Aging is universal, but it occurs at different rates in different individuals, so it is poorly reflected in chronological age. But even in healthy individuals, age is a risk factor for some acute complications of cancer treatment. That’s why assessing and treating the geriatric patient must be done on a patient-by-patient basis.
— Lodovico Balducci, MD
At the 2007 ASCO Annual Meeting, Lodovico Balducci, MD, received the inaugural B.J. Kennedy Award and Lecture for Scientific Excellence in Geriatric Oncology. Called the “patriarch of geriatric oncology,” Dr. Balducci is widely known in the oncology community for his warm humor and thick Italian accent. “My elderly cancer patients like to talk, share things with me. I like to listen, and one of my greatest motivations is that they get comfort in speaking with me,” Dr. Balducci told The ASCO Post.
Dr. Balducci was born toward the end of World War II, on April 7, 1944, in the Northern Italian town of Borgonovo. After the war, his parents returned to his father’s hometown of Rimini, where Dr. Balducci was reared until the age of 18.
“When I grew up, Italy was a developing country, and I remember the ruins of the war; Rimini was one of the war’s most bombed European cities. At that time, the town doctor and the priest were revered. Doctors were also the wealthiest of the professional class, so early in my youth, I became enamored of the respect the field commanded,” said Dr. Balducci.
Dr. Balducci was raised in an academic household; both parents were teachers in the humanities. He noted that his first inclination was to follow in his parents’ footsteps, but his childhood experience with depression and loneliness informed his choice to pursue a career in medicine.
“I loved classical Greek and Roman studies, but given my somewhat withdrawn personality, I knew that a career in the classics would have inadvertently made me withdraw even further. But in medicine, I would be forced to interact in very intimate relationships with colleagues and patients. In many ways, medicine served as a safety exit for me,” said Dr. Balducci.
He explained that unlike in the United States, in which students move from high school to college and, if they choose, on to graduate school, in Italy students go directly from high school to postgraduate school. Dr. Balducci, with the support of his parents, ventured to Rome and attended the Catholic University to study medicine, which at the time was Italy’s only private medical school.
“Of course there were public medical schools, but back then there was no entrance exam, so basically anyone who graduated high school could attend medical school. But the Catholic University had very stringent acceptance criteria, and the opportunity for mentoring and advancing your career was much greater than in public universities. A public university might have a graduating class of 4,000, while at the Catholic University it was 150,” said Dr. Balducci, adding, “I also wanted to put a few miles between me and my hometown, for a number of reasons.”
Journey to the United States
When deciding on a specialty, Dr. Balducci first eliminated surgery, commenting that he didn’t have the manual dexterity for the discipline. “I decided to pursue a career in endocrinology, but I decided to continue my career in the United States to get the best medical education possible; medicine in Italy at that time lagged far behind that in the United States,” said Dr. Balducci.
His move to the United States was waylaid, but the disappointment of having his plans stalled proved a blessing in disguise. “I flunked the English language exam necessary to be accepted in an American institution, but while studying to retake the test, I met a woman who soon became my wife,” said Dr. Balducci.
After Dr. Balducci finished his obligatory military service, he and his young wife, who was also a doctor, left Italy. Their first stop was a small private hospital in Winnipeg, Canada, called Misericordia General Hospital. It was 1972. While working at Misericordia, an opportunity opened up at the University of Mississippi Medical Center Cancer Institute, so the Balduccis left Canada, traveling to Jackson, Mississippi, where they completed their residency training. “I was happy with the training I received at the University of Mississippi. It was still in the heated time of the civil rights movement, and of course Mississippi was right in the middle of it. But everyone tried to go out of his way to be decent,” said Dr. Balducci.
A Conversion Takes Place
Oncology was still a nascent discipline in the early 1970s, but Dr. Balducci said his desire to enter the field was influenced by an elegant presentation by J. Tate Thigpen, MD. “I was accepted for a fellowship at MD Anderson, but for a variety of reasons, I decided to stay at the University of Mississippi, where I immediately began working in the laboratory, doing research on hematopoietic stem cells. I also started working at the VA Medical Center, and that’s where my conversion, if you will, took place,” said Dr. Balducci.
His “conversion” was the realization that instead of practicing procedure-based medicine, he could use his human-interaction skills to care for older, very vulnerable cancer patients. It was, in a sense, one of the seminal times in a field that had no name: geriatric oncology. “It started almost in my subconscious, but little by little, as I worked with older patients at the VA, I began to realize that older cancer patients had different needs from their younger counterparts. So, in that respect, my life’s career was discovered at the VA in Mississippi, a very long way from my hometown in Italy. It was destiny, I guess, because it was then that I decided to forge a path in geriatrics,” said Dr. Balducci.
After his fellowship, Dr. Balducci and his wife left the University of Mississippi and traveled south to the University of South Florida College of Medicine, where he became a Professor of Oncology and Chief of Geriatric Oncology at Moffitt Cancer Center. “While working at the VA in Mississippi, I’d written extensively on geriatric oncology, and the new CEO of Moffitt, John C. Ruckdeschel, MD, had seen my work and invited me to Moffitt. I agreed on the condition that he would let me start a geriatric oncology program. He did, and, as they say, the rest is history,” said Dr. Balducci.
Changing Perceptions, Saving Lives
Dr. Balducci’s groundbreaking work in geriatric oncology should be framed within its historical context. The field of oncology itself was new at the time Dr. Balducci began his work in geriatrics; in fact, his initial geriatric program at Moffitt was the country’s first in the field. Oncologists had laser-like focus on treating patients with the latest chemotherapy drug, so changing perceptions about the biology and psychosocial needs of the older cancer patients was no small challenge. Asked about the oncology culture barriers he had to confront at the time, with typical modesty, Dr. Balducci replied, “Everyone was searching for a cure at that time; I was just going in a new direction.”
He explained that aging involves a progressive loss of the functional reserve of multiple organ systems that over time develop into the so-called geriatric syndromes—conditions that are typical of, although not unique to, aging. “Aging is universal, but it occurs at different rates in different individuals, so it is poorly reflected in chronologic age. But even in healthy individuals, age is a risk factor for some acute complications of cancer treatment. That’s why assessing and treating the geriatric patient must be done on a patient-by-patient basis,” said Dr. Balducci.
He continued, “For instance, I’m currently treating an 86-year-old woman with chronic myelogenous leukemia [CML], breast cancer, and a history of colon cancer. She’s also had a stroke, which has left her with left-sided paralysis for the past 10 years. And yet she is not ready mentally to die. So, from a clinical standpoint, does she need chemotherapy for her breast cancer? We don’t know. But she definitely needs to continue treatment for the CML or she’ll die. My point is, there are no clinical trials that can tell a doctor how to treat this woman. You have to get close to her and make critical decisions,” said Dr. Balducci.
Although he has been working at the forefront of oncology, caring and developing better ways to treat our oldest and most vulnerable patients, the energy in his voice could reflect that of an enthusiastic oncology fellow. “My time at Moffitt has been the richest part of my career. I’ve had the privilege to work with wonderfully talented and dedicated people, including an aggressive and talented nurse practitioner, Janine Overcash, who joined me when she was just out of school. And probably the best thing that happened was when Dr. Martine Extermann, a young fellow from Geneva, joined my geriatric program. She’s still here and is actually the soul of our research program,” said Dr. Balducci.
Asked about the significant milestones reached during his career, Dr. Balducci responded, “The ability to assess a patient’s life expectancy with reasonable accuracy and to gauge one's ability to withstand treatment side effects. At Moffitt, we have developed the CRASH score calculator to determine the risk associated with treatments. Several other institutions have also contributed to this work.”
“Then there is the CALGB study published by Dr. Hyman Muss, which ended a controversy in the field by demonstrating that older women with breast cancer can benefit from adjuvant chemotherapy. Hy, who is a dear friend, deserves a lot of credit for this important work,” said Dr. Balducci.
Dr. Balducci’s current clinical research activities address the management of frail older people, assessment of quality-of-life factors and prognostic indicators in older patients with cancer, and interactions of comorbidity and functional status in this patient population. “Using prognostic tools and building on past work, we are looking at bringing the new trend of personalized chemotherapy into the geriatric setting to improve survival and quality of life for our elderly patients. I think our current work is in line with the Affordable Care Act’s value over volume care initiative,” said Dr. Balducci.
Asked if he’s had any mentors who have made an impression on him along the way, he said, “I have three role models: my wife, who is Head of Geriatrics at the Tampa VA, Dr. Kathy Foley, who is a heroine of mine, a person who has brought humanity back to oncology and eased suffering worldwide, and Dr. Patty Ganz, for her consistently novel approaches to quality of life,” said Dr. Balducci.
What does Dr. Balducci do to unwind? “Well I don’t have much free time, but we have two wonderful grandchildren who live in New Orleans whom we visit, probably more often than my son and his wife would like,” Dr. Balducci said jokingly, adding, “We also love opera, and I write when I have the time. Life is hectic but very rewarding.” ■