Rightfully, they walk into an appointment and ask, "Why would you treat me any differently than someone 20 years younger?" This has become a debate. We would like to apply things where there is evidence and, right now, there is strong evidence that patients older than 70 do not benefit from chemotherapy. That is a hard thing to say, because how do I know that a particular individual won't benefit [from chemotherapy]?
The answer has partly to do with what our research is focused on, which is a different paradigm for understanding how to risk-stratify patients. To do it, you need to break away from the question of, "What is this patient's survival?" to, “What is their relative risk of dying of cancer as opposed to other things?” That gives you very different inferences on how intensely to treat patients.
The converse works, too. [There are] patients who we would normally want to give chemotherapy, and we know right away if their organ function doesn't permit it. However, what if they have a constellation of factors? It just predicts that they are not likely to benefit if you consider their age and their poor performance. There are other factors, too, like a patient's economic wellbeing, their marital status, and their psychiatric wellbeing—these have physical manifestations in a person's prognosis. If we could somehow take these factors into account, we might be able to weigh benefits and toxicities better for each specific patient.
In head and neck cancer, it gets quite complicated rather quickly because patients have cancer, but sometimes they are smokers, so their lung function isn't very good. Or, maybe they are older with a relatively slow-growing cancer. The research is trying to distill down a better quantitative approach to managing our patients.
What would be your take-home message for the audience?
Now, we must do the hard work in reverse by trying to fit an individual into a paradigm. It is quite a tricky business, but one that we steadily learn and can sort out.
The other thing that changes the landscape is the whole treatment paradigm. For a long time, we have had the "classic 3"—surgery, radiation, and chemotherapy—but now you have this new kid on the block in immunotherapy. It is a different paradigm for cancer treatment and it has some very appealing options, especially when we talk about older patients whose immune functions are in decline. This is a [topic of] constant revisiting; that’s why we call it research.
What we would like to do is expand this idea beyond head and neck cancer. The way that we stage cancer across the board is fundamentally flawed. However, this is a hypothesis that requires us to test rigorously. Therefore, regardless of what we share, it does take careful study and will, hopefully, stimulate a little more interest in this field, which has long been sidelined in oncology.