Understanding the Unique Task of Treating Older Patients With Breast Cancer

It is vital that clinicians, caregivers and patients themselves be aware of the unique challenges that are often overlooked when treating older adults with breast cancer, Dr. Hyman B. Muss said in an interview with CURE.

These challenges can be dismissed in traditional care and research and can present as functional and cognitive changes during treatment; this can be a sign of declining health or accelerated aging in these older patients who are receiving treatment for their breast cancer. In order to maintain quality of life during treatment, Muss emphasizes that older patients must actively engage in their care.

Muss, who serves as serves as the Mary Jones Hudson distinguished professor of geriatric oncology, sat down to discuss these challenges, signs that a treatment is accelerating aging, and highlighted recent advancements and ongoing research aiming to treat older patients with breast cancer who are older.

Muss is also the director of the Geriatric Oncology Program the University of North Carolina (UNC), UNC-Chapel Hill Lineberger Comprehensive Cancer Center.

CURE: Are there any specific signs that older patients or their caregivers can watch for that may indicate that a treatment is accelerating their aging or impacting their overall health?

Muss: I think that's a great question. Older people frequently have caregivers helping them or being with them during treatments, and things to look for are common-sense observations like: Can mom or grandma still cook for herself? Is she capable of ordering groceries or using the telephone? Is she prone to falling? Is her balance a little bit off?

Many drugs, especially those used in breast and other cancers called taxane drugs, can damage your peripheral nerves. A younger person can often compensate for that, but a 70-year-old who is a little weakened or whose balance is slightly off can be really pushed to the point where they are at high risk of falls. Falls are a terrible thing in older people; there are 40,000 deaths a year from falls in this country, which is just slightly less than the deaths from breast cancer. So, it's a big deal. You should look for that.

You can also look for cognitive changes. Is she experiencing fatigue? Fatigue is very common, but it's a broad term. Fatigue where you say, "I'm a little tired," but you can still take care of yourself is okay. However, if your fatigue is interfering with your ability to care for yourself, and you're living alone or independently, or frequently, an older patient with cancer is a caregiver of someone else in the family — an older spouse, a sister, or a daughter who actually needs perhaps more help than they do — you have to take those into consideration.

The caregiver needs to look for those subtle changes. "Oh, mom hasn't been going to church lately," or "My mom can't walk the dog." These are common-sense observations but are very, very strong clues. I used to ask all my patients if they had a dog and whether they were walking it, because if someone said they didn't walk their dog, and you knew they loved their dog, it told you they weren't feeling well, that they couldn't do it.

The charts today are filled with massive amounts of information in our electronic medical records, but one or two sentences like that told you more about the patient than the 50 other little checked boxes.

Are there any recent advances or ongoing research that are aiming to treat patients with breast cancer who are older?

Previously, you know, 10 to 20 years ago, all the research that was done, let's say on breast cancer, was done on younger women. In fact, I'm old enough that they used to have age limits in clinical trials, saying age 18 to 75. So, should a 76-year-old playing tennis be excluded when a 75-year-old is barely able to function? It makes no sense.

So, clinical trials removed the age limits, but it's still the case that if you look at clinical trial data, especially with some of the new intensive drug therapies like CAR T therapy and some of the immune-chemotherapy regimens, older people are not well-represented in those trials. When those drugs go to the FDA, frequently, the average patient is much younger than the 75 to 80-year-old [patient] that you're seeing in the clinic.

Now, the FDA and pharmaceutical companies, to their credit, are trying to look at these subgroups of patients and see if older people do more poorly. But in general, we don't have that degree of data. Now we are collecting a lot of data; the cooperative groups and industry are collecting some geriatric data, some functional data, before the trial, and we're trying to integrate that into the trial, so we get more older patients.

It's not really a good way to treat people, to treat an 80-year-old based on data derived from 50-year-olds. You don't know if that drug that caused a little bit of fatigue or weakness in a 50-year-old is really going to take that older patient and change them from living independently to being in assisted living. You don't really know that, so those data need to be collected. Newer trials are focusing on older patients.

Some trials are deliberately targeting older patients to see if dose reductions and other strategies can minimize toxicity while achieving the same outcome and benefit from treatment. So, there's great interest, both in the United States and internationally, in focused trials on older patients and in increasing the number of older patients who participate in standard clinical trials, the majority of which are run by pharmaceutical companies to develop new drugs, which is fine.

They are trying to do it because if they can show older people tolerate the drugs well, they will have greater revenue, and the doctors who treat older patients will have better data. Of course, it may turn out that in certain populations of older people, those drugs are more toxic, and that would be very, very important to know to adequately give people the best care.

What advice do you typically offer to older patients who are navigating a breast cancer diagnosis and are concerned about maintaining their quality of life during or after treatment?

I tell older patients that they need to come prepared to the doctor's office to navigate breast cancer, and they ought to bring a caregiver or close friend, because when you're overwhelmed by the news, you don't remember anything. I also urge people to utilize the wonderful websites ASCO has, the American Cancer Society and the National Cancer Institute for questions to ask the doctor.

I strongly encourage patients to bring these questions with them. If they say, "My doctor's too busy," I say, "If your doctor's too busy, you need another doctor." You need to have a list of questions; you need to understand your diagnosis. We've learned that many people, when they get cancer, don't know whether their treatment is intended to cure the cancer or is palliative, meaning it won't cure it but may extend your life and even your quality of life. Older people need to know their diagnosis, their treatment options and toxicities, and they need to ask questions like, "How long does the treatment take? What are the major side effects? What are the chances of me doing well if I don't take treatment versus if I do? How is the treatment going to affect my hospital visits and my caregivers?"

Older people in studies are most concerned with their ability to live independently and the effects on their cognitive function. They'll often say, "The first thing is, I don't want to be a burden to my family. I want to live in my house as long as possible." They might not say, "I want to live to see my daughter graduate college," because they've already done that. So, their values and what they're interested in are different, and they need to ask questions that reflect that. ASCO has wonderful questions for not just breast cancer, but for everything: what to ask your doctor, how to prepare for your visit. I urge people to really do that and go through it.

The other thing that's being lost is that older people need to be prepared to spontaneously give a little paragraph about their lives and what's important to them to the doctor. It's becoming less common. Older people are very variable and caring for an artist is different from caring for someone with mild dementia or a college professor.

I'm still working, and I'm an older guy. I want people to ask me the right questions and tell me a little bit about themselves. So, I taught my fellows and residents, and still do, to ask the first question when you walk into a room, after introducing yourself and asking who everyone in the clinic is and how they're related to the patient (never assume "Is this your daughter?" because if it's their sister, you've immediately lost rapport). So, you say, "How are you related?" And then you say, "I know your diagnosis. Please tell me about yourself," and find out a little bit about what makes them tick. What are they like? What's most important to them in their lives right now? What do they know about their cancer (you'll tell them that, but they need to tell you about themselves)? "I love to play bridge three times a week. Am I going to be able to play if I take this treatment? Is it going to affect my ability? I love to walk my dog. I love to do whatever — go on vacations and travel."

It's very, very important that they are prepared so the doctor knows about them, not just their diagnosis and the treatments.

Transcript has been edited for clarity and conciseness.

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