The treatment of cancer in older patients poses problems, not only in terms of safety and heightened concerns for functional declines due to the therapy, but also, limited data upon which to make reasonable estimates of benefit in the context of competing causes of mortality and the impact of dose adjustments or early discontinuation. Results of clinical trials do not always extend into the “real world” scenario in large part due to the younger-than-average age enrolled in clinical trials compared to the general population for most cancer types. In this issue of AJHO, Dr Reagan and colleagues remind us that the age distribution for Hodgkin lymphoma is bimodal, with 20% of cases occurring in patients over the age of 60. Outcomes are worse in this age group — it is not clear whether it is due to biological factors or differences in diagnosis and management. There is ample evidence that older patients are undertreated — much of this coming from other disease types such as breast cancer.1 In the case of Hodgkin lymphoma, while a good fraction of patients appear to receive standard therapy, decline in function or age over 70 portends a worse outcome, and as the authors point out, trials of more tolerable regimens for older patients have been tested, but suffer from small size or lack of comparative arms to define optimal approaches.
As the treatment for Hodgkin lymphoma evolves toward novel therapies for patients who progress after standard treatments, including ABVD and salvage autologous stem cell transplant, such as the immunoconjugate brentuximab vedotin and checkpoint inhibitors like nivolumab and pembrolizumab, there is an opportunity to move these therapies into earlier lines, as these may have fewer toxicities and could be equally or more efficacious. This article provides early results of such strategies and commentaries as to whether this could represent a broader approach for malignancies in older populations. As our population ages and maintains a better level of health, overall, it is incumbent upon the oncology community to develop better tools for the systematic assessment of physiologic age and risk profiles from standard cancer therapies and to support research that will test modified regimens and even newer biological drugs as initial therapy. Importantly, if these treatments meet appropriate comparative effectiveness thresholds, it will be critical to disseminate these findings and incorporate them into practice.
- 1. Schonberg MA, Marcantonio ER, Li D, Silliman RA, Ngo L, McCarthy EP. Breast cancer among the oldest old: tumor characteristics, treatment choices, and survival. J Clin Oncol. 2010;28(12):2038-2045. doi: 10.1200/JCO.2009.25.9796..