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Case Study: Managing Lymphoma in an 80-Year-Old Patient

  • Advances in Hematologic Malignancies Issue 6, Spring 2017
  • Advances in Hematologic Malignancies Issue 6, Spring 2017

    Tammy Hshieh, MD, MPHand Caron Jacobson, MD

    Tammy Hshieh, MD, MPH Mr. F is an 80-year-old man who presented with enlarged neck and axillary lymph nodes. An excisional biopsy of one of these nodes showed classical Hodgkin lymphoma (HL). He was otherwise well, with normal routine lab study results and good exercise capacity; in fact, at the time of his diagnosis, he was working long hours restoring an old barn on his property. He was highly independent, including traveling to Dana-Farber alone by train from the North Shore of Massachusetts. He was started on Adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) combination chemotherapy for a total of 12 treatments over 24 weeks. He experienced a complete remission.

    HL is one of the success stories of contemporary lymphoma treatment, with high cure rates after combination chemotherapy with or without radiation. Standard therapy — 8 to 12 treatments of ABVD chemotherapy, with or without 3 weeks of radiation depending on stage and risk factors — is a grueling and long course and can be difficult even for the more typical HL patient in their 20s and 30s. Treating a patient at age 80 with this highly-curable malignancy is a challenge due to the side effects and duration of therapy. The high probability of treatment response, however, makes it an endeavor worth pursuing.

    Caron Jacobson, MD At Dana-Farber Cancer Institute, the Older Adult Hematologic Malignancy Program (OHM) embeds a geriatrician in the clinics, working side-by-side with medical oncologists. They evaluate patients at presentation, help determine the most appropriate treatment, and optimize patient care. They co-manage patients with treatment side effects and complications. Geriatricians specialize in differentiating disease from the effects of aging. Using comprehensive geriatric assessments, they identify risk factors that can be intervened upon. This includes reducing poly-pharmacy, finding alternatives to high-risk medications, bolstering community supports, managing cognitive impairment, counseling about fall safety and nutrition, and improving patients’ overall frailty when possible.

    Mr. F’s case is an excellent example of the tangible benefits an onco-geriatric practice can offer. Working as a team, the geriatrician and hematological oncologist were able to deliver intensive, curative chemotherapy to an elderly lymphoma patient, while minimizing untoward side effects and potential harm through weekly co-visits with oncology and geriatrics. The identification and appreciation of risk factors like mild cognitive impairment, particularly executive dysfunction, led to thorough and creative methods to improve medication usage and compliance, and to manage hydration and nutrition. For example, Mr. F was shown step-by-step how to use a Neulasta (pegfilgrastim) auto-injector and given written recipes for high-protein shakes tolerable to patients with mucositis. When Mr. F was most frail and neutropenic, geriatrics identified the risks of his weekly train ride and mobilized family support and transportation.

    Understanding poly-pharmacy resulted in attention to other medications Mr. F was taking, notably antihypertensives and bowel regimens. Important dose reductions and changes were made to avoid overtreatment of blood pressure or constipation, which can result in orthostasis, electrolyte imbalances, and falls.

    Through this teamwork, Mr. F was able to complete all 12 treatments without major problems. His recovery has been steady and his barn is nearly completely restored.

    Restored barn