Siding with the vulnerable

Silvio Monfardini’s great contribution to oncology has been raising the standard of care for older patients. His story is a shining example of what can be achieved when scientific rigour is combined with a deep-rooted commitment to equality and a willingness to take a lead.

» Janet Fricker

Whether defining the healthcare needs of older people with cancer, or supporting his local Communist Party, Italian oncologist Silvio Monfardini has not been afraid to stand up and fight for his principles. Monfardini has spent his career campaigning for underprivileged oncology patients – those who are older, have AIDS or who live in developing countries. “My philosophy has always been to do my best, whether playing rugby for my team or treating cancer patients,” says Monfardini, who helped define the discipline of geriatric oncology and is now devoting his ‘retirement’ to campaigning for the widespread introduction of multidimensional assessments when treating the very elderly.

“Today we’d be surprised if cancer in a child weren’t treated by a paediatric oncologist. Why then should cancer patients older than 70 not be treated by specialists in geriatric oncology?” he asks.

Monfardini, who has a bit of a bent for self-analysis, is the first to admit his character reveals contradictions: a rugby player who appreciates the beauty of wild mountain flowers, a teamplayer who was prepared to take a political stand that left him in the career wilderness, and a former Communist Party activist who enjoys the benefit of three homes – though to be completely fair, the latter has been necessitated by jobs in different parts of Italy.

Born in Milan in 1939, to a family of physicians fromTuscany, Monfardini spent the Second World War in the comparative safety of the Italian mountains, near lake Lugano, where he had been evacuated with his mother Anna, a school teacher, and her family. The few glimpses he had of war have remained with him. An image of silver planes glistening in the sky overhead, then terrible explosions: “I experienced amixed reaction – the feeling of utter helplessness, yet an attraction to the theatrical spectacle of the event.”The sight of a platoon of German soldiers marching through his village in jackboots left him with the impression of “something terrible and harsh”.

It was his father Renzo’s wartime experiences, where he served as an army doctor, that shaped Monfardini’s future politics. On 8 September 1943, when the Italian Government signed an armistice, Monfardini senior was stranded without orders in Yugoslavia – the generals had all fled. “From an early age I was appalled that in Italy the people in power didn’t take responsibility,” he says. “To see a political party where the leaders didn’t have advantages made communism enormously attractive to me.”

The Monfardini family returned to Milan in 1946. His ability to function as an outsider, he reasons, may stem from being raised as an agnostic by his father in a Catholic educational system. As a school boy, Monfardini’s interests were philosophy and history, but he showed aptitude as a mathematician and enrolled at the Milan Polytechnic to study engineering. “I soon discovered it wasn’t me,” he says. “I was laughing in situations where the other students remained serious. It just didn't hold enough human interest, and I found myself feeling more and more attracted to the ethical and moral dimensions of medicine.” 

The fact tha the succeeded in transferring to the University of Milan School of Medicine after two months without loosing an academic year, he attributes to his good fortune in meeting his wife Mellina, now a paediatric neurologist specialising in cerebral palsy. Mellina, who was top of their year, undoubtedly kept him on the academic straight and narrow. “I felt obliged to work hard to keep up with her,” he says, adding that without her influence he would have undoubtedly played more rugby, to the detriment of his medical studies.

A QUESTION OF LEADERSHIP

Monfardini had started playing rugby seriously at 17, graduating to play for Milan’s first division. “Rugby is my religion. It has taught me so many valuable lessons in life. The fact that you have to keep fighting to the final whistle even if you are loosing was very character building.” Rugby also taught him important leadership skills. “In order to accomplish anything, whether managing a cancer institute or a rugby team, you have to utilise everyone’s best qualities to fight for a common objective,” he says. It is a passion he now shares with his son Lorenzo, whom he encouraged to play as a child.

Graduating in medicine at the age of 25, Monfardini was attracted to endocrinology – the logic appealed to him. But before he had a chance to complete his training, Gianni Bonadonna, the first medical oncologist in Italy, approached him with the offer of a fellowship at the National Cancer Institute in Milan. Bonadonna was looking for endocrinologists, as he had started treating breast cancer with endocrine therapy.

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“When I first took the job, Bonadonna warned me that I would think about death six times a day”

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“When I first took the job, Bonadonna warned me that I would think about death six times a day. As an oncologist you can joke and laugh, but there is always a tinge of sadness in your life,” he says, adding that it was worse in the early days, when there were limited treatments they could offer.

Teaching in Tripoli. Monfardini is pictured here with physicians from the division of medical oncology at Tripoli General Hospital, Libya, following a lecture he presented, January 2008

At the Institute, Monfardini spent two years treating conditions like Hodgkin’s disease with sequential chemotherapy, and learning to handle the side-effects. Next followed a fellowship at the Memorial Sloan Kettering, New York, where he studied the impact of initial prognostic factors in chronicmyeloid leukaemia (CML), and found himself much impressed by the humanitarian approach of US doctors and nurses. “They had a real connection with patients which I think was partly achieved because in the US, unlike Italy, people were allowed to bring personal objects into hospital. It helped healthcare staff to see them as individuals,” he says.

His return to the National Cancer Institute in Milan marked the start of his family. Erica was born in 1971 – she is now a European marketing manager working in pharmaceuticals. Two years later came Lorenzo – he has followed his father’s footsteps and works as an interventional radiologist at the European Institute of Oncology in Milan. His third child, Ilaria, born 1981, also went into medical science, and now works as a researcher in pharmaceutical chemistry at the University of Genoa.

While his young family thrived, Monfardini’s career was temporarily blighted by his decision to join the Communist Party. “I was disturbed by the disparities I’d seen between the rich and poor and felt the Communist Party was the best way to rectify this imbalance,” he says.

The former director of the National Cancer Institute reacted by preventing him from working as amedical oncologist, making him assist in surgery instead. “I felt victimised for my political beliefs, but I refused to be intimidated by a bully,” he says, adding that thanks to the sympathetic attitudes of his colleagues he was able to continue following his research interests.

There were other complications. Every time he travelled to the US for a cancer meeting, such as ASCO, he had to be interviewed by the American consul and provide a fixed itinerary of all his intended movements. But becoming secretary of one of the Milan sections of the Communist Party also provided valuable experience. “It was like being a priest – I found myself the reference point for the community – anyone who had any sort of problem came to me. For the first time I understood that I had the ability to remain calmin the face of problems,” he says.

The situation at work resolved when Umberto Veronesi was appointed head of the cancer institute in the late 1970s, and Monfardini was allowed to work again as amedical oncologist. Around this time he started research into combining chemotherapy and radiotherapy in the initial stages of non- Hodgkin’s lymphomas and chemotherapy of testicular carcinomas.

CARING FOR GERIATRIC PATIENTS

In 1984 Veronesi appointed him as director of a new National Cancer Institute in Aviano, a rural area situated close to the border with Austria and Yugoslavia. Here he had responsibility for both the 100-bed cancer hospital and a research institute employing 30 basic science and epidemiology researchers.This period, says Monfardini, marks the start of his interest in the elderly.

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“In Milan older people rarely made it to the hospital, but in this region, I saw their problems first hand”

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“It was at Aviano I first become aware of the plight of older people with cancer. In Milan there was such competition for appointments that older people rarely made it to the hospital, but in this mountainous region, with its smaller population, I saw their problems first hand,” he says.

He became aware of the fact that aspects of age, such as comorbidities and functional status impairment, neurological and mental deterioration, reduced physical activity and the lack of family and social support all impacted on the treatment of cancer patients. For the first time he appreciated that 60%–65% of cancers occur in people over 65, and that this age group accounts for more than two thirds of tumour deaths.

“I began to recognise that it was important to take a holistic approach to cancer in the elderly, and that attention needed to be paid to other aspects of the patient’s health,”he says. Here he also studied AIDS related neoplasias, setting up patient registries.

In 1990, together with Ian Fentiman, he published an article in The Lancet, Cancer in the elderly: Why so badly treated?, then later that year he organised the first consensus meeting on geriatric oncology, in Venice – a joint initiative of the European Organisation for Research and Treatment of Cancer and the US National Cancer Institute.

After ten years in Aviano, he felt ready for a change and was appointed director of the National Cancer Institute in Naples. He was surprised to discover that transferring from northern to southern Italy proved a real culture shock. “I was unprepared for the hold that organised crime had on all aspects of life in the city. In this environment a bureaucratic paralysis made any real change impossible, despite the presence of excellent clinicians and researchers,” said Monfardini,who was also not happy that the administrative duties involved in running an institute left little time for patient contact.

So when, in 1996, he was offered the post of chief of the division of medical oncology at Padua General Hospital and the ancient University of Padua, he jumped at the opportunity, so he could focus once again on his interest in geriatric oncology. It was here that he started pushing for the routine use of the Multidimensional Geriatric Assessment in oncology, a screening tool for elderly patients that evaluates them as fit, vulnerable or frail, as a guide to the more appropriate therapy option. “The idea is that fit elderly patients can be treated in the same way as adults, vulnerable patients should receive adapted regimens and have increased surveillance for adverse events, while supportive care should be offered to frail individuals,” he explains, adding that he is currently trying to develop a 10-minute screening tool for use by busy oncologists to decide which patients require the full assessment.

Undoubtedly, an added bonus to the Padua job was that it gave him the opportunity to live in Venice, the part of Italy where he says he feels most at home. “Aesthetically I’ve always loved Venice, and I like the fact that it is the gateway to the East. I’m interested in the economic, navigational and commercial history of Venice.”

THE AFRICAN EXPERIENCE

In his career, another major initiative has been coordinating cancer chemotherapy courses for the International Union Against Cancer.

It was while organising courses in South East Asia, the Middle East, South America and Eastern Europe, that he became aware of the plight of cancer patients in developing countries.

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“It was highly relevant in Africa, where infections render young patients very fragile to chemotherapy”

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In June 2007 his attention focused on Africa, when he was invited to give a lecture on cancer in the elderly at the Uganda Cancer Institute in Kampala. “My talk was particularly relevant for African oncologists since concurrent infections render young patients much more fragile to treatment with chemotherapy,” he says.

With Jackson Orem, director of the Uganda Cancer Centre. This one small hospital serves the whole of central Africa

He was shocked to learn from the Institute’s director Jackson Orem that, despite supporting the whole of central Africa, they only had two medical oncologists, one haematologist and one radiotherapy machine. Furthermore, due to rapid industrialisation and the strength of the tobacco industry, cancer is a growing problem in Africa. “But most countries in sub-Saharan Africa have no infrastructure for surgical or radiotherapy services, which creates the appalling situation where in some places the incidence of cancer equals the mortality,” he says.

Travel scholarships are not the answer, he says, since they would only enable African doctors to stay in the US and Europe. A more sensible way forward, he suggests, is to give support to African institutions to train doctors in situ. He now supports an initiative that offers obsolete European equipment to Africa, but is wary of the effect that spreading himself too thin could have on his work on geriatric oncology.

The African visit gave Monfardini and his wife Mellina the opportunity to join a mountain trek to see gorillas on the borders of Uganda, Rwanda and the Congo. After a day-long trek they were rewarded by the “awesome” sight of a silverback and babies. Monfardini was gratified that at the age of 68 he was judged fit enough for the arduous expedition. This fitness he attributes to a lifetime spent sailing, cross-country skiing and mountaineering. In January 2008, a lecture tour to Tripoli provided him with the opportunity to go on a five-day tour of the eastern Sahara to view prehistoric rock paintings. “There were no roads. We regularly had to dig the jeep out of sand drifts and slept every night under canvas, having cooked our supper in the sand,” he says.

Such opportunities have been made possible by the fact that he is retired, although he still co-ordinates the geriatric oncology programme in Padua and Milan at the Fondazione Don Gnocchi, where he holds clinics, runs courses for specialists in both oncology and geriatrics, and is doing observational studies of the effects of adjuvant chemotherapy and endocrine therapy in older women with breast cancer.

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The French model he particularly respects, where cancer patients are treated in 15 geriatric research units

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With wife Mellina

“My dream is to bring oncology into the practical activity of geriatrics,” he says, adding that this is proving an uphill battle with shortages of geriatricians in many European countries. The French model he particularly respects, where cancer patients are being treated in 15 geriatric research units. Other current initiatives include editing the bimonthly electronic journal of the Association of Cancer in the Third Age, and campaigning for more research into the basic science underlying the transformation of ageing cells into cancer and for more clinical trials to be conducted in geriatric patients to understand how to treat them better. He also feels that not enough attention is paid to prevention in the elderly, arguing that it is absurd that mammography and colonoscopy are not supported after the age of 70. “The thing about retirement is that, although I’m possibly busier than ever, it’s given me the freedom to concentrate on the things that really interest me,” he says, adding that what free time he has is now spent with the family, seeing his three grandchildren, all of them under four years old, and his mother, now aged 97.

Next year marks the occasion of his 70th birthday, that magic number that defines you as a geriatric patient. Does he view this as an obstacle in his career? “Just as female gynaecologists can relate more to the problems of women, as an older oncologist I now feel that I have more empathy with my patients,” he says.