Bladder Ca Therapy and the Elderly

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Standard cisplatin-based regimens are not always the best option because of  associated toxicities.

SAN FRANCISCO—Conventional treatments for bladder cancer may be inappropriate in elderly patients because of underlying age-related functional impairment and comorbidities, according to a medical oncologist.

In a presentation given at the Fourth Annual Oncology Congress, Matthew Milowsky, MD, a medical oncologist at Memorial Sloan-Kettering Cancer Center in New York City, discussed the pros and cons of conventional bladder-preservation strategies for invasive bladder cancer, including the use of cisplatin-based chemotherapy in combination with radiation. He concluded that a new approach is needed for elderly patients.

“Chemotherapy with cisplatin is not always feasible for use in older patients because of its associated toxicities, such as deleterious effects on kidney function, high-frequency hearing loss, and vascular toxicity,” Dr. Milowsky explained. “So we need to think harder about this because…if you give the patient a drug that impacts a physiological parameter that is also impacted by aging, then you might be giving a double whammy.”

Therefore, he suggests that trials of alternative treatments focus on the elderly and that these subjects be stratified for treatment according to functional status, both in clinical trials and in routine clinical practice. Decline in functional status is a robust predictor of progression to disability, institutionalization, and death, he said.

“Right now function-based assessment is either done informally or it's not done at all,” Dr. Milowsky told Renal & Urology News. “And I think we all recognize that we need to formalize this process and specifically speak to the geriatric population. The way to do that is to incorporate these geriatric assessment tools into our trials and to design trials with the elderly specifically in mind.”

To tackle both of these challenges head-on, he will be heading a Cancer and Leukemia Group B cooperative group trial evaluating the efficacy of a non-cisplatin-based chemotherapy regimen—twice-weekly gemcitabine—and concurrent radiation therapy in achieving a complete response of the primary tumor in older patients with invasive bladder cancer.

The trial will incorporate a comprehensive, geriatric-specific functional-assessment tool that establishes subjects' baseline characteristics and enables investigators to follow patients over time.

Dan Theodorescu, MD, PhD, director of the Mellon Prostate Cancer Institute at the University of Virginia in Charlottesville, has researched treatments for invasive bladder cancer. He agrees with the need to explore and expand approaches that work best in elderly patients rather than trying to extrapolate from studies of younger individuals.

“The use of age-specific therapy adjustments and considerations has shown that aggressive treatment for bladder cancer is associated with improved overall survival even among patients 80 years old and older,” Dr. Theodorescu said.

Ninety percent of cases of bladder cancer occur in people older than 55 years, making it the fourth leading cause of cancer-related deaths in men aged 80 years and older, Dr. Milowsky noted.
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