Treatment Considerations in Older Patients With Breast Cancer

Arti Hurria, MD

Treating older patients with breast cancer does not entail a one-size-fits-all approach, says Arti Hurria, MD, an expert in the care of patients aged 65 and older.

“Treatment needs to be individualized for an older adult. A part of that process is knowing the data within oncology, but also the other part is knowing the data within geriatric oncology. That data being such that it can help you to individualize those treatment decisions. A key point is that to make a treatment decision with an older adult, you have to weigh not only what the benefits are, but also the potential risks of treatment,” said Hurria, who spoke on the topic during the 16th Annual International Congress on the Future of Breast Cancer.

OncLive: Please provide an overview of your presentation.

What are some of the factors physicians should consider with older patients?

Is there a specific treatment or regimen that you prefer to use for older patients?

What are the main challenges of treating older patients?

Are there any ongoing trials in which you think the older population is well represented?

What do you envision the future of this space will look like?

What is the key take-home message of your presentation?

The idea is that the aging process is very heterogeneous, so there is a real difference between chronological age and functional age as an individual gets older. Hence, there could be two 80-year-old individuals who are very different and who have very different functional statuses and other medical problems. All of that needs to be taken into account when you’re making that treatment decision. The idea is that if you can incorporate the principals of geriatrics into your oncologic care, you’ll be able to understand an individual’s functional age in comparison to their chronological age and utilize that when you’re making a treatment decision.It completely depends upon many different factors, but 1 has to be how aggressive the tumor is. Also, when we’re devising a treatment regimen for an older adult, it’s important to think about the side effects. If an older adult has pre-existing neuropathy, we’re very careful about taxanes. If they have pre-existing cardiac disease, we think about caution with anthracycline-based regimens. It’s taking into account what their other medical problems are and then coming up with an individualized treatment plan for that patient.The main challenge that we face is that older adults have been underrepresented in clinical research, in particular, the FDA registration trials. The studies lead to the approval of drugs and inform the package insert of how to dose those drugs. There have been very few patients that are older adults included within those studies. The challenge that oncologists face is how do I then dose the drug in an older patient population when the drug has primarily been studied in younger adults.There are now a number of studies that are focusing on the older patient population, across a whole range of research. There's something called the U13, which was a grant that was a collaboration between the Cancer and Aging Research Group, the NCI, and the NIA. We had 3 conferences that laid out the research agenda for older adults and formed the platform for how this research should unroll within the next 10 years to help this patient population. One key part of that was the therapeutic studies and open studies that specifically focus on older adults, so we can understand how to dose these drugs and what are the side effects the patient might experience.I think it’s going to be incredibly exciting. Right now, we’re in the midst of the baby boomers aging. By 2030, the largest growth in population is going to be people over the age of 80. These are the patients that we’re seeing, because cancer is a disease that is associated with aging. Any bit that we can move the needle in this space is going to have huge implications for our field and how we treat patients. With that in mind, it’s an incredibly exciting time for geriatric oncology and we welcome people to join us in doing this work so we can help this growing patient population.The key point from my presentation was that treatment needs to be individualized for an older adult. A part of that process is knowing the data within oncology, but also the other part is knowing the data within geriatric oncology. That data being such that it can help you to individualize those treatment decisions. A key point is that to make a treatment decision with an older adult, you have to weigh not only what the benefits are, but also the potential risks of treatment.

Is there anything you would like to add?

To understand what those risks are, you can utilize a calculator that can calculate the risk of chemotherapy toxicity. You can go to the Cancer and Aging Research Group website and you can plug in 11 easy questions about your patient, and you can find out where they fall on the risk of side effects from cancer treatment, chemotherapy in particular. It will also tell you how you can intervene to try to decrease those risks. The biggest point is that chronological age does not equal functional age. Age tells us very little about an older adult, and if we can deepen the way we think about this patient population, we can individualize treatment decisions for them.I’d like to add that it’s an absolutely wonderful patient population to take care of. You get to spend time with people’s moms, and their grandmothers, and their aunts, and those are all people that we love and we can learn so much from. I would advise anyone who is junior or just starting their career in this field of geriatric oncology, they have such a chance to make a difference, but not only that, the patient population is just incredible.

In an interview with OncLive at the meeting, Hurria, director of the Cancer and Aging Research Program at City of Hope, discussed the unique challenges with treating elderly patients with breast cancer and the exciting opportunities she envisions for advancing care in this setting.Hurria: What I talked about was how you make a treatment decision for an older adult with breast cancer and the factors that you should consider in that treatment decision-making process. We talked about what the data is regarding treatment for older adults with breast cancer and then brought in some of the data from geriatrics in order to think about that decision-making process with that older adult.