Reproduced from Oncology Frontier
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| Hyman B. Muss, MD Breast Cancer, Geriatric Oncology Program, School of Medicine, UNC-Chapel Hill |
Oncology Frontier: Aging is a definite risk factor for cancer. Is breast cancer also a disease of aging? Could you explain the possible reasons for that?
Dr Muss: Breast cancer to me is a disease of aging.
In fact，for all adult human cancers， the incidence per 100000 people rises dramatically with age. Breast cancer is similar to that.
We don't really know why but I suspect that as we age we accumulate damage to our DNA and we become more prone to cancer risks.
If you are fortunate to reach an old age, you unfortunately take on a higher cancer risk.
Is the primary goal of treatment the same in older patients compared to younger patients?
Dr Muss: The goals of treatment can vary between older and younger patients.
In younger patients, especially with early stage breast cancer, the goal is to increase the chances of cure.
Younger women might tolerate more side effects to see their children graduate college and have a long and fulfilling life.
An older person on the other hand, in order to achieve a small improvement in cure rate of a few percent, may not be willing to undergo chemotherapy side effects such as those that cause nerve damage and so on because it is not worth it to them.
They don' t want to lose functionality. They don't want to be a burden to their families. So the goals of treatment can vary greatly when comparing older and younger women with breast cancer.
What are the main issues for clinicians in treating older women with breast cancer?
Dr Muss: The issue for the clinician is factoring in not age per se， but how long the patient is going to live.
There are a lot of tools to use.
Are they generally healthy? Are they going to live another ten or twenty years or are they very frail? Breast cancer may not be a key illness in their life.
You need to know their life expectancy; you need to know what their goals of treatment are. Do they want to increase their chance of cure? If so, are they willing to take more intensive treatment particularly chemotherapy?
You need to really make sure they understand the issues, but if they are healthy and have a good life expectancy， I think you treat them with state-of-the-art treatment.
Your talk posed the question: “Chemotherapy for Older Patients with Breast Cancer: Should We Use More or Less?” Because of impaired function of major organs and the presence of co-morbidities， “less” seems to be the right answer to this question. Do you have different views on that?
Dr. Muss: I don't think it's about“more”or“less".
It's about treating a patient according to their goals of treatment, life expectancy and the benefits chemotherapy is going to provide.
For older people who are already frail or who have other problems, giving them potent chemotherapy regimens is not likely to make them live longer and can be very toxic.
Most younger people do not have comorbidities associated with older age (diabetes, heart disease, emphysema, stroke).
For older people who are otherwise healthy and who historically, have been undertreated with chemotherapy who might indeed benefit, they should be given all the options available.
Oncology Frontier《肿瘤瞭望》：Being older than 60 or 65 is a very common exclusion criterion of clinical trials， so it’s hard and somewhat arbitrary to make a treatment decision for this subgroup of population. Could you give us some suggestions on how to include the aged in a clinical trial or how to develop clinical trials focused on older patients?
Dr. Muss: I think the days of excluding people according to age should be over.
In the United States, we can't do that anymore. We should allow any age.
If the doctor and patient feel the clinical trial works in their favor， then that patient should be allowed to sign on. The first thing is not exclude age as a number. Secondly, there should not be exclusion criteria like kidney function and so on unless it is directly related to the treatment.
If you have a treatment that metabolizes through the kidney or causes kidney damage, then any person of any age should be excluded but not as a blanket exclusion which includes age.
Then we need to teach doctors about the fact that a lot of healthy older people can tolerate these treatments and encourage the doctors, nurses and associated staff to offer clinical trials to their older patients.
There is a definite age bias.
Education will be a key part of this.
Reference:
Video, [ASCO2015]老年乳腺癌的化疗和临床试验：关注年龄本身，你就错了 ——美国北卡罗来纳教堂山医学院内科学教授Hyman B. Muss 访谈 2015/5/30 肿瘤瞭望© Wechat
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