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

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. Clinical 125,000 Patient Visits 4300 New Patients Diagnosed 1000 on Clinical Trials. Research 318 Members $70M NCI Funding

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

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  1. Geriatric Oncology: Breast Cancer UNC Lineberger: Cancer and Older Adults November 19, 2015Hyman B. Muss, MD

  2. UNC Lineberger Cancer Research Spans UNC’s Campus Clinical 125,000 Patient Visits 4300 New Patients Diagnosed 1000 on Clinical Trials Research 318 Members $70M NCI Funding $154M Other Cancer- Related Funding 34 Multi-Investigator Grants Training 26 Pre & Post-doctoral Training Grants

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

  4. 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

  5. U.S. Breast Cancer Incidence and Mortality Rates: SEER 2005-09 Median Age ~ 61 Per 100,000 women http://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=4&page=sect_04_table.12.html

  6. U.S. Breast Cancer Death Rates Over Time Smith B D et al. JCO 2011;29:4647-4653

  7. Prevention • Maintain a healthy weight • Exercise • Healthy diet – fruits and vegetables • For very high risk • Tamoxifen or raloxifene • What you don’t need • Expensive supplements • Negative friends

  8. Screening in Older Women • Breast Self Exam • Value uncertain • Physical Exam by Health Care professional • Mammography • Up 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”

  9. What is the Goal of Treatment? • Early stage breast cancer • Adjuvant therapy to increase cure • Treatment should not be as bad as disease • Metastatic disease • “You can’t improve on being asymptomatic.” • Maintain QOL and function first • Improve symptoms when present • Provide “structured” palliative care

  10. 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.

  11. 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”

  12. Adjuvant Systemic Therapy • At diagnosis in stage I- III patients • proportional reduction in recurrence of 25-50% • improves survival • Known options: • Chemotherapy • Hormone therapy (if ER or PR +) • Anti HER2 drug trastuzumab (if HER2 +) • Combinations of these • Considered in all but smallest Stage I tumors

  13. 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

  14. Adjuvant Therapy: Proportional ReductionAssume 100 pts, “Cure” 30%, 10 yr follow Math: 90% cure without Rx means 10% will not survive. 30% of 10% is 3% or three lives saved of 100 pts treated.

  15. Radiation Therapy • Depending on risk of recurrence ADDS to cure • Lumpectomy • alone - 30% recur, most same area • Radiation standard of care • Less than 10% recur in breast • In 70+ selected pts small tumors ay avoid • Mastectomy • large tumors, many + lymph nodes

  16. Survivorship • One third of Americans will get cancer • Right now 10.8 million cancer survivors • Most common cancer survivors • Breast, Prostate and Colon Cancer • 60% (6.5 million) are > 65 years • 14% of survivors > 20 yrs from diagnosis

  17. Geriatric Oncology atUNC-Lineberger?

  18. Is cancer the patient’s major illness?

  19. Geriatric Assessment • Evaluates functional and social status in addition to other medical issues. • Trials show: • Identifies problems not routinely found • Interventions 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

  20. Brief Geriatric Assessment 10 minutes 20-30 minutes

  21. Serially Measuring Molecular Age 16 40 64 80 Weeks of Age Burd et al, Cell 2013

  22. Combination Score (serum) Telomere Length (DNA) Log2 p16INK4a (PBTL mRNA) 10 12 20 R2= 0.09 9 18 10 8 16 R2= 0.12 14 7 8 12 6 10 6 5 R 8 4 4 6 3 R2= 0.42 4 2 2 2 1 10 20 30 40 50 60 70 80 90 10 20 30 40 50 60 70 80 90 10 20 30 40 50 60 70 80 90 AGE AGE AGE Molecular Changes with Aging Sharpless and colleagues, UNC

  23. Exercise is Good 10 8 6 Log2 [p16INK4a mRNA] 4 R2=0.16 p<0.001 2 0 0 25 50 75 100 125 Exercise (min/session)

  24. BCRF, Yow, COH trials Age < or ≥ 65 Cancer Type and Stage Treatment Physician and Patient Select Treatment Post 3m Post 6m Metrics END PRE Intervention Outcomes

  25. Metrics – What We Measure

  26. 1/22/15

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