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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