Age Is Just a Number: Blood Cancer Care in Older Patients

Medscape

14 hours ago

Andrew Artz, MD, MS
After years spent caring for older patients with leukemias and other hematologic diseases, Andrew Artz, MD, MS, takes pride in his role of moving the field away from one-size-fits-all approaches. Too many times, he's seen older adults kept away from the most effective treatments based solely on their age, without thoughtful consideration of their fitness or personal treatment goals.
The director of the Aging and Blood Cancers Program at City of Hope Cancer Center in Duarte, California, Artz said that his ultimate goal is to develop guidelines that embed multiple assessment measures to make it easier for older patients to successfully complete grueling treatments like allogeneic stem cell transplantation and chimeric antigen receptor (CAR) T-cell therapy, even as they provide clinicians with more direction on how to customize the care of individual patients.
Simply put, older age has been one of the largest barriers to referral for allogeneic transplantation, he said.
'Historically, we only had the 'eyeball test' [in which the physician bases fitness decisions on visual assessment only] and then the patient basically had to argue with the physician to get what they wanted,' Artz told Medscape Medical News . 'Patients don't want to be dismissed with some imprecise tool, and they don't want to be told they're too old for treatment. Over time, there's been more alignment with what the patients want and what we try to achieve.'
Artz is the senior author of a recent paper that shows how far this area of health services research has come. He and coauthors developed and validated a first-of-its-kind composite health assessment risk model for allogeneic transplant recipients older than 60 years. The goal was to test the model's prognostic abilities with non-relapse mortality (NRM) and survival following transplant.
The authors studied the prognostic impact of 13 health variables, eventually settling on seven: age, hematopoietic cell transplantation-specific comorbidity index, albumin, C reactive protein, weight loss, patient-rated Karnofsky performance status, and cognition by the Montreal cognitive assessment (MoCA)—to make up the primary model. They noted that all but MoCA are readily available in the clinic and that cancer guidelines already call for cognitive impairment screening in older adults.
'It is encouraging that the primary-CHARM score was the only prognostic factor for overall survival in a multivariate analysis along with disease risk assessed by the refined Disease Risk Index,' the authors wrote. 'This met our study framework to quantify patient vulnerability to gauge NRM separate from disease risk tools.'
Artz recently sat down with Medscape Medical News . The following interview has been edited for clarity.
What drew you to focus on improving care for older adults with blood cancers?
Even very early in training, I noticed that many of our clinical trials inappropriately exclude older adults. And we can't necessarily infer effects on older adults to the younger adults in the trials. I grew up in West Virginia, where people's health was generally less robust than elsewhere. My grandfather was an immigrant who lived a very healthy lifestyle, exercising and generally staying active. He did all the things that now are formalized in studies about keeping the mind and body active. That made me wonder about what makes some older adults healthier than others.
Why did you decide to focus on health services research vs clinical research?
During premedical training, I worked in nursing homes as a nurse's aide and saw older people who were frail and deconditioned and that really stuck with me. I struggled with how to wed my interest in the biology of cancer and hematology with caring for older adults. Eventually I settled on looking at aggressive malignancies and transplant curative-intent approaches for people who historically might be given palliative therapy or no therapy. I began to realize we could pursue curative approaches for some of these patients.
I am very appreciative of my translational and basic science colleagues. I view myself as someone who takes the baton from them and moves into studying these discoveries with pragmatic clinical trials to understand real-world outcomes.
How has the concept of fitness for treatment evolved in older patients?
Patients will change over time, of course, but we can potentially intervene to change their fitness or resilience. Some limitations or vulnerabilities can be improved, and we can also use people's strengths to help them prepare for and tolerate treatment.
Risk stratification is one step, but it's really using that information to then make decisions to ensure people recover faster. To me, tailoring our approaches to both treatment and the optimization of their health and fitness is the best because that's how we expand eligibility and access for our patients.
How do you get older patients ready for CAR T or transplant?
On an individual level, we'll ask patients what they would like to recover to and use that as a motivator. But in the research setting, we use a set of patient-reported tools and simple objective measures that are reproducible. There won't be a single easy tool, but most of the tools are complementary and overlapping.
Comorbid conditions are essential to optimize, whether by adding or adjusting medications or doing something else to limit further damage. We are very active and targeted in optimizing patients and then using a shared decision-making model to motivate patients. We'll explain that, if you lose weight, you won't have enough muscle mass for treatment. And we might also need to change some medication that's making you orthostatic and keeping you from staying active to keep up your muscle mass. Most of the time it's not as simple as just sending someone to physical therapy because it's not fair to ask a physical therapist to try to make someone stronger in 4 weeks without considering other factors.
What is the most important element of care optimization in older adults?
It's realizing that because each patient has different limitations and each treatment is different, it's up to you to offer treatment options based on both the disease and the specific patient and their goals, above and beyond the standard considerations that apply to all patients. It's like saying airbags should be available for everyone in the car, but how each person adjusts their seat for the ride depends on how tall they are. That requires a little bit more effort to tailor the solution.
Also, social support is critical, including making sure caregivers are available and can advocate for the patient. We universally recommend that and then broaden and deepen social support as needed to help with common geriatric syndromes like weight loss, functional decline, and polypharmacy. We also work with patients to develop both short- and long-term goals for their recovery because that tends to keep them and their families motivated.
Artz reported an advisory role for AstraZeneca and Magenta Therapeutics and provided consulting to AbbVie.