Personalized Breast Cancer Care for Older Adults Goes Beyond Age

When treating older patients with breast cancer, it is important to understand that there are many unique aspects that should inform personalized treatment decision-making for this population, according to Dr. Hyman B. Muss, who went on to say that chronological age as it stands by itself is not an adequate measure of health status for these individuals.

Factors to consider when treating these patients can include functional capacity, social support, comorbidities and molecular biomarkers, among others. It is these individualized considerations that make up the patient on a more individual level which will best inform their care.

To further discuss this topic, Muss sat down for an interview with CURE where he discussed treatment considerations, as well as how to understand the life expectancy of older adults with breast cancer, among other important topics.

Muss serves as the Mary Jones Hudson Distinguished Professor of Geriatric Oncology and the director of the Geriatric Oncology Program the University of North Carolina (UNC), UNC-Chapel Hill Lineberger Comprehensive Cancer Center.

CURE: What are some treatment considerations required when treating breast cancer in older patients? How did treatment plans differ from those of younger patients?

Muss: The challenge with older adults is that using age alone doesn't account for the great variability in their health status. If your clinic has 40-year-old women, they will generally be very healthy, and you might intuitively think, "Oh, this is a healthy group." However, in the United States, when someone is 75, there's an intrinsic age bias, a perception that older people are not as fit or able to tolerate things well. Yet, there's great variability.

There are older women, I'm sure you've met, who can play tennis three days a week and move quicker than you or I. Then there are people who are very disabled, and a large middle ground where, when you see them in the clinic, you're just not sure. So, the challenge with older women is not to rely on their chronological age but to actually have an idea of their life expectancy.

How do you approach understanding the life expectancy of older adults with cancer, and what factors beyond the diagnosis do you consider when planning treatment?

Fortunately, there are some wonderful tools for doctors and health professionals, built on the vast datasets the United States has collected on our population over the years, that allow us to accurately predict life expectancy. So, when ‘Mary Smith’ comes in, and you do a geriatric assessment, you find out not just her diagnosis and treatment, but also how functional she is.

Can she take care of herself? Can she do all the activities needed to live independently, use the phone, etc.? Does she have good social support, which, by the way, is related to life expectancy? People who are lonely and don't have many friends, irrespective of their diseases, do worse than a matched person with a similar health status who has friends and is very active. You also look at their medications and other illnesses. You need to put all that information together, which you can, to derive an accurate life expectancy…

That will shape how you talk to the patient, what options you discuss, and what values you want to elicit from the patient concerning their treatments. The challenge is putting all that together in a medical environment that demands high throughput and doesn't frequently allow doctors, nurses, and navigators to do that.

How does aging at the molecular level influence a patient's response to something like chemotherapy?

When we say molecular aging, what does that mean? It refers to the changes we can measure at a cellular level that correlate with the aging process, even if individuals are the same chronological age. For example, you can measure what we call senescent cells in their bodies. As we age, all our organs decline in function. We can't take in as much oxygen through our lungs, our neurons don't fire as quickly, we lose cells and strength in our heart, and our muscles decline.

Why does this happen? As we get older, there are changes in our DNA and proteins. Many cells in our body, in all organs — from the brain and blood to your muscles — become less active. These cells are unable to divide and make new cells, but they don't die. Instead, they can secrete a lot of chemicals, inflammatory factors, and these chemicals can accelerate all types of diseases of aging, including cancer and atherosclerosis. So, when we talk about biologic aging, we measure things like the [number] of senescent cells in your blood or body, the proteins in your blood, and your metabolites. We can then determine that a 50-year-old might biologically be 40 or 80.

What are some biomarkers of aging, and how might they provide a more accurate picture of a patient’s functional status than chronological age?

You can also look at things that we [as a society] don't typically think of as biomarkers of aging, like your oxygen extraction efficiency. For instance, if you take a group of women who are 50 and put them on a bicycle, having them breathe oxygen, they will extract a certain amount of oxygen at a very high level of activity. But if you take those same women and give them all chemotherapy at 50, they will not be able to extract as much oxygen. Chemotherapy has really biologically aged them, because as we get older, you can plot a very clear curve showing that the older we get, the less oxygen we can extract from our blood. So, oxygen extraction efficiency is a biomarker of aging.

If you have two 75-year-olds and know the normal population level, you might see one woman who can't extract much oxygen from her blood, and that will frequently reflect how far she can walk, whether she can push a chair across the room, drive, get out of the house, or carry groceries up the elevator.

A biomarker of aging is something we measure that correlates with your functional status but may be very different from your chronological age, which is your birthday. It's a fascinating area, and people are conducting all kinds of tests and studies to find markers. You can even measure your telomere length. Telomeres are small portions of your DNA that shorten as we age, and when they shorten, they don't allow the DNA to work as well.

You can pay around $1,000 to send your blood out, and they'll tell you your telomere length and estimate how many years you have left. I wouldn't recommend it; I think the tests are inaccurate and not worth the money. However, telomeres do, in a way, reflect your age, but it's very crude and was very popular a few years ago.

I think everyone wants to know how long they'll live, and there's really no good way to do that, especially if you're not wearing seat belts and smoking.

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