Geriatric Oncology: Breast Cancer UNC Lineberger: Cancer and Older Adults

November 19, 2015

Hyman B. Muss, MD

UNC Lineberger Cancer Research Spans UNC’s Campus

Research318 Members

$70M NCI Funding

$154M Other Cancer-

Related Funding

34 Multi-Investigator Grants

Training26 Pre & Post-doctoral

Training Grants

Clinical125,000 Patient Visits

4300 New Patients Diagnosed

1000 on Clinical Trials

Treating Patients with All Types of CancerThe N.C. Cancer Hospital

Multidisciplinary Care:Studies show patients have better outcomes

• One-stop shopping• Exchange of knowledge

and opinions• Coordinated treatment

plans• Fewer patient

appointments, faster treatment

• Coordinated care through specialties & follow-up

U.S. Breast Cancer Incidence and Mortality Rates: SEER 2005-09

25-9 35-9 45-9 55-9 65-9 75-9 85+0

50

100

150

200

250

300

350

400

450

500

IncidenceMortality

Per 100,000 womenhttp://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=4&page=sect_04_table.12.html

Median Age ~ 61

U.S. Breast Cancer Death Rates Over Time

Smith B D et al. JCO 2011;29:4647-4653

Prevention

• Maintain a healthy weight

• Exercise

• Healthy diet – fruits and vegetables

• For very high riskTamoxifen or raloxifene

• What you don’t needExpensive supplementsNegative friends

Screening in Older Women• Breast Self Exam

Value uncertain

• Physical Exam by Health Care professional

• MammographyUp to age 75: Annual or biannual

• reduces breast cancer mortality by 20-30% Consider in 75+

• If survival likelihood greater than 5 years• Can perform every 2-3 years• Concern for “overdiagnosis”

• Early stage breast cancerAdjuvant therapy to increase cureTreatment should not be as bad as disease

• Metastatic disease“You can’t improve on being asymptomatic.”Maintain QOL and function firstImprove symptoms when present Provide “structured” palliative care

What is the Goal of Treatment?

Adjuvant Therapy

The use of chemotherapy, hormone therapy and/or

radiation therapy either before or after surgery. The aim is to

destroy microscopic metastases that may be present and if left

untreated will eventually lead to relapse.

Look, since you don’t know whether I am cured or not

why don’t wait and see if my cancer comes back and then

treat me? If you would like I’ll come everyday for tests

so we can find it early.Answer: “Drug Resistance”

Adjuvant Systemic Therapy• At diagnosis in stage I- III patients

proportional reduction in recurrence of 25-50%improves survival

• Known options:ChemotherapyHormone therapy (if ER or PR +)Anti HER2 drug trastuzumab (if HER2 +)Combinations of these

• Considered in all but smallest Stage I tumors

What the patient hears

• You have breast cancer

• We don’t know if your cancer has spread

• Here is your bill for you work-up

• Here is your risk of recurrence without Rx

• Here is your risk with adjuvant therapy

• Here are the side effects of treatment

• We cannot tell if adjuvant Rx has helped

• If you relapse then it didn’t work

Adjuvant Therapy: Proportional ReductionAssume 100 pts, “Cure” 30%, 10 yr follow

PrimaryTumor (Mo)

10 year Survival

No Treatment

Treatment saves:

10 year Survival

With Treatment

1 cmNo positive lymph

nodes-90% 3 of 10 93%

2 cm10 positive Lymph

Nodes20% 24 of 80 44%

Math: 90% cure without Rx means 10% will not survive. 30% of 10% is 3% or three lives saved of 100 pts treated.

Radiation Therapy

• Depending on risk of recurrence ADDS to cure

• Lumpectomy alone - 30% recur, most same areaRadiation standard of care

• Less than 10% recur in breast

In 70+ selected pts small tumors ay avoid

• Mastectomy large tumors, many + lymph nodes

Survivorship

• One third of Americans will get cancer

• Right now 10.8 million cancer survivors

• Most common cancer survivorsBreast, Prostate and Colon Cancer

• 60% (6.5 million) are > 65 years

• 14% of survivors > 20 yrs from diagnosis

Geriatric Oncology atUNC-Lineberger?

Is cancer the patient’s major illness?

Geriatric Assessment

• Evaluates functional and social status in addition to other medical issues.

• Trials show:Identifies problems not routinely foundInterventions based on GA can:

• Improve Quality of life and maintain/improve function• Possibly extend survival

• But, not enough geriatricians to do it

• So we have to learn how to do it ourselves

Brief Geriatric AssessmentDOMAIN ASSESSMENT MEASURE

Health Professional Self Reported

Functional Status

Timed Up and GoKPS- Physician Rated

Activities of Daily Living (ADL)Instrumental Activities of Daily LivingKarnofsky Self ReportedNo. of Falls in the last 6 months

Co-morbidityNumber /Type of Comorbid ConditionsNo. of MedicationsVision and Hearing Assessment

CognitionBlessed Orientation

Memory-Concentration

Psychologic Mental Health Index-17

SocialSocial Activity Limitation Measure (MOS)Social Support Survey (MOS)

Nutrition BMI Unintentional Weight Loss 6 mths

10 minutes

20-30 minutes

Serially Measuring Molecular Age

16 40 64 80

Weeks of Age

Burd et al, Cell 2013

Telomere Length(DNA)

R2= 0.09

2

4

6

8

10

12

10 20 30 40 50 60 70 80 90

AGE

Log2 p16INK4a

(PBTL mRNA)

R2= 0.42

1

2

3

4

5

6

7

8

9

10

10 20 30 40 50 60 70 80 90

AGE

Molecular Changes with Aging

Sharpless and colleagues, UNC

Exercise (min/session)

Log

2 [p16

INK4a

mR

NA

]

0 25 50 75 100 1250

2

4

6

8

10

R2=0.16p<0.001

Exercise is Good

Age < or ≥ 65

Cancer Type and Stage

Treatment

Physician and Patient Select

Treatment

Metrics

PRE END

Outcomes

Intervention

Post 3m Post 6m

BCRF, Yow, COH trials

Metrics – What We MeasureMetric

MeasureDescription

Geriatric Assessment (CARG)Measures function (physical and mental),

other diseases, anxiety, depression, nutrition and social support

Health Behavior Questionnaire Exercise and Alcohol Use

Short Physical Performance Battery Engagement in Physical Activity

OEE/Outcome Expectations for ExerciseFitBit (data capture throughout chemotherapy)Physical activity log daily during chemotherapy

Physical function

CBC, renal, hepatic, albumin Basic organ function

Biomarkers (p16, IL-6, D-Dimer, CRP Markers of inflammation and aging

DEXA scan for Muscle mass Lean body mass and fat mass

CTCAE (during chemotherapy) Side effects of treatment – MD reported

PRSM (PRO – during chemotherapy Patient reported side effects

FACT-Breast Quality of lifeFACIT-Fatigue

FatiguePSEFSM/Perceived Self-Efficacy for Fatigue Self-Management

Program satisfaction

1/22/15