Geriatric Oncology

Highlights

March 1, 2011, Volume 3, Issue 1

35 th ESMO (Milan, Oct 8-12, 2010) by Riccardo Audisio and Etienne Brain

Inside this issue:

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A Product of the SIOG Education Committee Co-Chairs: Arti Hurria and Arash Naeim

Nadine Jackson, Supriya Mohile, Hans Wildiers

Newsletter

ESMO 2010 1

ASH 2010 2

SABCS 2010 4

SIOG Malaysia 2011 5

U 13 6

Blood Ca in the Elderly 8

Rome, March 2011

What at ASCO 2011? 9

The 35th ESMO Congress, which was held in Milan on October 8-12, 2010, hosted

two sessions entirely dedicated to onco-geriatrics. A first poster session took

place on Saturday Oct. 8; submissions from Italy, Ireland, and France were

presented and discussed with the authors. This generated a lively debate and the

poster presented by Dr. Brunello from Padua was awarded first prize with a

report on “Multiple Tumours in Elderly Patients”.

The Discussion Session of a second poster Symposium was organised on

Monday Oct. 11: the 10 best posters were displayed in the presence of all

authors. This session was chaired by Dr. Pierre Soubeyran from Bordeaux,

France, and Prof. Riccardo Audisio from Liverpool, UK. The chairs also acted as

discussants with the aim of generating a debate and adding remarks. The

audience of 80 delegates was very lively and contributed to the discussion. All

contributors from Italy, France, Belgium, Japan, Argentina and Algeria were in

attendance of the Symposium and kindly answered all queries.

Most submissions focused on screening tests and their ability to define frailty

when compared to a golden standard CGA, prediction of toxicity or adapting

chemotherapy regimens.

A phase I trial with pharmacokinetic data on elderly patients was presented

from France and an experience on the toxicity of Gemcitabine from Algeria.

The value of systematic enrollment of older patients into clinical trials was

discussed, as well as the management of NSCLC and the management of

osteopenia consequent to the use of aromatase inhibitors.

Much other interesting information on the management of older cancer patients

was presented during this 5-day Congress.

Geriatric Oncology has not yet been entirely accepted by the oncological

community, nevertheless the interest is vivid and this raises hopes for a much

better future. The need of incorporating an assessment tool when reporting on

older cancer patients has been stressed, despite the fact that it is not yet possible

to agree on one single specific assessment tool.

More work is needed before we will be able to deliver specific treatments

tailored according to the frailty of the patient. This will assist in treatment-

planning and decision-making process. For the time being, as long as we do not

have this “perfect instrument” in hand, the attempt to compare clinical strategies

and related outcomes on the basis of frailty assessment seems to be the most

promising avenue.

Prof. Riccardo Audisio - St Helens Hospital, Liverpool, UK

ESMO Congress (continued)

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In addition to the two above-mentioned sessions specifically

dedicated to geriatric oncology, this 35th ESMO Congress

was also strewn by a geriatric taste in many disease-oriented

sessions.

Lung was “carried” by an “Asian wind.” A Japanese and a

Korean team investigated with success two different

antimetabolites-based regimen (the novel oral

fluoropyrimidines S-1 or gemcitabine + UFT) as first line

treatment for advanced non small cell lung cancer (NSCLC)

occurring after 70 years (#476, #477). Tolerance and activity

profiles were encouraging. New treatments targeting the

EGFR biomarker with or without chemotherapy gave

similar positive results (#420P, #423), even well beyond the

worthless threshold of 65, especially when selection of cases

on EGFR status was performed (#423P). In a large

retrospective work covering 1994-2007, the group from

Osaka showed the value of surgery for NSCLC up to the

octogenarian strata (#463). Another Japanese experience

investigated the role of new anthracylines for small cell lung

cancer but had to close for safety reasons, concluding to the

fragility of aggressive myelotoxic treatments (#442P).

Colorectal cancer was reviewed with a “geriatric eye”.

Efficacy provided by oxaliplatin in adjuvant setting remains

debatable with the positive conclusions of BO16968 trial

which do not match those from MOSAIC and ACCENT

(#641P). However chronological age is definitely not a

discriminative factor, as in regimen where capecitabine

stands for 5-FU (X-ACT trial) (#642P) or when anti-EGFR

therapy with cetuximab is added to chemotherapy

(irinotecan, FOLFIRI or FOLFOX) (#597P, #601P), yielding the

same rates of potential secondary resection of liver metastasis

(601P).

Targeted treatments were also discussed for oesophageal

tumours, non-Hodgkin lymphoma (NHL) and breast cancer.

The tyrosine kinase inhibitor erlotinib was investigated in

combination with external radiotherapy; however given a

low accrual, the trial was closed to inclusion with only

modest hints of activity registered (#831). An Italian group

developed a safe R-CHOP regimen adjusted for 70-90+ NHL

(median age 77) (#1141PD). A small retrospective series from

Bologne (IT) showed the imperative need for careful cardiac

monitoring when trastuzumab is used in combination with

chemotherapy in 65+ pretreated metastatic breast cancer

patients, with up to 20% of cases with cardiac events (#295P).

Finally, supportive cares and psychosocial issues were also

present in the box of geriatric oncology. A French group

identified NT-proBNP as a valid marker to predict the

occurrence of adverse events and outcome under

chemotherapy after 75 years (#1293 P). Others reminded the

lack of meaning conferred to chronological age to address

quality of life issues (#1226).

Yes! ESMO witnessed this year the growing interest for

geriatric oncology and will pursue to support these efforts

with the launch of a Geriatric Faculty for Educational

program.

E. Brain, MD PhD- Institut Curie, Hôpital René Huguenin, St-Cloud, F

52th ASH Annual Meeting (Orlando, Dec 4-7, 2010) by Heidi D. Klepin

The 2010 annual meeting of the American Society of

Hematology (ASH) was held in Orlando Florida from

December 4 to 7. Each passing year, there has been a

notable increase in aging-related topics on the program

spanning from benign hematology to oncologic issues; this

year was no exception. The first part of the annual meeting

is dedicated to educational programs. This year’s program

included aging-specific topics within three of the sessions.

One session entitled “Marrow responses to aging and

inflammation” focused specifically on mechanisms

underlying anemia of inflammation and anemia of aging.

This well attended session shed light on on-going research

investigating the pathophysiology of anemia in older adults

including the contributory roles of inflammatory mediators

and hepcidin. Additional topics covered in educational

sessions included treatment of acute leukemias (myeloid

and lymphoid) in elderly patients. In addition, the Ad Hoc

Scientific Committee on Hematology and Aging sponsored a

symposium entitled “The Biology of Longevity” in the

Scientific Program. This symposium, chaired by Andrew

Artz MD, MS, spanned discussions of genetics/epigenetics,

caloric restriction, and mitochondrial function as they

related to longevity.

The plenary session included presentation of a randomized

trial which would be of interest to older adults with

follicular lymphoma (although was not an elderly-specific

trial). Dr. Ardeshna presented “An Intergroup Randomised

Trial of Rituximab Versus a Watch and Wait Strategy in

Patients with Stage II, III, IV, Asymptomatic, Non-Bulky

Follicular Lymphoma (Grades 1, 2 and 3a). A Preliminary

Analysis.” In this study 462 patients (median age 60) were

randomized to watchful waiting (control) or rituximab

(weekly X 4 or weekly X 4 with maintenance). The primary

end points were time to initiation of new therapy and

quality of life (QoL). At three years there was a significant

difference in time to initiation of new therapy favoring the

rituximab-maintenance arm (median 33 months in (continued p. 4)

3

4

(ASH 2010: continued)

(versus CHOP alone) improved time to failure but not

overall survival while there was no benefit to maintenance

rituximab in patients treated with upfront R-CHOP.Another

multi-site study (phase 2), presented by Peyrade et al (#853),

focused on the “very elderly” (age >80 years) with large cell

lymphoma. They investigated the tolerability and efficacy of

Rituxan- “mini” -CHOP (attenuated dosing of

cyclophosphamide, doxorubicin, and vincristine) in 150

patients and reported 2-year overall survival of 58.9% with a

complete response rate of 40%. This may represent a

promising alternative treatment for patients considered unfit

for standard RCHOP but requires additional study in a

randomized setting.

Multiple abstracts focused on myeloma treatment in the

elderly were presented (#619,620,622). The GIMEMA group

presented updated data on a RCT of bortezomib (V),

melphalan, prednisone, thalidomide (T) with VT

maintenance (VMPT-VT) versus VMP alone in adults ≥65

years. VMPT-VT improves 3 year progression free survival

but benefits are not significant in patients >75 years or with

poor risk cytogenetics. Patients > 75years may experience a

more favorable risk/toxicity balance with standard VMP.

Finally, at least 50 posters addressing aging-related topics

were presented; these included studies of tumor biology,

risk assessment (including geriatric assessment) and elderly-

specific treatment trials. While aging topics still represent a

small fraction of the educational and scientific program at

ASH-the yearly trends suggest this will continue to grow-

particularly with the support of an active international

geriatric oncology research community. Heidi D. Klepin, MD, MS – Wake Forest Univ. Winston-Salem, NC

Report from SABCS by Martine Extermann

This years’ edition of the San Antonio Breast Cancer Symposium had several reports that were of interest to older cancer

patients, even if few studies specifically targeted them. Among the general data, two randomized study results were presented:

those of NCIC CTG MA.27, comparing adjuvant anastrozole to exemestane, and those of ACOSOG Z1031, comparing

neoadjuvant anastrozole, letrozole, and examestane. Both demonstrated that there is no difference whatsoever in effectiveness

among the three aromatase inhibitors. In the metastatic setting, an update of the FIRST study was presented. First line

fulvestrant 500mg IM/month (which now should be considered the standard dose) was compared to anastrozole 1mg/day.

Fulvestrant resulted in a longer time to progression (23.4 vs 13.1 months, p=0.01). Best response to subsequent therapy was the

same in both groups.

Another interesting paper by Tang et al. (abstract S4-9) addressed a question that nags geriatric oncologists: What relative

weight should we give to classic predictive parameters and a gene expression assay such as Oncotype-DX ® in predicting

benefit from adjuvant chemotherapy in hormone-sensitive node negative breast cancer? The study compared the performance

of a composite index integrating the Oncotype results with tumor size, grade, and age, versus Oncotype alone. Using a Cox

interaction model on the data of NSABP B-20, there was a significant interaction of Oncotype with chemotherapy effect

(p=0.037), whereas the combined index only had a non-significant trend (p=0.10). Therefore, adding clinical elements did not

add to the predictive power of the Oncotype test. Although these retrospective data would not constitute definitive evidence,

this should prompt us to weigh carefully the import of gene expression results in our decision making, even for small tumors.

control, not reached in experimental arm). At the time of

presentation the quality of life (QOL) data was not available

and overall survival was no different. This presentation

generated debate regarding change in the standard of care

from watchful waiting. The impact of early treatment on

QOL (data pending) will be a major determinant of the

benefits of early therapy among older adults, particularly if

an overall survival benefit cannot be demonstrated.

There were approximately 20 oral abstract presentations

during the scientific session addressing aging-specific topics;

many of these reported on elderly-specific clinical trials

representing a variety of tumor types. Treatment of acute

myelogenous leukemia (AML) in the elderly was

particularly well represented with an entire session

dedicated to this topic. Data was presented addressing the

feasibility of adding bortezomib to standard 7+3 induction

(#331); safety and activity of single agent lenalidomide in

patients not candidates for induction (#332); feasibility of

adding sorafenib to induction chemotherapy (#333); optimal

dosing of ara-C (# 334); lack of benefit of gemtuzumab when

given in combination with 7+3 induction (#335); and efficacy

of clofarabine in combination with low-dose ara-C and

decitabine as front-line therapy (#336). While no practice

changing studies were presented, these studies demonstrate

the ever increasing efforts to improve outcomes for this

high-risk population.

Elderly specific trials in lymphoma and myeloma were also

well represented. Morrison et al presented updated results

from the Intergroup E4494 study of CHOP vs RCHOP

followed by maintenance rituximab in patients >60 with

diffuse large cell lymphoma (#589). After 9.4 years of

followup, maintenance rituximab with CHOP

How much chemotherapy should we give? Partial results from CALGB 40101 were presented. The study randomizes 2x2

patients to receive AC or TC, and 4 versus 6 cycles. The results of the second randomization were presented: 6 cycles do not

yield better results than 4 cycles of the same regimens. This is good news for our older patients.

When a cancer unfortunately recurs, data from the Karolinska Institute (abstract S3-5) should prompt us to biopsy a metastatic

lesion: more than 1 in 3 patients changed hormone receptor status and 1 in 10 changed Her2 status between primary and

metastatic disease. Usually going from positive to negative, but changes in the other direction occurred too. As we are often

tempted to rely heavily on hormonal therapy in older patients with metastatic breast cancer, these results are important.

No oral presentation specifically addressed older patients. However, several posters targeted them. Among them I would

highlight the following. Ruddy et al. reported adherence to oral CMF by the women enrolled in the CALGB 49907 trial

(adjuvant capecitabine versus AC or CMF). The adherence during the cycles received was excellent (97%). However, only 65%

of patients persisted through 6 cycles of treatment, versus 92% of those who received AC. As fatigue and neutropenia were

associated with non-persistence, this seems an argument towards shorter treatment regimens. Nevertheless, if a regimen with

an oral component is prescribed, patients appear to reliably take the oral medications, although they may request an early stop.

Another poster by Dixon et al. reported the Edimburgh experience in treating frail older patients with letrozole alone. They

report on 79 patients deemed not eligible for surgery, median age 81 years (57-98). The median follow-up was 2.06 years, the

median time to first progression was 3.1 years. Of the 38 deaths that occurred, 20 were due to causes other than breast cancer.

The Her2 status did not affect survival: 30% of the Her2 negative and 20% of the Her2 positive patients were alive at 5 years

(p=0.82). Although their study was not specifically targeting the elderly, the report of de Wit et al. on the PELICAN III trial

from Germany is interesting. This trial compared pegylated liposomal doxorubicin with capecitabine in 210 patients with

metastatic breast cancer (no difference in efficacy). The poster reports the correlation of a limited geriatric assessment (ADL,

IADL, ECOG/Karnofsky PS, Comorbidity by CIRS-G, and polypharmacy), and two nutritional/inflammatory laboratory risk

scores: the Prognostic Inflammatory and Nutritional Index (PINI) and the Glasgow Prognostic Scale with the patient outcomes.

Lower c-reactive protein, serum amyloid A, and higher albumin levels correlated with improved TTP. CRP was associated with

survival (p=0.0489). There was no significant association of the limited CGA, the PINI, or the GPS with outcomes, but the study

numbers were small. The integration of frailty indicators into ongeriatric trials is therefore still a work in progress, but it is

encouraging to see a cooperative group integrate such research into a trial design.

Prof. Martine Extermann, immediate SIOG Past-President, H. Lee Moffitt Cancer Center, Tampa, FL

1 s t Asian Congress on Cancer in the Older Patients by Beena Devi

The First Asian Congress on the Older Patients was held in

Kuching, Malaysia on the 22-23 January 2011 under the

auspices of SIOG. The main organizer for this congress was

the Sarawak Hospice Society (SHS). This is the first time

such a congress is held in Asia and the first time any

Malaysian oncology congress had ACOE and ESMO label

accreditation. In addition, this congress was endorsed by

UICC and ESSO. The speakers were from USA, UK, Europe,

Japan, Korea, Singapore and Malaysia.

The surgeons from our hospital held a pre-congress dialogue

session with Prof Riccardo Audisio and Dr. Michael

Jaklitsch. Various topics related to breast, lung, and colon

cancers were discussed including areas of possible

cooperation. Following that, we conducted a hospital tour

for our experts.

The congress was officially opened by Dato Sri Wong Soon

Koh, the Deputy Minister for Finance II, who is also the

Minister of Environment and Public Health. The opening

received wide media coverage on the national television as

well as the local newspapers in various languages. After the

official opening, Dr. Riccardo Audisio was interviewed by

the press. This provided an opportunity to talk about the

congress and gave SIOG greater visibility in Malaysia.

The congress was well attended with almost 500

participants from 16 countries. Participants included

doctors, nurses, pharmacists and radiographers. Many of

the topics presented at this congress by the panel of expert

speakers were exciting and educational for both doctors and

nurses. The topics included the global as well as South East

Asian perspective on older patients, under treatment,

clinical assessment tools, surgical treatment of breast, lung

and oesophageal cancers, supportive care for breast cancer,

cultural barriers observed in Malaysia, newer radiotherapy

techniques that can be used in older patients, targeted

treatment of lung, colorectal, and hematologic cancers.

Preliminary findings of using the Groningen Frailty Index

in an Asian oncology patient population were presented.

An interesting topic on the cultural barriers to cancer care in

the elderly from the three ethnic groups in Sarawak was

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Minister sounding the gong to open the Conference

presented. The findings revealed the challenges faced by

the public as well as the healthcare professionals. The

topics discussed were relevant to the local needs of the

participants so that they could apply the knowledge

when they returned home.

The feedback from the evaluation forms was very

encouraging. Most participants felt the need to have

more of these meetings in Asia as a continuation from

this meeting. The challenges felt in Asia are different

from those of developed countries and ideas and

knowledge can be enhanced when participants from

various countries meet and discuss about their work.

Beena Devi, MD – SIOG National Representative for Malaysia

U13: Geriatric Oncology Research to Improve Clinical Care by Supriya Mohile

The Cancer and Aging Research Group was formed by a coalition of investigators with the goal of linking new and

senior geriatric oncology researchers in designing and implementing clinical trials in older adults and promoting the

development of academic geriatric oncologists. In 2010, CARG received a U13 grant in collaboration with the

National Institute on Aging and the National Cancer Institute to fund three conferences on the subject of “Geriatric

Oncology Research to Improve Clinical Care.” The mission of this conference grant program was to utilize a

multidisciplinary team of investigators in geriatrics and oncology to review the present level of evidence in geriatric

oncology, identify areas of high research priority, and develop research approaches within the next 10 years, to

improve clinical care for older adults with cancer. The first of these conferences “Biological, Clinical, and Psycho-

social Correlates at the Interface of Aging and Cancer Research” was held last September 25th and 26th in Chicago,

Illinois in collaboration with the 2010 Cancer and Leukemia Group B committee meeting. The goals of the conference

were to identify the clinical, psychosocial, and biological factors that should be considered in high-quality research

for older adults with cancer. The conference brought together a wide-ranging group of interdisciplinary scholars

from oncology, geriatrics, nursing, and social work. Important topics of discussion included: 1) consideration of

common biological mechanisms that underlie both carcinogenesis and aging 2) the importance of evaluating the

context of care for older adults may influence the treatments chosen, given their higher prevalence of co-morbidities,

functional losses, cognitive impairments, and polypharmacy and 3) avenues for future geriatric oncology

translational and clinical research. Results from the conference will be disseminated at the American Society of

Clinical Oncology and the American Geriatrics Society.

Supriya Mohile, MD, MS – University of Rochester, NY

Have you renewed your SIOG membership ?

cpiguet@genolier.net

Download membership form at: www.siog.org

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PENCIL YOUR AGENDA

Blood Cancer and the Elderly

European Expert Forum Impact of Age & Co-morbidity in Haematological Oncology

Rome, Italy – March 19-20, 2011

An inaugural European expert forum on blood cancer and the elderly, organised by ecancer, is taking place in Rome this

March. The meeting will focus on the impact of age and co-morbidity in haematological oncology and aims to become

the primary multi-disciplinary educational meeting designed to highlight diagnostic, treatment and management

advances for elderly blood cancer patients.

Around 1,000 attendees are expected, making this Europe’s largest ever meeting focused on the elderly cancer patient.

Leading this meeting, CME accredited by the European School of Haematology, is a highly experienced European

Steering Committee.

The programme endeavours to provide evidence-based scientific updates and educational content, as well as tools to

improve awareness, knowledge and skills to facilitate the effective management of elderly blood cancer patients. In this

way, it hopes to provide a significant education and collaboration platform for health care professionals treating these

patients.

The need for an improved understanding, the development of policies and guidelines to direct care and communication

within multidisciplinary teams to develop appropriate assessment tools to tailor treatment to individual patients are all

urgently needed. This stems from the growing number of patients with cancer >65 years of age. By 2030, a third of the

population will be >65 years old, and 60% of all cancers occur in this population. This figure is expected to increase to

70% in the next 20 years.

There is clear evidence that older cancer patients are undertreated, frequently being offered suboptimal therapy or best

supportive care, and they are frequently excluded from clinical trials. Biological and not chronological age of patients

should be a key deciding factor in how patients are managed.

Many of the newer, less toxic agents available offer the opportunity to treat all categories of patients, irrespective of age.

Their reduced toxicity and ability to be administered at home will result in reduced hospitalisation costs, improved

patient willingness to take medicines, so improving outcomes.

The chances of survival can be significantly reduced in elderly patients because of limited access to treatment,

therapeutic scepticism and inadequate management of age-related co-morbidities.

The eminent Scientific and Educational Committee for this meeting has ensured that the programme will be varied,

relevant and informative, and the wide-ranging faculty will deliver content to stimulate, educate and generate

discussion.

We hope you can join us or follow the meeting on the ecancer website. For further information,

please visit http://www.bloodcancerintheelderly.com/

About ecancer ecancer is the open access peer-reviewed publication and web TV channel of the European Institute of Oncology (IEO)

and the Organisation of European Cancer Institute’s (OECI). It was set up as a not-for-profit organisation supported by

ECCO (The European CanCer Organisation), the Umberto Veronesi Foundation and SwissBridge, and the Organisation

of European Cancer Institutes (OECI).

ecancermedicalscience (ecancer) is committed to drive forward a comprehensive and ambitious programme urging for

the review and improvement of cancer care in the elderly patient.

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ATTENDING ASCO 2011?

Geriatric Oncology Sessions of

Interest at the American Society of

Clinical Oncology by Supriya Mohile, MD, MS

The American Society of Clinical Oncology

annual meeting will be held in June of 2011

in Chicago, Illinois.

Several sessions will focus on important

clinical and research areas in geriatric

oncology. The Geriatric Oncology Program

Committee sponsored 3 important

education sessions:

• Results from the first U13 conference,

“Biological, Clinical, and Psychosocial

Correlates at the Interface of Aging and

Cancer Research,” will be held as an

extended education session (Chairs:

Arti Hurria and William Dale).

• Anthony D’Amico will chair an

education session entitled,

“Management of Prostate Cancer in

Older Adults: To treat or not to treat”

with Shabbir Alibhai and William Dale

as speakers.

• Supriya Mohile will chair a session that

will focus on prediction, prevention, and

treatment of chemotherapy toxicity in

older patients. In this session, Arti

Hurria will discuss how to anticipate

toxicity from cancer treatment in older

adults and Gary Lyman will discuss

prevention and treatment of

hematologic toxicity.

In addition Hyman Muss and Harvey

Cohen will chair a Special Session on

“Designing clinical trials for older patients:

Nuts and bolts”, with L. Repetto,

M. Extermann, H. Klepin and D. Sargent as

speakers.

Other important education sessions that are

co-sponsored by the Geriatric Oncology

Committee include, “Breast Cancer in Older

Women—the Whole Picture”and “Therapy

of the Elderly Patient with Acute Myeloid

Leukemia.”

Please also reserve time on your schedule to

attend the “B.J. Kennedy Award and

Lecture for Scientific Excellence in

Geriatric Oncology” and the “Geriatric

Oncology Clinical Science Symposium”

(where the top-rated geriatric oncology

scientific abstracts will be presented).

15% discount for SIOG members

Order your copy online at: www.informahealthcarebooks.com/oncology.html

(indicate coupon code: SIOG)

NB: Discount also applicable to the other ESMO Handbooks

SIOG is a UICC member

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