1. Geriatric Oncology: Breast Cancer UNC Lineberger: Cancer and Older Adults November 19, 2015 Hyman B. Muss, MD

2. UNC Lineberger Cancer Research Spans UNC’s Campus Research 318 Members $70M NCI Funding $154M Other Cancer- Related Funding 34 Multi-Investigator Grants Training 26 Pre & Post-doctoral Training Grants Clinical 125,000 Patient Visits 4300 New Patients Diagnosed 1000 on Clinical Trials

3. Treating Patients with All Types of Cancer The N.C. Cancer Hospital

4. Multidisciplinary Care: Studies show patients have better outcomes One-stop shopping Exchange of knowledge and opinions Coordinated treatment plans Fewer patient appointments, faster treatment Coordinated care through specialties & follow-up

5. U.S. Breast Cancer Incidence and Mortality Rates: SEER 2005-09 Per 100,000 women http://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=4&page=sect_04_table.12.html Median Age ~ 61

6. U.S. Breast Cancer Death Rates Over Time Smith B D et al. JCO 2011;29:4647-4653

7. Prevention Maintain a healthy weight Exercise Healthy diet – fruits and vegetables For very high risk  Tamoxifen or raloxifene What you don’t need  Expensive supplements  Negative friends

8. Screening in Older Women Breast Self Exam  Value uncertain Physical Exam by Health Care professional Mammography  Up to age 75: Annual or biannual reduces breast cancer mortality by 20-30%  Consider in 75+ If survival likelihood greater than 5 years Can perform every 2-3 years Concern for “overdiagnosis”

11. Early stage breast cancer  Adjuvant therapy to increase cure  Treatment should not be as bad as disease Metastatic disease  “You can’t improve on being asymptomatic.”  Maintain QOL and function first  Improve symptoms when present  Provide “structured” palliative care What is the Goal of Treatment?

12. Adjuvant Therapy The use of chemotherapy, hormone therapy and/or radiation therapy either before or after surgery. The aim is to destroy microscopic metastases that may be present and if left untreated will eventually lead to relapse.

13. Look, since you don’t know whether I am cured or not why don’t wait and see if my cancer comes back and then treat me? If you would like I’ll come everyday for tests so we can find it early. Answer: “Drug Resistance”

14. Adjuvant Systemic Therapy At diagnosis in stage I- III patients  proportional reduction in recurrence of 25-50%  improves survival Known options:  Chemotherapy  Hormone therapy (if ER or PR +)  Anti HER2 drug trastuzumab (if HER2 +)  Combinations of these Considered in all but smallest Stage I tumors

15. What the patient hears You have breast cancer We don’t know if your cancer has spread Here is your bill for you work-up Here is your risk of recurrence without Rx Here is your risk with adjuvant therapy Here are the side effects of treatment We cannot tell if adjuvant Rx has helped If you relapse then it didn’t work

16. Adjuvant Therapy: Proportional Reduction Assume 100 pts, “Cure” 30%, 10 yr follow Primary Tumor (Mo) 10 year Survival No Treatment Treatment saves: 10 year Survival With Treatment 1 cm No positive lymph nodes- 90%3 of 1093% 2 cm 10 positive Lymph Nodes 20%24 of 8044% Math: 90% cure without Rx means 10% will not survive. 30% of 10% is 3% or three lives saved of 100 pts treated.

17. Radiation Therapy Depending on risk of recurrence ADDS to cure Lumpectomy  alone - 30% recur, most same area  Radiation standard of care Less than 10% recur in breast  In 70+ selected pts small tumors ay avoid Mastectomy  large tumors, many + lymph nodes

20. Survivorship One third of Americans will get cancer Right now 10.8 million cancer survivors Most common cancer survivors  Breast, Prostate and Colon Cancer 60% (6.5 million) are > 65 years 14% of survivors > 20 yrs from diagnosis

21. Geriatric Oncology at UNC-Lineberger?

22. Is cancer the patient’s major illness?

23. Geriatric Assessment Evaluates functional and social status in addition to other medical issues. Trials show:  Identifies problems not routinely found  Interventions based on GA can: Improve Quality of life and maintain/improve function Possibly extend survival But, not enough geriatricians to do it So we have to learn how to do it ourselves

24. Brief Geriatric Assessment DOMAINASSESSMENT MEASURE Health ProfessionalSelf Reported Functional Status Timed Up and Go KPS- Physician Rated Activities of Daily Living (ADL) Instrumental Activities of Daily Living Karnofsky Self Reported No. of Falls in the last 6 months Co-morbidity Number /Type of Comorbid Conditions No. of Medications Vision and Hearing Assessment Cognition Blessed Orientation Memory-Concentration Psychologic Mental Health Index-17 Social Social Activity Limitation Measure (MOS) Social Support Survey (MOS) NutritionBMI Unintentional Weight Loss 6 mths 10 minutes 20-30 minutes

25. Serially Measuring Molecular Age 16 40 64 80 Weeks of Age Burd et al, Cell 2013

26. Molecular Changes with Aging Sharpless and colleagues, UNC

27. Exercise (min/session) Log 2 [p16 INK4a mRNA] 0255075100125 0 2 4 6 8 10 R 2 =0.16 p<0.001 Exercise is Good

28. Age < or ≥ 65 Cancer Type and Stage Treatment Physician and Patient Select Treatment Metrics PRE END Outcomes Intervention Post 3m Post 6m BCRF, Yow, COH trials

29. Metrics – What We Measure Metric Measure Description Geriatric Assessment (CARG) Measures function (physical and mental), other diseases, anxiety, depression, nutrition and social support Health Behavior Questionnaire Exercise and Alcohol Use Short Physical Performance Battery Engagement in Physical Activity OEE/Outcome Expectations for Exercise FitBit (data capture throughout chemotherapy) Physical activity log daily during chemotherapy Physical function CBC, renal, hepatic, albumin Basic organ function Biomarkers (p16, IL-6, D-Dimer, CRP Markers of inflammation and aging DEXA scan for Muscle mass Lean body mass and fat mass CTCAE (during chemotherapy) Side effects of treatment – MD reported PRSM (PRO – during chemotherapy Patient reported side effects FACT-Breast Quality of life FACIT-Fatigue Fatigue PSEFSM/Perceived Self-Efficacy for Fatigue Self- Management Program satisfaction

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