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© 2003 American Society for Clinical Oncology
Comprehensive Geriatric Evaluation in Elderly Patients With Lymphoma: Feasibility of a Patient-Tailored Treatment PlanNational Cancer Institute Aviano (PN) Istituto Humanitas, Rozzano, Italy To the Editor: Elderly patients affected by cancer are generally not treated in an optimal way because of the perception that they are fragile by definition; with the result that physicians are often reluctant to treat them with the standard of care for that specific cancer.1 The major concerns, for instance, are the toxicity caused by chemotherapy and possible negative effects on patients’ quality of life. In fact, most of the cancer clinical trials usually exclude elderly patients, and it has been demonstrated that for elderly patients, performance status is not a sufficient index because it does not include a comprehensive evaluation of various age-related factors. The use of scales aimed at evaluating functional, nutritional, emotional, cognitive, socioeconomic, and physical status can provide further information. Therefore, the new concept of comprehensive geriatric assessment (CGA) for elderly cancer patients has emerged as a mandatory evaluation to guide therapeutic options and establish the prognosis.2–4 CGA is a multidimensional, interdisciplinary patient evaluation that leads to the identification of a patient’s problems on the basis of standardized interviews and validated scales, such as activities of daily living (ADL), instrumental activities of daily living (IADL), geriatric depression scale, and mini–mental status evaluation.5 Non-Hodgkin’s lymphoma (NHL) is a typical example of a neoplastic disease in which treatment in young patients is aimed at curing the disease. However, for elderly patients, therapeutic results to date have been disappointing because old studies using aggressive treatment schedules have shown a higher toxicity, and regimens specifically designed for elderly patients failed to reach the same results as those expected for younger patients.6,7
In March 2000 at the National Cancer Institute of Aviano and in June 2001 at the Istituto Humanitas of Rozzano, Italy, we began a pilot study for elderly patients affected by aggressive NHL that allows a patient-tailored treatment with the goal of maintaining a balance between the desire to cure the patient and guaranteeing a good quality of life. All patients aged 70 years or older affected by aggressive NHL are initially evaluated to exclude those with frailty (which is dependent on one or more ADL criteria, three or more comorbidities, or one or more geriatric syndromes), who undergo a more palliative approach. Patients with an ADL and IADL score of at least 5, and whose hepatic and renal function and hemopoietic reserve are sufficient, are treated with a curative intent using a patient-tailored approach. Patients with an IADL score of less than 5 and patients older than 80 years of age are treated with 75% of the planned dose. Patients without specific comorbidities receive standard cyclophosphamide, doxorubicin, vincristine, and prednisone; patients with mild cardiopathy receive cyclophosphamide, epidoxorubicin, vincristine, and prednisone; patients with severe cardiopathy receive cyclophosphamide, vincristine, and prednisone; and patients affected by diabetes mellitus receive cyclophosphamide, epidoxorubicin, and vincristine. Hematopoietic growth factors (granulocyte colony-stimulating factors) are administered from days 8 to 13. As of September 2002, all 23 patients referred at our two institutions have been enrolled in the study; two patients were fragile and therefore not suitable for aggressive chemotherapy. Median age is 74 years (range, 70 to 89 years). Two patients are still undergoing treatment. Therefore, 19 patients are fully evaluable, and their characteristics are shown in Table 1
We strongly believe that this approach based on CGA is suitable and highly effective for all nonfragile elderly patients affected by aggressive NHL. It should be stressed that this approach does not exclude any elderly patient from potentially curable chemotherapy, as opposed to therapeutic approaches used in the past. Moreover, this approach can also eventually be used for any other cancer type. We also believe that a patient-tailored approach based on CGA will be mandatory for future studies aimed at determining the best treatment for all elderly cancer patients.
REFERENCES 1. Fentiman S, Tirelli U, Monfardini S, et al: Cancer in the elderly: Why so badly treated? Lancet 28:1020–1022, 1990
2. Repetto L, Fratino L, Audisio RA, et al: Comprehensive Geriatric Assessment adds information to Eastern Cooperative Oncology Group Performance Status in elderly cancer patients: An Italian group for Geriatric Oncology study. J Clin Oncol 20:494–502, 2002
3. Balducci L, Extermann M: Management of cancer in the older person: A practical approach. Oncologist 5:224–2037, 2000 4. Balducci L, Beghe C: Cancer and age in the USA. Crit Rev Oncol Hematol 37:137–145, 2001[Medline] 5. Monfardini S, Ferrucci L, Fratino L, et al: Validation of a multidimensional scale for use in elderly cancer patients. Cancer 77:395–401, 1996[CrossRef][Medline] 6. Tirelli U, Zagonel V, Errante E, et al: Treatment of non-Hodgkin’s lymphoma in the elderly: An update. Hematol Oncol 16:1–13, 1998[Medline] 7. Tirelli U, Carbone A, Monfardini S, et al: A 20-year experience on malignant lymphomas in patients aged 70 and older at a single institution. Crit Rev Oncol Hematol 37:153–158, 2001[Medline]
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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