Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011

Dr Antonio Almeida (Portuguese Institute of Oncology, Lisbon)

Advances in myelodysplastic syndrome

Myelodysplastic syndrome is a big topic here at the Blood Cancer in the Elderly conference here in Rome. Antonio Almeida, you’ve been talking about it and what is it, do you think, are the really big problems here that, in your view, clinicians need to take attention of?

There’s one big issue is the issue of diagnosis. It’s a chronic disease, traditionally there were no treatments for it other than supportive care – transfusions and antibiotics. So patients were very much condemned to having these transfusions and I think this is still present in many doctors’ mind-sets and with more elderly patients they refrain from investigating them, so the patients are left with the symptoms and the disease itself, without having a diagnosis and without having the new appropriate treatments which could improve their lifespan.

And there’s also a question of ageism, patients may well be elderly and many patients may have low expectations of having anything done about it.

Absolutely. We’ve spoken a lot about the ageist attitude in doctors and healthcare workers but we must not ignore the fact that many of these patients feel old themselves and because anaemia is so debilitating in terms of symptoms, it makes them feel worse. Very often patients refuse to have painful investigations because they feel it will not improve their lifestyle, it will not improve their lifespan. The treatments are cumbersome and so they will literally tell us, “Oh, I’m too old. Why do I need this?”

How do you advise clinicians to tackle these problems of diagnosis and ageism within the family or the patient?

A lot of it goes through education, both education of physicians - general care physicians, general physicians in hospitals who see these patients come into A&E and to make them aware that there are treatments and that being anaemic and transfusion dependent does not need to be the outcome in these patients.

The second thing, it’s very important to stress to the patients and their families that even though they are ill now, and it seems to be a very chronic indolent thing, they can improve and they can get better. Patients, when they become transfusion independent, their lives are transformed because when you’re having transfusions you have a peak of haemoglobin then most of the time you’re well below your comfort zone until you have another transfusion. So it’s only a few days in which you are in a comfortable healthy state, whereas when you become transfusion independent your haemoglobin is always high and your quality of life improves dramatically.

What are the treatments that you recommend for older patients?

Before deciding on the treatment, the patient does need to have an accurate diagnosis because there are two classes of MDS patients. We have the low risk patients and the high risk patients and I know I seem to be stressing the diagnosis, but without a bone marrow it’s impossible to make these decisions.

For low risk patients there are lots of new drugs such as lenalidomide, and other new drugs that are coming, as well as growth factors that may greatly improve their lifespan, their transfusion requirements. And for higher risk patients who have the highest risk of transformation into AML, the new demethylating agents have been very successful. Certainly I don’t think any high risk patient should go through a clinic without being considered for hypomethylating treatment. It improves lifespan, it improves survival and it improves quality of life and I think it’s very effective.

How much evidence is there that you can hold back this tendency to progress to leukaemia and are there other agents and other new therapies that might do it?

With the hypomethylating agents, the new trials are very conclusive and they certainly show with azacytidine that there is an improved survival compared to any other treatment that we have. So it really is the gold standard at the moment.

So what would you advise doctors to be doing right now about MDS in elderly patients?

I would advise them to characterise the disease properly with a bone marrow and with cytogenetics and to evaluate the patients for these new treatments that are available. Certainly there are also clinical trials, some currently running for low risk patients who are transfusion independent and some who will be starting for low and high risk patients. I think all patients should be considered for these trials because they will bring great benefit, they’re not shots in the dark, they are trials with known benefit and that will help patients now and in the future.

It’s a difficult disease though, and not all that well understood, clearly, by the public and indeed maybe by doctors. So are you optimistic?

Yes, I think I am optimistic because even though it is a difficult disease and it does come under this umbrella of incurable diseases, clearly to say that there is a cure is a great attraction but to say we’re going to make you better, but we’re not going to cure you, may seem like a bit of a ‘So what?’ kind of attitude. But when you see patients get better and have another two years of life, it’s a huge reward and it’s a huge reward both for physicians and for patients and their families. I’ve had patients’ relatives write me letters after they’ve died to say, “We know it was only two more years but we’ve done so much in these two years and we’ve seen our grandchildren and we’ve travelled,” and it does make a huge difference to people’s lives.

Antonio, thank you very much for joining us here on ecancer.tv.

Thank you.