Management of Older Patients With Breast Cancer

Hyman Muss, MD, Linberger Cancer Center at the University of North Carolina, Chapel Hill, NC, outlines a process —including considerations for life expectancy, goals of therapy, benefits and risks of therapy, toxicities, and shared decision-making— to optimize the management of older people with cancer.

Transcript

My name is Hyman Muss, and I'm a professor of medicine at the University of North Carolina School of Medicine. I have a major interest in cancer in older adults. I'm also the Mary Jones Hudson Distinguished Professor of Geriatric Oncology, in which position I've helped lead a program that specifically addresses how to improve cancer care for older patients.

Among the common pitfalls of treating older patients are using age alone to define a patient. One of the key points that I try to make when we discuss this is, it's not the age of the patient that's key. It's their life expectancy. If you have, in the United States, a 75-year-old woman in average health, they're going to live 12 years. Most physicians don't know this, they're shocked about this, but they're going to live 12 years. But in that 12-year range, it's a very wide bell-shaped curve. And some patients are going to be 2 to 3 years, and some patients it's going to be 20 years. So how do you figure it out? Well, there is some very excellent tools for this, and one of them is ePrognosis. This website uses a series of questions that you answer about the patient to estimate life expectancy. It’s built on some of these huge studies that have been done in the United States for 20 to 30 years, studies like the NHANES study that collected data on patients and had permission from those patients to explore the death index. When you die in this country, you go in the National Death Index. If you didn’t sent your questionnaire that year about how their health was, they did this for patients for 20 to 30 years and if they don't find you, they can look in the death index and figure out if you died. From this, and all the questions, they develop good tools. I use these tools. They are tools for adults aged ≤65-year-old who live in a community setting.

You can also do nursing home and end-of-life settingds in these tables, but there are at least 2 models, 2 calculators, that you can use to look at life expectancy. I use it to calculate how long an older patient is likely to live, exclusive of their cancer. As an oncologist, what you want to know in an older person is how long would they live If they didn't have cancer, then you can factor the cancer in. Now obviously if they have acute leukemia and they're very sick, it's a different issue. But for many of the cancers we have, the solid tumors, lower grade lymphomas and leukemias, knowing your life expectancy without cancer helps you really define treatment and how to speak with the patient. I think that's a key issue.

This can take 10 minutes, and you can train office staff to do it. It takes just a few minutes, requires some input from the patient, questions that you don't ask all the time. A lot of these questions would be done in a geriatric assessment, which is something I recommend doing, but it takes some time. Today, time is your most precious gift in the clinic. We’re being asked to do more with less, more clicks, more stuff all the time. If you can do the geriatric assessment, it's excellent. If you can't, these calculators and some of these tools don't have many questions, and they can help you. Life expectancy is key. When I work with trainees and fellows, they say, "Hi, I just saw Mary Smith, she's 76 and she has X and Y." I say, "Stop. Did you calculate her life expectancy?" If not, we go over how to do it and then the next time they know how to do it. Some of my friends in practice and surgical friends are doing this, because it helps them better work with the patient on shared decision making.

Once you've done that, you need to define the goal of treatment. We’ve got 250 cancers. Some are very acute or terrible, and those goals of treatment, and some are potentially curable acute leukemias, but some are not. You must define where you are. You may have a potentially curable cancer, but with an intensive therapy. You might have an incurable cancer with a relatively healthy patient exclusively of the cancer and poor therapy. You need to go over the goals of care and what it is.

It going to be palliative care? For anything incurable, even if it's a disease you might live very long with, there is palliative care. In fact, my friends in palliative care would say, "Hi, you're wrong. Palliative care is for anybody with any problem who needs help with symptoms, whether they're physical or psychosocial." But I'm putting it in the context of incurable cancers. There, your goals of therapy are to control the disease. If it's causing symptoms, try to get a remission for the longest period with the least toxicity. That is important, the least toxicity. Because there may be a regimen that published a progression-free survival of a month or 2 longer than another treatment, but it's extremely toxic. You must keep that in mind. What's the goal of treatment? What are the options out there? If it's curative therapy, and I personally take care of lots of older women with early-stage breast cancer, then you have to look at the benefits of the treatment in that patient population versus how we get those benefits.

What about regimens, especially chemotherapy or adding immune therapy to chemotherapy? The way I do it – at least for breast cancer patients, and there are similar calculators for lung and other cancers that you can look it up – is I put in all the clinical characteristics of the cancer patient, and I use a program from the United Kingdom called Predict Plus. And it'll tell you how the patient is going to do. Let's use a breast cancer patient as an example with surgery alone, with surgery plus endocrine therapy if they're hormone receptor positive, and then surgery, chemotherapy, and endocrine therapy, if they're a very high risk ER-positive patient. Age goes in it, and they factor yearly mortality into the program using census data from the UK, which is like the US. It's better to use a prognosis to look at life expectancy, but it's built-in in this program.

Then you know how to discuss the treatment with the patient. How precise you are depends on the patient, their knowledge base, and their personal style. Some people want to know numbers. In my experience, most people don't. The chemotherapy, at least in a group of patients like that, is it likely to have a high impact or very small impact? Certainly, in the other therapies you can factor in, there are side effects too. You may have options for several treatments. You know the side effects of those treatments, and you can apply it to that patient. There are also several calculators. One is in the MyCARG website, there's others at the Moffitt Cancer Center that allow you to calculate the toxicity of chemotherapy in people 65 and older, as far as serious side effects. You can go into those calculators. They take a few minutes, and you can now have a pretty good idea of the side effects of the therapy.

Now you know the life expectancy of the patient, you know the potential benefits of treatment and the goals of treatment, and you know the toxicity of the treatment. Then you can sit down and go through the last process, which I think is the hardest, and that’s shared decision-making. That’s where you sit with the patient, and usually their family, you go over all the information as best you can, show you have factored in geriatric issues that pertain to them from your calculators. If you're really cool, you've done a geriatric assessment. I'd love for people to be doing that, but I understand the issues. Then you come to a conclusion. Should you take this treatment or not? Make sure they understand the benefits. Be sensitive to their goals, not your goals. We've all had patients that turn us down or don't want to do things that we suggest, which we know in a group of patients like them are going to be highly valuable. That changes the way we think and the way we frame things.

In older people, especially if the treatments are likely to be modest or they're palliative, what does this patient want? For older people, their greatest fear if they're independent, is loss of independence. “I don't want to be a burden in my family.” I've heard it numerous times. Of course, the family's sitting in there with them and saying, "Oh mom, you're never a burden. We love you," but patients know better about their children and families. They’re worried about it. They also worry about any cognitive loss, which is usually not a great problem, but can occur. You have to address these issues and then come to a final decision on management.

I think those principles of geriatric assessments are great if you can do it. If not, life expectancy, goals of therapy, benefits and risks of therapy, toxicities, and then shared decision-making – if you follow that scenario, you will optimize management for older people with cancer and probably with many other diseases as well.