Treatment decisions: Challenges treating older adults with breast cancer
Kathryn Bob’s doctor sent an order for the HER2-targeted therapy lapatinib (Tykerb) to the pharmacy. The treatment Kathryn had been taking had not kept her stage IV breast cancer in check. Only the pharmacy would not fill her prescription.
“The pharmacy says, ‘You’re already taking nortriptyline [to prevent migraines] and it conflicts with the Tykerb, so we won’t fill the Tykerb prescription for you,’” the 74-year-old from Mililani, Hawaii, says.
Like many people over age 65, Kathryn has multiple health conditions, each with different concerns and treatments. These conditions, which doctors term comorbidities because they’re “co-illnesses” alongside cancer, present one of the unique challenges in treating older adults with breast cancer. As we age, we are more likely to be living with health conditions like diabetes, rheumatoid arthritis and heart disease. Breast cancer itself is associated with aging: The chances of being diagnosed get higher as you grow older, and more than half of all people who die of breast cancer are over age 65. Other diseases, their medicines and the overall health of a person all affect how we deal with breast cancer.
“[Aging] adds a whole other layer of consideration when thinking about what [cancer] treatments to take, what the benefits and risks may be,” says Rachel Freedman, MD, MPH, a medical oncologist who specializes in breast cancer at Dana-Farber Cancer Institute, in Boston.
Just a Number
For doctors, age is an easy piece of information to get. But age alone isn’t enough to tell how well a person may respond to treatment. Each person has a mix of conditions, history and wellness that need to be considered when making treatment decisions. You can’t always expect the same result based on age.
Kathryn has had complications. She was first diagnosed in 2007 with early-stage breast cancer. Within hours of her first chemotherapy treatment with paclitaxel (Taxol), she felt pain in her knees. Along with her migraine medicine, she has Type 2 diabetes and effects on her thinking and memory from treatment. This spring, her doctors recommended she stop driving.
At 79, Rita Rattner, of New Rochelle, New York, is 5 years older than Kathryn and has been in treatment for metastatic hormone receptor-positive breast cancer since she was 74. Though she developed arrhythmia, a condition where the heartbeat is not regular, Rita says she has handled treatments well and still walks 3 miles a day.
Arti Hurria, MD*, director of the Center for Cancer and Aging at City of Hope National Medical Center in Los Angeles, says the main concern in treating older adults is fitting the cancer treatment to the individual’s overall health and ability to handle side effects. Decisions should be made in line with personal preferences.
An important tool to help your doctor get a sense of your total health is a geriatric assessment (geriatrics is the study of aging). The assessment looks at many different parts of an older person’s well-being, from health and physical fitness to thinking and memory to social and practical support.
“We have someone’s passport age but we also have their functional age,” Dr. Hurria says. “That assessment really helps us get at the concept of functional age and knowing the whole person.”
The challenge is that many oncologists don’t do geriatric assessments, Dr. Hurria says, usually because they don’t know about the assessment or don’t have the time. The Cancer and Aging Research Group, an organization Dr. Hurria founded, has a simplified geriatric assessment to make it easier for oncologists to get this information. Their version is shorter and you can complete much of it at home then bring the answers to your doctor, saving time during appointments.
Behind the Scenes
Doctors often don’t have enough information on how breast cancer treatments work in older adults. Though nearly half of breast cancer diagnoses are in people over 65, older adults make up a much smaller share of most clinical trials, the research used to prove a treatment works.
Jeanette Hopkins, 65, of Post Falls, Idaho, was diagnosed with stage II triple-negative breast cancer in June. She had chemotherapy before surgery. Jeanette has other health issues including an eye condition called wet macular degeneration, but those issues haven’t interacted with cancer treatment until recently, when she lost the ability to tell some colors apart. With the timing of this new symptom, her eye specialist thinks chemotherapy may be part of the cause, but doesn’t know for certain yet and is looking into it.
“As our population ages, because the average age and life expectancy is going up in the U.S. and around the world, we’re going to be seeing more of these patients,” Dr. Freedman says. “Yet we don’t have the same evidence base to treat and take care of them.”
Dr. Freedman says doctors have to make decisions not knowing if the medicine will work as well in an older person, or if the risk of side effects is different.
Getting older adults into clinical trials has been a challenge that researchers have known about for years. Despite recent research into this problem, solutions have been tough to come by. As with other issues of aging, what seems to be one problem actually covers several areas. One of the biggest problems in getting older adults in clinical trials is comorbidities.
To look at a medicine’s effect and to protect people’s health, clinical trials often restrict people with certain health conditions. Since older adults are more likely to have comorbidities, they are more likely to be excluded from trials.
There are other obstacles less visible than exclusion criteria, Dr. Hurria says, like meeting the needs of older adults who may not be able to travel or who must bring a caretaker with their own concerns to appointments.
As for older adults, a study in people with breast cancer found they are just as willing to join a clinical trial as younger people, if their doctors give them the opportunity.
Rita’s doctor referred her to a clinical trial 5 years ago when she was first diagnosed with metastatic disease. She spoke to a family member who teaches medicine, and joined up.
“I felt confident [in my team],” Rita says. “If I don’t come out of it well, at least there can be some kind of research done and it can help other people.”
The catch is that doctors have to offer clinical trials to older people for them to join. Dr. Hurria says that same study found that doctors are less likely to suggest clinical trials to older adults than to other groups. The doctors said they worried about the effects on older adults who have other health conditions and may be frailer.
Dr. Hurria says this is a reasonable concern. Many clinical trials add a new medicine to a standard one to see if it will improve outcomes. That often means more side effects, and for older adults, these can be especially hard if they have other conditions and are already taking medicines for them. She says more clinical trials should be designed specifically for older adults and frailer adults to test treatment combinations that have more manageable side effects.
Making Yourself Heard
As doctors work to change institutions, you can still make sure you get the appropriate care for you. Although there is a shortage of geriatric oncologists, look for one or for an oncologist with a research interest in that area, Dr. Hurria says.
No matter what, communication is important. Both Dr. Hurria and Dr. Freedman spoke about including your priorities when making decisions.
Make sure your medical team, as well as any caregivers or family with you, knows what you want out of treatment and any concerns you have. Ask questions and understand why your doctors do or do not recommend a treatment, Dr. Freedman says.
You can start a good conversation by doing the patient sections of the geriatric assessment on the Cancer and Aging Research Group website at mycarg.org, Dr. Hurria says. This could start some important discussions and prompt your doctors to complete the rest of the assessment. If you want help, ask someone you trust to work with you.
“Admittedly, we’re not great about asking how many falls somebody has had in the last 6 months or how far can you walk before you’re tired,” Dr. Freedman says. “These elements are extremely important in predicting how somebody’s going to do with treatment, and even how long they’re going to live.”
Though Jeanette is happy with her cancer team’s communication, she has also pressed when something was important for her. She found a dietitian and counselor on her own, even though her treatment center offered them.
“I sought them out based on what was most important to me,” Jeanette says. And taking that step has helped her feel good, and stay positive, through treatment.
* Dr. Hurria died in November 2018. We dedicate this piece to her memory, and to all those she touched through her care and advocacy throughout her life.