Gauging Appropriate Care for Older Breast Cancer Patients

Arti Hurria, MD; Kathy D. Miller, MD


April 07, 2017

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Kathy D. Miller, MD: Hi. I am Kathy Miller, professor of medicine at the Indiana University School of Medicine in Indianapolis. Welcome to Medscape Oncology Insights from the 2016 San Antonio Breast Cancer Symposium (SABCS).

We are all getting older, and that means that our patients are getting older. Newly diagnosed patients are older and our patients who are surviving are living longer. That gives us the privilege of caring for a growing population of older breast cancer patients, along with the challenge of identifying the unique needs of these patients and providing optimal care. This has been a longtime concern of my next guest, Dr Arti Hurria. Dr Hurria is professor of medical oncology and director of the Cancer and Aging Research Program at the City of Hope Comprehensive Cancer Center in Duarte, California. Welcome, Arti.

Arti Hurria, MD: Thank you. It is an honor to be here.

Dr Miller: How did you first get interested in the older patient?

Dr Hurria: I have always loved the idea of taking care of someone throughout a lifetime, and there is nothing like being able to care for someone throughout their aging process. With cancer being a disease associated with aging, it was a natural fit for me to train in geriatrics and oncology.

At times, age can be a barrier that we want to look beyond as we evaluate that patient.

Dr Miller: There are some topics that are a little challenging to bring up with women: age and weight. How do you approach the topic of age with those older patients you are seeing?

Dr Hurria: I have found that they actually understand that they are aging. They really want the best treatment and they want that treatment to be individualized. If age needs to be a part of that factor, they want me to be thinking about it. More importantly, they want to be thought of independent of their chronologic age. They want us to look at them based upon what their functioning is, how they are in their daily lives. At times, age can be a barrier that we want to look beyond as we evaluate that patient. Our patients want that too.

Assessing Functional Age in the Older Patient

Dr Miller: I hear a lot of people talk about chronologic age versus physiologic age. Age is certainly not just a number. How do we really evaluate the fitness or the functional status of our patients?

Dr Hurria: That is a wonderful question. This is really what geriatricians focus on every day. The idea behind geriatrics is to really understand what the functional age is of the patient. Geriatricians do something called a geriatric assessment to try to understand what factors other than age predict someone's risk for morbidity or mortality from a certain outcome. They are asking things like, "What is their function? What are their other medical problems? What is their cognition? What is their social support, their psychological state, and their nutritional status?" It is really taking this very comprehensive look at who an older individual is and then utilizing that as a part of the decision-making process.

Dr Miller: I can hear a lot of our listeners in a busy practice thinking, "I have 30 minutes to see a patient and maybe a luxurious 60 minutes for a new patient. I am not trained in geriatrics and do not have a geriatrician in my area. That is a lovely idea, but how do I do that?"

We now have a geriatric assessment tool that can be completed primarily by the patient.

Dr Hurria: This is the great news. We have spent the past decade and a half trying to figure that out for oncologists. I completely understand because I trained in geriatrics and then went into a fellowship at Memorial Sloan Kettering, where the volume of patients is very, very high. The key is that if we are going to incorporate this new oncology practice, we need to make these tools feasible. That is really what we have worked on developing. We now have a geriatric assessment tool that can be completed primarily by the patient—very little healthcare provider time is needed. Our data have shown that the vast majority of older adults can do this on their own. A patient can even complete it at home and give you a printout and a summary of the information. This is on the Cancer and Aging Research Group website.

We have also figured out how to do it within the clinic, using iPads. I am at a comprehensive cancer center where I am the only geriatrician. We have patients complete the assessment on the iPad, and we have programmed it now so that the results can be available for the oncologist when we see the patient.

Dr Miller: How long does it take the average patient to complete the survey, whether they are doing it with good old-fashioned pencil and paper or on an iPad? What sort of questions does it ask?

Dr Hurria: It takes less than half an hour to answer all the questions and even less than that for those who are very fit and functional.

Dr Miller: Maybe one test could be a measurement of how long it takes them to do the assessment?

Dr Hurria: Actually, that would probably be a great cognitive test. We have not specifically looked at that, but I think it is something that we should look at for the outliers. The questions, Kathy, are really practical and have direct implications for cancer treatment. They are things like, "Can you do your shopping? Can you take transportation? How are you going to get to the hospital if you have fever and neutropenia in the middle of the night? Can you manage your finances?" People hold onto their ability to manage their finances to the very end. The minute they give that up, you have to start wondering whether there is a problem with calculation or memory in some way. It opens a door to just exploring those things.

There are simpler tools. The practicing oncologist wants to know, "Can I predict who is going to have severe side effects from my treatment?" That is really what they need to know, and they need to know it relatively quickly, as they are making a treatment decision.

Predicting Life Expectancy

Dr Miller: I think they also want to know, independent of the cancer, how long this person might otherwise be expected to survive. As that time gets shorter and shorter, the concern about toxicity gets greater. You have to start wondering, is this someone I should be treating even if I think I could treat them safely?

Dr Hurria: You are a geriatrician at heart, I have to say. The questions you have just asked are so wonderful. There are super-easy tools for both of these. Let me first start with that.

Let's talk first about life expectancy, and then we will talk about predicting toxicity. For life expectancy, a site called ePrognosis has several tools you can use that can estimate someone's life expectancy. You can estimate 2-year life expectancy, 4-year life expectancy, and life expectancy for someone who is hospitalized. These take a few minutes to do. You will get an answer very quickly, right there in the clinic with your patient. The challenge is that they have not been validated among patients with cancer. You have to think about that.

Dr Miller: They are only looking at other health factors independent of the cancer?

Dr Hurria: Exactly. If you say, "I do not really have time for that," you can use a table that looks at life expectancy by age, within the National Comprehensive Cancer Network guidelines. If you can even just say, "This is a healthy 70-year-old" or "This is a sick 70-year-old patient," it will give you the life expectancy for someone who is healthy, average, or sick at 70. I keep that in my pocket as a quick reference so that I can think about that as I am making a treatment decision. It takes seconds.

Predicting Chemotherapy-Associated Toxicity

Dr Miller: The other question is toxicity. We have seen few older patients in our Coalition of Cancer Cooperative group trials. Even those selected, and probably healthier older patients who enroll in those trials, do have greater risk for serious toxicity. How do we predict that in the average older patient who comes to us?

These are very simple, practical questions that you can ask the patient right there in practice.

Dr Hurria: The Cancer and Aging Research Group has worked on this over the past several years. There have been two studies: a development study[1] and then a validation study.[2] We took 500 patients all over the age of 65 across the United States from 10 participating centers and we let the doc be the doc. We said, "You give the treatment that you think is right for your patient. We are just going to capture those geriatric assessment factors and identify which ones predicted who was at risk for significant side effects."

We developed the model and validated it in an independent cohort. Overall, 750 patients participated. We found key things that predicted toxicity. Number one: Age is a predictor. An age over 72 years was a predictor in the dataset. It makes sense because it is really during that seventh decade of life when we start to see a lot of the physiologic changes of aging actually come to bear. Number two: Gastrointestinal and genitourinary cancers predicted risk. Number three: Tumor and treatment variables predicted risk (eg, polychemotherapy, dosing of chemotherapy, anemia, low creatinine clearance).

There are five assessment questions that identify geriatric patients at risk:

  1. Have you fallen in the past 6 months?

  2. Are you able to take the correct dosage of your medications at the right times?

  3. Do you have difficulty with your hearing?

  4. Have you decreased your social activities because of your physical health?

  5. Or because of your emotional health?

These are very simple, practical questions that you can ask the patient right there in practice. If you go to the Cancer and Aging Research Group website, click on the Chemotherapy Toxicity Calculator and ask your patient those 11 questions; it will be able to stratify whether your patient is low-, intermediate-, or high-risk. It does not tell you to treat or not treat. It gives you a place to start so that you can say to the patient, "Here is what we are going through together if we are going to go down this road. Is it worth it to you?"

One other thing we did was to look at whether the doctor can predict who is going to have that toxicity.

Dr Miller: I am going to bet that the answer is "no." Patients are tricky. If you just say, "How are you doing?" They will say, "I am doing okay." Nobody wants to admit that they are struggling. I think we all like to believe that we are doing okay for far longer than someone else might think.

Dr Hurria: Yes, you got it right. The doctor is such a wonderful patient advocate that they want that patient to be okay too. We found that the single-item assessment that we often do, such as the Karnofsky score or ECOG (Eastern Cooperative Oncology Group) performance status, cannot predict risk, while the 11-item model can. It is exactly as you said; these were great doctors. It is really a complex issue. You need more than one question.

Relationships With Adult Children of Patients

Dr Miller: In our last couple of minutes, I want to talk to you about another—sometimes difficult—relationship that we have to negotiate with our older patients: their adult children, who come in different flavors. Some think that mom and dad are going to live forever and ought to be treated like they are 20 even though they are 94, and some are surprised that mom and dad are not functioning as well as they thought they were. How do you negotiate those relationships?

Dr Hurria: A couple of things come into play. Number one: We want to engage the family because social support is so important for older adults. They need the family in this process. If the patient wants the child in the room and gives permission, then it is okay. It is sort of like in pediatrics, where you are helping parents care for their children. With geriatrics, you are helping the children do the same. They are going through the journey with the parent, and those feelings they describe are all emotions of love in some way or another. Really, for me, it is establishing rapport with that child and understanding what the parent—my patient—wants. How much do they want their kids to be involved? Then, to that degree, I involve them along each step.

Here is the key: Part of what a geriatrician does is assess. Does the patient have the capacity to make a decision? Patients may have the capacity to make a decision even in the setting of dementia or mild cognitive impairment. Part of my assessment is to work with that patient. Assessing capacity is super-easy—anyone can do it. Can the patient understand the risks, benefits, and alternatives? Can they state their choices? Once they can do that, then I can almost relieve the kids a little and say, "You know what? Your mom is able to make this decision with me. Really, you are just here to support that decision." Especially when individuals have parents with cognitive issues, they sometimes feel like they have to make the decision. It takes that burden off.

Dr Miller: This is really great information and great tools to help us have better discussions with our patients and, hopefully, make better decisions with them. Thank you, Arti, for joining us. This is Dr Kathy Miller, reporting from SABCS 2016.


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