It was one of the most important studies of his career, and yet not a single word was published. Pierre Soubeyran, MD, PhD, was a young oncologist beginning his career at the Institut Bergonié in Bordeaux, France, in the mid-90s when he was asked to assist his colleagues with a trial examining outcomes in patients with cancer under the age of 65. As he examined the results, Dr. Soubeyran realized the patients in the study responded differently than those he treated on a daily basis, many of whom were older than the trial’s cutoff age.
Dr. Pierre Soubeyran
However, the inspiration—the idea that elderly patients with cancer respond to, and therefore need, different treatment than younger patients—led Dr. Soubeyran to a career in geriatric oncology.
“That study told me that younger patients are the easiest to treat, but the main situation we face in cancer care is treating elderly patients,” Dr. Soubeyran said. “I wanted to solve that problem, and, progressively, I realized the challenges associated with treating elderly patients.”
For his commitment to promoting research in elderly patients with cancer, ASCO will award Dr. Soubeyran the 2016 B.J. Kennedy Award and Lecture for Scientific Excellence in Geriatric Oncology.
The B.J. Kennedy Award honors ASCO members who have made outstanding contributions to the research, diagnosis, and treatment of cancer in elderly patients, and in bringing an understanding of geriatric oncology to fellows and junior faculty. It is named for B.J. Kennedy, MD, one of the fathers of both medical and geriatric oncology in the United States.
Dr. Soubeyran’s award and lecture will take place on Monday, June 6.
Screening for Vulnerability
Born February 16, 1961, Dr. Soubeyran received his medical degree in 1989 from Victor Segalen Bordeaux 2 University (now Bordeaux Segalen University), in France. After completing residency at Institut Bergonié, Bordeaux 2 University and at The University of Texas MD Anderson Cancer Center, Dr. Soubeyran joined the Institut Bergonié as a medical oncologist in 1993.
During his 23-year career at the Institut Bergonié, Dr. Soubeyran has published several influential studies on topics including screening for vulnerability in elderly patients with cancer, predictors of early death risk in older patients treated with first-line chemotherapy for cancer, and diffuse large B-cell and peripheral T-cell non-Hodgkin lymphoma in frail elderly patients.
Much of Dr. Soubeyran’s work focuses on screening and identifying patients, an area of importance in geriatric oncology yet one he feels still lacks adequate research. The differences between two elderly patients with cancer, Dr. Soubeyran noted, are often greater than those of younger patients with a similar disease. Elderly patients typically have comorbidities and frailties that greatly affect potential treatment options.
Effective care depends on identifying these crucial differences, which often go overlooked. Tools developed by geriatricians to screen older patients, Dr. Soubeyran said, are for patients aged 80 or older. However, in oncology, treatments and techniques needed for elderly patients with cancer begins closer to age 70.
Screening elderly patients is also expensive. One of Dr. Soubeyran’s most influential studies, “Screening for Vulnerability in Elderly Cancer Patients: Validation of the G8 Screening Test,” notes that “geriatric assessment is an appropriate method for identifying older [patients with cancer] at risk of life-threatening events during therapy. Yet, it is underused in practice, mainly because it is time- and resource-consuming.”1
“To change things, we have to demonstrate that this approach is cost-effective or has important benefits for the patient. Simply identifying patients is not enough,” Dr. Soubeyran said.
An active researcher, Dr. Soubeyran’s scientific interests include clinical and biological research on lymphoma and geriatric oncology. He is currently leading trials focused on these topics as part of the French Lymphoma Academic Research Organization Lymphoma Research Group and the French Geriatric Oncology Cooperative Group DIALOG.
Dr. Soubeyran is involved in the development of geriatric oncology at the clinical level as a co-coordinator of the French National Cancer Institute (INCa)–accredited Coordination Unit of Geriatric Oncology of Bordeaux. He also works on the research level as the president of the Scientific Council of the French Society of Geriatric Oncology and as coordinator of the INCa-accredited French Geriatric Oncology Cooperative Group DIALOG.
Clinical research is especially important in geriatric oncology, a relatively nascent field when compared to oncology as a whole. The ASCO award is named after Dr. Kennedy because of his constant efforts to include more elderly patients in clinical trials. Still, oftentimes older patients are not included in trials, as they have different responses to treatment than younger, healthier patients. And the typical endpoints of clinical trials—progression-free survival and overall survival—are not often adapted to elderly patients.
Clinical Trial Design
Dr. Soubeyran has led clinical trials designed for elderly patients, such as the phase II EORTC trial, which examined diffuse large B-cell and peripheral T-cell non-Hodgkin lymphoma in frail elderly patients. The trial targeted patients aged 70 or older who were deemed ineligible to receive cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy, allowing researchers to identify truly frail patients.
As a result, only 32 patients participated in the trial, and response rates were lower than they were with CHOP therapy. But the results provided a good definition of a truly frail population that could be used as a starting point for future trial design. They also showed that designing and conducting cooperative group studies in frail patients is feasible.
With an increasing population of elderly patients, it is vital that more clinical trials are designed for elderly patients, Dr. Soubeyran said. Although the field is improving in this regard, more work must be done.
“We have to work on the question of endpoints,” Dr. Soubeyran said. “That’s a very important topic that we have to share with panels of patients. For elderly [patients], to be alive 1 or 2 years after the treatment is not sufficient to determine a positive result.”
One of the barriers to improving clinical trial registration among elderly patients is their differing health conditions. Fully fit elderly patients are often capable of receiving the same type of treatment as younger patients. However, as noted in the 2008 paper co-authored by Dr. Soubeyran, “Vulnerable and Frail Elderly: An Approach to the Management of the Main Tumor Types,” many elderly patients fall into the category of either vulnerable or frail. Vulnerable patients can be treated with a moderated approach, while frail patients are too sick to receive active treatment.
“Some form of geriatric evaluation is needed to distinguish those who can be treated as adults from those—the vulnerable ones—who need a modified approach and also from those who are frail or too sick to receive an active treatment,” according to the study. “Only scarce data are available to guide treatment of vulnerable or frail patients, the neglected majority of older patients [with cancer].”3
Once patients are identified as either vulnerable or frail, an oncologist can adjust their treatment accordingly, Dr. Soubeyran said. That could mean treating frail patients palliatively or looking to modify or reduce the treatment of vulnerable patients in order to reduce toxicity.
“The criteria to differentiate these groups from each other are very difficult because they depend on the patient, but they also depend on the treatment you propose,” Dr. Soubeyran said. “If you propose an aggressive treatment, the threshold won’t be the same. Patients will be more rapidly frail or vulnerable because the risk is increasing. You will have the excess toxicity much more rapidly.”
The number of elderly patients with cancer will only increase in the coming years. As a result, he said, the future of geriatric oncology lies not only in clinical studies but also in understanding genetic disease patterns for these patients. Recognizing genetic patterns in treatment will allow physicians to understand which of their elderly patients are vulnerable or frail. That, in turn, will change the way patients receive treatment earlier in the process.
The goal is to make treatment more efficient and cost-effective by allowing physicians to understand their patients better.
“The next step that we have to solve is seeing whether we have to go one step further—not only making a diagnosis but also intervening with patients,” Dr. Soubeyran said.
– Jack Lambert