Innovations in cancer treatments start with discoveries in the laboratory – which is where Fox Chase Cancer Center has made powerful inroads for more than 100 years to advance care for patients in the local community and throughout the world.
Although the global population is growing older every year – and despite the fact that people become more likely to develop some kind of cancer as they age – relatively few studies have been conducted to guide treatment options for older adults with cancer. There is a tremendous lack of data regarding the many different issues faced by older adults – and the higher the age group, the less data there is for physicians to draw from as they make treatment decisions.
That’s what drives Dr. Efrat Dotan, Chief of Gastrointestinal Medical Oncology at Fox Chase, in her work to uncover data-driven insights into this unique patient group. With research expertise in geriatric oncology and treatment of GI malignancies, she recognizes the critical nature of evaluating and addressing the holistic needs of older adults with cancer, while also considering the numerous other issues that could factor into their health and the best way to provide their care.
After Dr. Dotan finished her hematology/oncology fellowship at Fox Chase in 2010 to become a gastrointestinal oncologist, she was approached to become a clinical investigator focused on development of a geriatric oncology clinical and research program. As she developed her own clinic and panel of patients, Dr. Dotan realized how challenging it was to arrive at the right treatment options for this patient group because of the lack of evidence-based data. That led to her increased involvement in clinical research focused on the management of older adults with GI cancers, who generally find themselves excluded from clinical trials as they age.
What she has found over the years is that there is no clear definition of what constitutes a typical “older” cancer patient, and when it comes to meeting the needs of those patients, many of them have other physical, financial, cognitive, psychosocial and/or social support issues that must be considered in treatment decisions. These factors are an important part of a geriatric patient assessment – an expansion of the routine clinical assessment targeted for people of advancing age.
“Some patients may be 78 years old but play tennis every day and are very fit, so they can be treated quite aggressively. On the other hand, you have older patients who are very frail or have cognitive impairment or other medical issues that are unrelated to the cancer itself,” Dr. Dotan says. “That’s why I am interested in understanding how to use our medical oncology treatments in older patients and think about the most efficient and effective way to evaluate them holistically to truly meet their needs.”
Without the benefit of data to provide direction, oncologists are tasked with decisions about care and treatment for a patient group that could range in age from their 50s or 60s into their 80s. Will recommended treatment have a similar benefit for patients of varying ages? Will the toxicities increase or decrease, and how does the medical team achieve the right balance? How would treatment affect factors that are important to older patients, such as maintaining independence vs. a possible need for a nursing home?
“When you're treating older adults, the goals may be very different from when you treat younger patients,” Dr. Dotan says. “Many older patients would rather give up longevity if treatment might affect their function or cognition, or if it would render them incapable of doing their daily activities. So those goals-of-care decisions are highly critical and require a shared discussion with the patient, as well as openness to potential adjustments for the outcome they want.”
To that end, Dr. Dotan has led several key trials and research projects, conducted at Fox Chase and multiple other sites, on incorporating geriatric assessments into oncology practice and conducting comparisons with what is typically found in routine clinical assessments.
One recent study, for geriatric patients with breast cancer, showed assessment discrepancies in several primary areas: the failure to identify psychological and social issues, and the physician’s lack of understanding of how to tangibly support the patient’s needs; along with missing significant cognitive abnormalities, a crucial factor in deciding how the patient should be treated.
A similar trial for gastric cancer patients delivered many of the same results, showing poor identification and treatment of numerous issues that are particularly significant for aging patients. Added to that trial, however, was an attempt to fill some basic data gaps with the use of a patient activity tracker. This enabled researchers to directly correlate the level of patient function to their tolerance of treatment – providing a more objective, in-depth understanding of what was happening with the patient before and during therapy, as opposed to the physician’s perception alone.
When it comes to incorporating age-specific assessments as a regular part of geriatric oncology, the obstacles of time, resources and reimbursement still remain. But recent data is beginning to demonstrate the benefits, which Dr. Dotan believes will drive the increased use of geriatric assessments for certain patients as a starting point.
“By participating in this trial, physicians got exposure to the geriatric assessment and understood how to incorporate it, and the results really highlighted how it can benefit in identifying what the patient needs. The novelty in our study was that no one had really done the comparison and realized here’s what we’re missing when we’re not doing this,” Dr. Dotan says.
Dr. Dotan also led and published a study of 750 patients concluding that a combination of body mass index (BMI) and levels of albumin, a protein made by the liver, can predict how well older adults with cancer will be able to tolerate the side effects of chemotherapy – the first such findings to document a protective effect of high BMI in this population. This study demonstrated the importance in considering nutrition as part of a comprehensive geriatric assessment before recommended chemotherapy for older adults with cancer.
When it comes to therapeutic clinical trials, Dr. Dotan’s main area of research involves the evaluation of new treatment approaches for pancreatic and biliary cancers – including work with the ECOG-ACRIN Cancer Research Group (where she is chair of the geriatric oncology working group) and the NCI’s Pancreas Task Force.
A key highlight of her leadership in the geriatric oncology field has been her role as national principal investigator for the NCI-sponsored GIANT trial, focusing on metastatic pancreatic cancer patients who were older than 70 and considered vulnerable because of health-related and other issues.
This large national study (EA2186) randomized 176 patients to two treatment regimens, both with a dose reduction that the team felt would be comfortable and safe. Although it is still under analysis, Dr. Dotan stressed that because there is almost no existing data, there is no positive or negative result to this trial – it is serving as one more groundbreaking step to gather information that could help pinpoint better treatment options for such patients.
“This is the first such trial that looked at a vulnerable older patient population to even see what may be worthwhile treatment-wise, so any information will give us some insight in guiding those decisions,” Dr. Dotan says. “Then we can sit in front of these patients and make recommendations based on data and practice evidence-based medicine.”
Dr. Dotan and her research team expect to present the findings of the GIANT study this summer at the American Society of Clinical Oncology annual conference in Chicago, the largest such worldwide congress in this field.
In addition, Dr. Dotan is participating in another similar, smaller study at Fox Chase on how to adjust treatment for older pancreatic cancer patients whose condition does not fit with standard chemotherapy – again, to uncover data where very little is available. “What I'm really blessed with here at Fox Chase is that there is such a robust group of scientists that have an interest in pancreas cancer but also understand the importance of aging,” she says.
As chair of the geriatric oncology working group within ECOG-ACRIN, Dr. Dotan has worked with multiple investigators on studying numerous other diseases affecting the aging and vulnerable patient population – including lung cancer, rectal cancer, head and neck cancer, and melanoma. She focuses on how to achieve more effective patient evaluations and collect the right information regarding their needs – such as level of patient function and independence, long-term effects of treatment, and other factors that have heightened importance among this patient group.
Fox Chase is home to some of the nation’s top cancer specialists, with robust research programs and cutting-edge clinical trials that are not easily accessible elsewhere. As research is accelerating to identify and address the various special issues of older cancer patients, innovative approaches and strategies are evolving to support them in accessing the geriatric assessment-driven care they need.
That is the ultimate goal of the studies by researchers like Dr. Dotan – and a key benefit of Fox Chase’s elite standing as an NCI-designated Comprehensive Cancer Center. The extraordinarily talented scientists of Fox Chase thrive in a setting that is ideal for making fundamentally important discoveries that facilitate better patient outcomes.
“I am the perfect example of what makes this an amazing place. I grew into what I am today because of Fox Chase,” Dr. Dotan says. “We have a great culture of taking care of patients the best way possible while also having a true dedication to research and supporting clinical trials that everyone agrees with and wants to contribute to. It is amazing how we are able to prioritize and stay engaged in both.”
With support from its partnership with Temple Health’s research, treatment and prevention programs, Fox Chase Cancer Center is making a world of difference for geriatric patient populations in the greater Philadelphia region and all other communities it serves.
“Fox Chase is so well-known for the work it does and people may think it's a gigantic institution, but it feels like a very small place where everybody knows everyone and you feel like you’re in a family,” Dr. Dotan says. “Especially in our current environment, where physicians are being pulled in so many different directions – to find a place that really values this is unique. You can always find the right person to help you move forward.”
As one of the four original cancer centers to receive comprehensive designation from the National Cancer Institute, Fox Chase Cancer Center has been at the forefront of cancer research for more than 100 years. With a singular focus on cancer, we combine discovery science with state-of-the-art clinical care and population health.
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