Best Practices for the Collaborative Management of Older Adults with MCL

Announcer:
You’re listening to Project Oncology on ReachMD, and this episode is sponsored by Lilly. Here’s your host, Dr. Charles Turck.

Dr. Turck:
Welcome to Project Oncology on ReachMD. I'm Dr. Charles Turck, and joining me to discuss how we can take a collaborative approach to managing older adults with mantle cell lymphoma are Dr. Jonathon Cohen and Ms. Amy Goodrich. Dr. Cohen is an Associate Professor in the Department of Hematology and Medical Oncology at Emory University School of Medicine. He's also the Co-Director of the Lymphoma Program at the Winship Cancer Institute of Emory University in Atlanta. Dr. Cohen, thanks for being here today.

Dr. Cohen:
Yes, thank you so much for having me.

Dr. Cohen:
And Ms. Goodrich is a research associate and nurse practitioner in the Hematologic Malignancies Program and Research Nursing Manager at the Johns Hopkins Kimmel Cancer Center in Baltimore. Ms. Goodrich, it's great to have you with us.

Ms. Goodrich:
Thanks for having me.

Dr. Turck
So, let's start with some background on mantle cell lymphoma, or MCL for short. Ms. Goodrich, would you tell us about the prevalence of this disease in older adults?

Ms. Goodrich:
Sure. So, let's start with a little background on mantle cell lymphoma. It's a low-volume lymphoma; it accounts for about 6 percent of all B cell malignancies. The older adult population is typically where we see this disease. The average age of diagnosis is about the mid-60s. So, we do see a fair number of older middle-aged and older patients with mantle cell lymphoma.

Typically, patients come to this diagnosis with advanced-stage disease, and it has a prevalence to occur in the spleen, and the bone marrow, and the GI tract as well. And although we think about mantle cell as a disease that needs to be treated immediately, there are populations of people who have more indolent disease who are asymptomatic who we can watch. And certainly, in this older population, something that we consider is: do they really need treatment? So those are some of the things that we're thinking about when we see these older folks with mantle cell lymphoma.

Dr. Turck:
And turning to you now, Dr. Cohen, what are some of the unique needs of this patient group?

Dr. Cohen:
So, patients with mantle cell, as Ms. Goodrich just mentioned, tend to be middle-aged or older. And so we do see a large number of patients that would fall into that elderly category, some people in their 60s, 70s, 80s and beyond. And one of the challenges with managing patients in this age group is that, as you might imagine, there's a wide range of ways in which those patients present. So, I have some patients that I see that are running 10Ks and half marathons, and they're 79 years old. And then I have other patients who are 62 years old who are unfortunately dealing with a number of comorbidities that are limiting their daily activities.

And so one of the things that's critically important when evaluating a patient with mantle cell is to, especially an older patient, try to get a sense not only of their chronological age, but what their actual medical comorbidities are, what their day-to-day life is, and whether they're fully independent or whether they need assistance with some of their activities of daily living. And we know that in a number of different studies looking at outcomes for patients with non-Hodgkin lymphoma in general that as older patients progress towards frailty, their outcomes in general unfortunately are not as good. And it's much more challenging for those patients to be able to tolerate therapy. And so I think in addition to making the diagnosis, completing the staging evaluation, and identifying treatment options, it's critically important to really do a good assessment of what a patient's functional status is so that you can identify a therapy that's going to be appropriate for them.

Dr. Turck:
Now with that in mind, let's turn our attention to the need for multidisciplinary care coordination. Dr. Cohen, who's involved in an MCL care team, and what are each of their roles?

Dr. Cohen:
So, mantle cell lymphoma is an uncommon disease. And as a result, I think it's important that an oncologist with experience managing the disease is at least involved in that patient's care. And so Ms. Goodrich mentioned just a bit ago about the fact that some patients have aggressive disease and require therapy right away while other patients could potentially be observed. And so having an expert oncologist as well as a hematopathologist that can assist with the diagnosis and evaluation is important.

Once a patient is diagnosed and is undergoing treatment, there's a number of professionals that are involved with safely managing that patient, especially for our patients who are older and may have other comorbidities. So, I frequently work not only with advanced practice providers and nurses in my clinic, but I also work with social workers and dietitians. We have spiritual health; I also want to point out that many of my patients are also seeing cardiology, nephrology, primary care, and so forth. And so there are a wide range of specialists that bring their expertise to bear to safely manage patients.

Dr. Turck:
For those just tuning in, you're listening to Project Oncology on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Jonathon Cohen and nurse practitioner Ms. Amy Goodrich, who are sharing best practices for taking a collaborative approach to managing older adults with mantle cell lymphoma, or MCL.

Now coming back to you, Ms. Goodrich, what strategies do you recommend to improve communication and planning among the MCL care team?

Ms. Goodrich:
Right, so Dr. Cohen did a great job of describing that multidisciplinary team. And when you think about all of those roles that he mentioned, there's a lot of overlap in who is capable of doing which pieces of that. And so it is important to be communicating and make sure that everyone understands which piece someone else is going to take on. So, who's going to do the education, who's going to be in touch with the patient or pull them in for frequent visits or labs. He made a great point of talking about cardiology. I am often the one who contacts primary care providers, cardiologists, and endocrinologists if there are drug-drug interactions or if we're going to put people on steroids and expect their diabetes to become less well-controlled. Certainly, when we're using our BTK inhibitors, there are a lot of drug-drug interactions and cardiology considerations there. And so making sure that everybody understands which piece people are going to take and own and run with. And then keeping folks on the team in the loop every step of the way. Dr. Cohen talked about older folks; do they have transportation? Can they get to the pharmacy? This is where our social worker sometimes is the complete linchpin here.

So, depending on the patient's needs, the multidisciplinary team can be relatively small. But if a patient does have a lot of comorbidities and not a robust social network and transportation options, we really might be casting a very large net within the multidisciplinary team to make sure that this patient is successful on their therapy and is monitored correctly.

Dr. Turck:
Now we're almost out of time for today. So, before we close, I'd like to hear some final takeaways from each of you. Dr. Cohen, let's start with you.

Dr. Cohen:
I think one of the things that you've heard is that the management of patients, especially older patients with mantle cell lymphoma, can be complex. There may be comorbidities that need to be managed, there may be some social challenges, there may issues with frailty, and so forth. But I also want everyone to keep in mind that just because a patient is older, it does not mean that they can't be safely and effectively treated for their lymphoma. And I have a number of patients in my clinic who are in their 70s and 80s and beyond with mantle cell lymphoma, some of whom are being observed, others who have been on therapy, and many of whom have done quite well with good quality of life and excellent outcomes. And so I think although it may require a little bit more collaboration and there's a little bit more complexity, I think it's also important to recognize that this is a group of patients that can do quite well with our currently available therapies. And it's often appropriate to offer those treatments to them which can be life-prolonging and also prolong quality of life.

Dr. Turck:
Thanks, Dr. Cohen. And Ms. Goodrich, I'll give you the final word.

Ms. Goodrich:
Sure. And I just want to make sure that we are always keeping the patient in the middle of all of this focus. We may think that we're doing a great job and we've met all their needs and we've got all their loose ends tied up, but we've got to keep going back to the patient, and really their caregivers as well, to make sure that we really are supporting them to our fullest capacity to assure that patients are successful on therapy and get the maximum outcomes.

Dr. Turck:
Thank you both for sharing those takeaways. And as that brings us to the end of today's program, I want to thank my guests, Dr. Jonathon Cohen and Ms. Amy Goodrich, for joining me to discuss best practices in the management of older adults with mantle cell lymphoma. Dr. Cohen, Ms. Goodrich, it was pleasure having you both on the program.

Dr. Cohen:
Great. Thank you very much.

Ms. Goodrich:
Thank you.

Announcer:
This episode of Project Oncology was sponsored by Lilly. To access other episodes in this series, visit ReachMD.com/Project Oncology, where you can Be Part of the Knowledge. Thanks for listening!