HEALTH

Cancer's age wave (ASCO annual meeting)

When assessing cancer screening and treatment needs, the advice is to consider a patient's physiologic condition, rather than age alone.

By Susan J. Landers, AMNews staff. July 16, 2007.

Reports from conferences important to physicians

Cancer is a disease of aging. More than 50% of all malignancies develop in people 65 and older. Since all indicators point to more people living longer -- one in every five is expected to be in this age category by 2030 -- concerns are being raised over which older patients should be treated and how aggressively.

An element of uncertainty also arises from the fact that these patients generally are excluded from clinical trials that test the safety and efficacy of therapies.

Demand outpacing supply
Age matters
Treating the whole patient
Physicians as cancer survivors
Treatment tips
Research findings
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The challenges posed in treating this age group were discussed in several sessions at the American Society of Clinical Oncologists annual meeting in Chicago June 1-5.

An additional concern, this one triggered by the anticipated boom in elderly cancer patients, is that there will not be enough oncologists available to treat them. A work force report released by ASCO last March indicated that the demand for services would likely outpace the number of trained specialists.

An education session at the annual meeting was devoted to solutions to this pending work force shortage. One possibility discussed was the formation of patient care teams consisting of oncologists and primary care physicians, nurses and social workers. Another is a stronger emphasis on treatment by primary care physicians for patients in remission.

"It is essential that we look ahead and see where our future is going, to know how we can best meet the challenge," said Michael Goldstein, MD, an assistant clinical professor of medicine at Harvard Medical School in Boston. The issue affects all who see patients with cancer, he said.

More than 50% of all cancers develop in people 65 and older.

Care for the elderly with cancer is complex, and one expert in geriatric oncology urged that physicians manage cancer patients not according to their chronological age, but consider physiologic age instead. "Every time I hear that adjuvant chemotherapy for breast cancer is ineffective beyond age 70, I am tempted to ask whether anybody has studied adjuvant chemotherapy in women of different hair or eye colors," said Lodovico Balducci, MD, professor of medicine and oncology and program leader of the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida in Tampa.

Dr. Balducci, who has studied older cancer patients for 35 years, received the first B.J. Kennedy Award for Scientific Excellence in Geriatric Oncology at the meeting. He also delivered a lecture on cancer care for the elderly. Stressing that people age differently, Dr. Balducci used the example of his twin aunts.

Despite having the same genetic material, growing up in the same small town in northern Italy and sharing the same occupation -- elementary school teacher -- they were, by age 90, very different. One had severe dementia while the other remained cognitively sharp until her death at age 100.

Geriatric assessments are useful

Dr. Balducci recommended the use of geriatric assessments to help identify older patients who may be candidates for cancer screening and treatment. Such assessments cover a patient's physical and mental health, support network, ability to perform basic tasks of daily life and safety of their physical environment.

In an education session on the management of frail elderly women with breast cancer, Dr. John Michael Dixon, a consulting surgeon at Edinburgh Breast Unit at Western General Hospital in Scotland, agreed that age alone was not the deciding factor when considering treatment for these patients.

He noted that there are alternatives to mastectomy, even for patients in their 70s.

"Older women don't want mastectomies any more than younger women," he said. "The art is in choosing the right treatment for the right patient."

Assessing for frailty among breast cancer patients is important when considering a course of radiation therapy, added Krystyna Kiel, MD, assistant professor of radiation oncology at Northwestern University in Chicago. But the definition of frailty can be a little vague, she allowed. She considers frailty to be "a clinical syndrome manifested by diminished muscle strength, decreased physical activity, inability to walk, frequent falls, poor appetite and impaired cognition and depression."

When assessing cancer treatments for older patients, among the first things to consider is the chance they will succumb to some disease other than breast cancer, she said. Co-morbidities are common among this age group. "Is radiation important for someone with limited survival? Perhaps not," she noted. Plus six to seven weeks of radiation is difficult for even the most able of patients, she said.

In a session on hematologic cancer in the elderly, Harvey Cohen, MD, director of the Center for the Study of Aging and Human Development at Duke University Medical Center in Durham, N.C., asked, "What's different about older patients?"

Patients in their mid-70s and older are a heterogeneous group when it comes to health status, but there is a tendency for them to have multiple and interactive diseases, Dr.Cohen said. They also often underreport symptoms, perhaps attributing aches and pains to aging.

Paul Hamlin, MD, a medical oncologist at Memorial Sloan-Kettering Cancer Center in New York City, added that age is the most important predictor of outcome in non-Hodgkin's lymphoma. But should treatment be limited to those 60 and younger? Maybe not. He suggested that "perhaps 70 is the new 60."

ADDITIONAL INFORMATION:

Demand outpacing supply

By 2020, the demand for oncology services is predicted to increase by 48%.

The supply of oncologists is predicted to fall short by nearly 4,000 physicians -- roughly a third of the 2005 supply.

Age matters

People 65 and older have a cancer incidence rate 10 times greater than younger people and a mortality rate 16 times higher. Cancer is second only to heart disease among causes of death for people older than 65. Other factors also influence treatment options:

Comorbidities: Older patients are more likely to have additional conditions.

Physiological vs. chronological age: Chronological age should not be the deciding factor.

Activities of daily living: Geriatric assessments can help determine ability to function independently.

Frailty: Muscle weakness, inability to walk, poor appetite and impaired cognition should be weighed.

Sources: American Society of Clinical Oncology, National Cancer Institute, Centers for Disease Control and Prevention

Treating the whole patient

Treatment for cancer pain calls for an individualized approach for all patients, including the elderly, said Amy Abernathy, MD, a medical oncologist at Duke University Medical School, in Durham, N.C. Dr. Abernathy spoke during an education session at the American Society of Clinical Oncology on pain, depression and fatigue in older cancer patients.

Key factors in addressing pain are to treat aggressively and to keep the focus on enabling the patient to continue to enjoy daily activities, she said.

Dr. Abernathy described patient "Chuck" as someone who wants to fish more than anything else. As a result, she focuses on reducing his cancer-related shoulder and arm pain to allow him to continue to board his boat and toss in his line. Musculoskeletal pain is probably one of the most common causes of pain among the elderly, she said. "As patients become inactive, and as they lose weight, the risk of musculoskeletal pain and the impact on joints is real."

Jimmie Holland, MD, a psychiatrist at Memorial Sloan-Kettering Cancer Center in New York who has worked with cancer patients for decades, noted that elderly patients are likely to express depression, or what can also be called distress, via poor appetite and fatigue. But interventions can work. Even phone calls seem to lower levels of depression in this group, as many believe that no one cares about them, she said. Low doses of antidepressants such as escitalopram oxalate or paroxetine are also effective.

Physicians as cancer survivors

Washington -- When his cancer patients who are undergoing radiation treatment complain about the nasty taste of food, Nicholas Vogelzang, MD, director of the University of Nevada Cancer Center, can sympathize. As someone who had radiation treatment for non-Hodgkin's lymphoma more than 20 years ago, he's been there.

"I could pretty much time my vomiting to about 45 minutes after my radiation," he said during an education session at last month's American Society of Clinical Oncology annual meeting in Chicago. Dr. Vogelzang joined a group of physicians who are also cancer survivors in detailing what was good and what was bad about their experiences.

They are among the ranks of cancer survivors, now more than 10 million strong, often cared for, posttreatment, by primary care physicians.

"One of the roles of primary care more and more is to care for patients who have very long survivorship," said Dr. Vogelzang.

These patients face numerous ongoing health concerns, he said. Although his own completion of therapy was a cause for great celebration, there next came a gnawing, creeping concern: "Is it going to come back?" So far it hasn't.

Dr. Vogelzang saw his oncologist for five years after his treatment ended. But he since has turned to a primary care physician -- an internist -- for "wise counsel" regarding side effects and other health issues.

When he experienced fatigue, his new internist quickly diagnosed hypothyroidism. He had a melanoma in situ on his arm and an esophageal stricture. His internist also detected a heart problem that led to a bypass operation.

Theresa Gilewski, MD, a medical breast oncologist at Memorial Sloan-Kettering Cancer Center in New York City, interviewed nine physicians who have had cancer, for a film on the subject. Dr. Gilewski aired the film during the ASCO session at which Dr. Vogelzang spoke.

Those featured ranged from a fourth-year medical student to an 81-year-old. Some had completed treatment decades earlier, while others had only recently faced it.

Among their comments: "Being the 'interesting' patient is awful."Many found the experience humbling and frustrating. They detailed indignities that could have been avoided, such as unnecessarily leaving a patient uncovered or failing to return a bedside table to its reachable location.

Some also addressed end-of-life care. "Many physicians are frightened by death to the point where they cannot be helpful," said one. Another said it was easy to hide behind the science and urged physicians to "think about the whole patient. Think of the pain and suffering."

Treatment tips

Here are some treatment tips from the meeting:

Complementary medicines for cancer. Patients who have cancer or are cancer survivors often bring a bag of pills and powders to their physicians and ask, "Will this help me?" said Bruce D. Cheson, MD, director of hematology at the Lombardi Comprehensive Cancer Center at Georgetown University Hospital in Washington, D.C. But the clinical trials that could answer such questions generally have not been done.

Now, in the case of three alternative medications, there are some data. For two -- ginseng and flaxseed -- the results are promising. A pilot study of ginseng at the Mayo Clinic in Rochester, Minn., suggested that the herb could decrease fatigue in cancer patients. A study of flaxseed and dietary fat restriction from Duke University in Durham, N.C., found both may slow the growth of prostate cancer. However, a third study from the University of Texas M.D. Anderson Cancer Center in Houston found that shark cartilage extract did not increase the survival time of patients with non-small-cell lung cancer.

Teaching breast self-exams. A small study at a North Carolina cancer clinic found that most women with breast cancer had found their own tumors through self examination -- and that was true even for women who had regular mammograms.

This finding led researchers at the Leo Jenkins Cancer Center, a clinic at the Brody School of Medicine at East Carolina University in Greenville, N.C., to recommend that patients be taught in their physicians' offices how to properly perform breast self-exams and that this detection method be used along with mammograms.

Lead investigator Andrea Rosenberg, MD, a second-year resident in internal medicine at the medical school, presented the findings.

Managing hot flashes. Hot flashes are not just a nuisance. They also have a striking effect on patients' quality of life, said Debra Barton, RN, PhD, associate professor of oncology at the Mayo Clinic in Rochester, Minn. It's more than just evaluating how many and how severe they are, but also their accompanying panic disorders, anxiety and mood swings, she said.

It's important to find out what women have tried in the past and for how long. Physicians were urged to plan with a patient ahead of time how they will determine whether an intervention has helped.

As a foundation for treatment, behavioral management including wearing loose, open-weave clothing, should be taught to every person, Dr. Barton said. Data have shown that body temperature begins to rise as early as 20 minutes before a hot flash, so tactics to keep core temperature low are helpful.

Research findings: Breast cancer detection, reduced radiation doses and survival disparities

Magnetic resonance imaging was shown to be superior to mammography in detecting certain breast tumors. In a study of 390 patients, the tool detected additional tumors in a breast in which cancer had already been detected and also in a patient's supposedly healthy breast. These results from researchers at the Mayo Clinic in Jacksonville, Fla., were among research presented last month at the American Society of Clinical Oncology annual meeting in Chicago.

A second study, from the University of Bonn, Germany, found that MRI was more accurate than mammography in detecting "high grade" ductal carcinoma in situ.

Current American Cancer Society guidelines recommend annual MRI screenings for women at high risk of breast cancer, such as those with BRCA mutations. They recommend against MRI screening for women who have less than a 15% lifetime risk as calculated by the BRCAPRO model.

Sounding a cautionary note, Judy Garber, MD, MPH, director of the Cancer Risk and Prevention Clinic at the Dana Farber Cancer Center at Harvard University in Boston, noted there are many false positive MRIs, which can lead to additional follow-up, such as ultrasound exams.

Meanwhile, data presented regarding a phase III trial of breast radiotherapy after surgery, from the United Kingdom, found fewer but larger doses of radiation appear to be as effective as the conventional schedule of 25 doses, or fractions, in reducing the risk of cancer recurrence among women with early breast cancer. This approach, called hypofractionation, resulted in no greater detrimental effects to healthy breast tissue, said the researchers.

An additional study found that, despite modest overall improvements in survival rates for women with advanced breast cancer, rates for black women have not improved. Researchers from the M.D. Anderson Cancer Center at the University of Texas in Houston, examined data from the National Cancer Institute's Surveillance, Epidemiology and End Results program. They suggested that a variety of factors might be responsible for this, including access to health care, utilization of screening programs and differences in treatment.