years after receiving the transplant. However, using a transplant that uses donor cells, called an allogeneic transplant, to treat lymphoma has less certain benefits. For older patients with AML and MDS, allogeneic transplant currently offers the only chance for a long-term cure, but with the trade off of high short-term risk. Regardless of the type of transplant, you will need to weigh the potential risks and the potential benefits.
2. Do I have a support system in place?
Older adults need an adequate psychological, emotional, practical, and financial support system in place to help them through the transplant process. It can be difficult to navigate the health care system alone and keep track of the disease, symptoms, medications, and appointments. A 24-hour caregiver is also needed to stay with the patient after the transplant, sometimes for up to 100 days. In addition, the patient needs to be able to cope with the many emotional ups and downs that occur during the intense period before, during, and after the transplant. The costs of this procedure may also be very high. Talk with your transplant coordinator and an oncology social worker about these issues. There are many resources that can help you address these types of difficulties.
3. What’s my fitness level?
An important and often overlooked aspect of a bone marrow transplant for older adults is the evaluation and management of geriatric fitness. As you age, your functional reserve, or the ability to cope with physical and mental stress, declines. This can increase your risk for treatment side effects, speed up the development of physical problems or cognitive problems (which affect the ability to think, remember, and pay attention), and even result in a loss of independence. These complications may affect your transplant outcomes, quality of life, and recovery. But there are ways to prevent them and improve your recovery from the transplant.
Ask your transplant doctor whether you should see a geriatric oncologist before the transplant to receive a geriatric assessment. A geriatric oncologist is a doctor who specializes in treating older people with cancer. Also, ask if any specific interventions, or changes or additions to your care, can help you through the transplant process. For example, many older adults take multiple medications at the same time, but this may reduce the effectiveness of the treatment. A transplant pharmacist may be able to adjust your medications before the procedure. Problems with daily living activities, such as walking, bathing, and climbing stairs, may require intensive physical therapy and occupational therapy. Cognitive issues, such as memory problems or depression, may be addressed with a referral for counseling or other type of therapy.
Bone marrow transplantation has a long track record of success for treating certain cancers. While older age is no longer considered a barrier to receiving this treatment, making sure that it is right for you and that you’re prepared for the transplant experience are vital parts of the decision-making process.