Download Presentation - UNC Lineberger Comprehensive Cancer Center

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
Research
318 Members
$70M NCI Funding
$154M Other CancerRelated Funding
34 Multi-Investigator Grants
Clinical
125,000 Patient Visits
4300 New Patients
Diagnosed
1000 on Clinical Trials
Training
26 Pre & Post-doctoral
Training Grants
Treating Patients with All Types of Cancer
The 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
500
450
Median Age ~ 61
400
350
300
250
Incidence
Mortality
200
150
100
50
0
25-9
35-9
45-9
55-9
65-9
75-9
85+
Per 100,000 women
http://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=4&page=sect_04_table.12.html
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 risk
Tamoxifen or raloxifene
• What you don’t need
Expensive supplements
Negative friends
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”
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
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:
Chemotherapy
Hormone 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 Reduction
Assume 100 pts, “Cure” 30%, 10 yr follow
Primary
Tumor (Mo)
10 year
Survival
No Treatment
Treatment
saves:
10 year
Survival
With
Treatment
1 cm
No positive lymph
nodes-
90%
3 of 10
93%
2 cm
10 positive Lymph
Nodes
20%
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 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
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
Geriatric Oncology at
UNC-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 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
Brief Geriatric Assessment
DOMAIN
ASSESSMENT MEASURE
Health Professional
Functional
Status
Co-morbidity
Cognition
Activities of Daily Living (ADL)
Timed Up and Go
Instrumental Activities of Daily Living
KPS- Physician Rated Karnofsky Self Reported
No. of Falls in the last 6 months
10
Blessed
Orientation
minutes
Memory-Concentration
Psychologic
Number /Type of Comorbid Conditions
No. of Medications
Vision and Hearing Assessment
20-30
minutes
Mental Health Index-17
Social Activity Limitation Measure (MOS)
Social Support Survey (MOS)
Social
Nutrition
Self Reported
BMI
Unintentional Weight Loss 6 mths
Serially Measuring Molecular Age
16
40
Weeks of Age
Burd et al, Cell 2013
64
80
Molecular Changes with Aging
Log2 p16INK4a
(PBTL mRNA)
Telomere Length
(DNA)
10
12
R2=
0.09
9
10
8
7
8
6
6
5
4
4
3
R2= 0.42
2
2
1
10
20
30
40
50
AGE
60
70
80
90
10
20
30
40
50
60
70
80
AGE
Sharpless and colleagues, UNC
90
Exercise is Good
Log2 [p16INK4a mRNA]
10
8
6
4
R2=0.16
p<0.001
2
0
0
25
50
75
Exercise (min/session)
100
125
BCRF, Yow, COH trials
Age < or ≥ 65
Cancer Type
and Stage
Metrics
PRE
END
Post 3m Post 6m
Treatment
Intervention
Physician and
Patient Select
Treatment
Outcomes
Metrics – What We Measure
Metric
Measure
Description
Measures function (physical and mental),
other diseases, anxiety, depression,
nutrition and social support
Exercise and Alcohol Use
Geriatric Assessment (CARG)
Health Behavior Questionnaire
Short Physical Performance Battery
Engagement in Physical Activity
OEE/Outcome Expectations for Exercise
FitBit (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
CTCAE (during chemotherapy)
Lean body mass and fat mass
Side effects of treatment – MD reported
PRSM (PRO – during chemotherapy
Patient reported side effects
FACT-Breast
Quality of life
FACIT-Fatigue
PSEFSM/Perceived Self-Efficacy for Fatigue SelfManagement
Fatigue
Program satisfaction
1/22/15