Expanding treatment options for blood cancer in older adults
New approaches to the blood cancers at Penn Medicine are allowing older adults to receive effective treatment, improving overall survival and quality of life.
Hematologic malignancies, like most cancers, disproportionately affect older adults. As of 2021, more than one million people over age 65 were living with blood cancer.
Historically, concerns about toxicity excluded many older adults chemotherapy, including bone marrow transplants. More recently, the survival for the population has improved with advances in treatment regimens that have made chemotherapy less toxic, and improvements in bone marrow transplant.
“There are more treatment options now for older patients,” says Catherine E. Lai, MD, MPH, Associate Professor and Physician Leader of the Leukemia Clinical Research Unit at Penn Medicine’s Perelman Center for Advanced Medicine. With many new and emerging therapies, physicians should never assume that a patient is too old to be treated, she adds. “Regardless of a patient’s age, we likely have an option to offer them.”
Bone marrow transplants in geriatric patients
The intensity of chemotherapy dosing in traditional bone marrow transplantation is generally thought to be too risky for patients over the age of 60 or 65, says Alison Wakoff Loren, MD, MSCE, Chief of the Division of Hematology Oncology and Director of Blood and Marrow Transplantation at Penn Medicine. “That meant we couldn’t offer curative therapy to the bulk of patients suffering from diseases like myelodysplastic syndrome or acute myeloid leukemia (AML).”
Over time, experts were able to reduce chemotherapy doses by taking advantage of donor cells’ immune effects against the cancer. As the science progressed, Penn Medicine was at the forefront of developing reduced-intensity transplant protocols that now allow bone marrow transplants for patients into their 70s. “That was a huge advance,” says Dr. Loren. “A lot of thought goes into selecting people for transplant, and we now have several physicians with a clinical interest in bone marrow transplants in older patients.”
When deciding on a treatment course, age is a less important factor than a patient’s functional status. “We offer bone marrow transplants, despite the risk, to people who would otherwise succumb to their disease. When you think about it that way, it’s unfair not to offer this opportunity to as many people as we can,” Dr. Loren adds. “We’re committed to extending curative treatments to as many people as possible.”
CAR T cell therapy for older adults
While bone marrow transplants have gotten safer, they aren’t appropriate for all patients. Fortunately, the advent of CAR T cell therapy—first developed at Penn Medicine—has provided many patients with a hopeful alternative. “CAR T cell therapy can have lifesaving, curative potential in patients with ALL and non-Hodgkin lymphoma, and can get patients with multiple myeloma into remission,” says Noelle Frey, MD, MS, Director of the Clinical Cellular Therapy, Cell, and Transplant Therapy Program at the Abramson Cancer Center.
That potential extends to older adults, says Dr. Frey, who has treated patients as old as 90 years with CAR T therapy. “There’s a misconception out there that CAR T cell therapy is only for young, fit patients. But as leaders in this type of treatment, we’ve done a lot of work on managing side effects, making it a lot safer even for older adults and patients with other health problems. We never assume someone is ineligible for this therapy just based on their age.”
With its long history of managing clinical trials for CAR T therapy and with physicians who specialize in this treatment, Penn Medicine has achieved unmatched expertise in managing complications from cellular therapy. “We’ve gotten so much better at predicting who might experience side effects and finding ways to prevent them. That means we’re able to offer this therapy to more people than we could in its earliest days,” Dr. Frey says.
Notably, the treatment is effective in relapsed and refractory settings, when patients have few, if any, remaining options. “One of the most exciting things about CAR T cell therapy is that it can work when traditional therapies don’t,” Dr. Frey adds. “Even when patients are older, and nothing else is working, we can consider them for CAR T.”
New advances and clinical trials in hematologic malignancies
As bone marrow transplants and cell therapy have evolved, so have other therapies and treatment approaches. Treatment regimens for older patients is less toxic and just as effective, if not more effective in certain patients than historical cytotoxic chemotherapy. There have also been FDA approvals of targeted oral therapies for patients with particular mutations. These improvements have increased the likelihood of patients going into complete remission, improve quality of life and increase overall survival.
The Abramson Cancer Center is also involved in a variety of clinical trials for older adults.
“We’ve undertaken efforts to expand into the geriatric oncology space, including clinical trials specifically designed for this population,” Dr. Lai says.
In addition to trials of new therapeutic agents, researchers are studying new prehabilitation and rehabilitation approaches that can help get patients stronger for treatment and regain function afterward. “We have a lot of trials looking into frailty and physical strength rehabilitation after bone marrow transplants, for example,” notes Dr. Loren. “We’re really trying to focus on all the peri-transplant care to make sure our most vulnerable patients can get through their treatment.”
Partnering with Penn Medicine
With specialists in every blood cancer subtype, as well as experts in bone marrow transplants and CAR T cell therapy, Penn Medicine has a lot to offer older patients and their referring providers. “Referrals are more important than ever,” Dr. Lai observes. “With so many more options and trials for older adults, we can help guide patients to appropriate treatments.”
The hematologic malignancy team takes a collaborative approach, partnering with referring providers to streamline care. “We work hard to make sure that everyone is on board with the treatment plan and that patients get as much of their care as possible close to home,” Dr. Loren says. “We want treatment to be as convenient as possible, and we’re very comfortable working with our community partners to make that happen.”
Referrals and consultations
To refer a patient to the Penn Medicine Division of Hematology and Oncology, please call 877-937-7366 or refer a patient online.