UNC Lineberger Geriatric Oncology program leaders Hy Muss, MD, and Jan Busby-Whitehead, MD, co-authored an editorial in the December 10, 2011 issue of the Journal of Clinical Oncology. Muss is professor of medicine. Busby-Whitehead is professor of medicine, and director of the UNC School of Medicine’s Center for Aging and Health and Division of Geriatric Medicine.
Their editorial, titled, “Older Women with Breast Cancer: Slow Progress, Great Opportunity, Now is the Time,” is complementary to a research article, published in the same issue, titled, “Improvement in Breast Cancer Outcomes Over Time: Are Older Women Missing Out?”
People are living longer, and cancer is primarily a disease of the elderly. Estimates are that 20 percent of the US population will be 65 years and older in 2025. In breast cancer, the incidence rate is 82.2 new patients per 100,000 in women younger than age 65 years versus 403.8 per 100,000 for those age 65 years and older.
Authors of the research article examined data from the National Vital Statistics Reports and Surveillance, Epidemiology, and End Results (SEER) to study the rate of breast cancer death in the general population and the risk of breast cancer death in newly diagnosed patients, and compared change over time in these outcomes for older versus younger women. They discuss the advances and challenges of caring for older women, ages 65 and older, with breast cancer. Their analysis of these data showed that breast cancer outcomes have preferentially improved in women age less than 75 years.
In their editorial, Muss and Busby-Whitehead concur, stating, “Although both the rate of death as a result of breast cancer and the adjusted risk of death as a result of breast cancer in the population are decreasing, these improvements were much less for older patients. “
They posit that overall improvements in survival are likely due to the wider use of mammographic screening and adjuvant therapy and suggest that a small part of the gap in survival for older women could be closed by the appropriate use of mammography for women age 75 years and older with a reasonable life expectancy. They recommend that geriatricians provide screening information to older patients and counsel them concerning mammography screening on an individual basis.
Muss and Busby-Whitehead note that major gains in adjuvant systemic therapy such as tamoxifen and aromatase inhibitors have also played an important role in improving survival and that clinicians should encourage the appropriate use of these medications in older patients. They cite a growing body of data suggesting that chemotherapy also leads to improved survival in elders, especially those with hormone-receptor negative breast cancer. Underuse of post-operative radiation therapy may also contribute to these poorer results.
Another reason that elders have benefited less from overall improvements in breast cancer-specific survival is that most oncologists have little or no geriatric training. Muss and Busby-Whitehead offer resources such as the American Society of Clinical Oncology’s education outreach and websites and the geriatric education website Portal of Geriatric Education Online education, supported by the Donald. W. Reynolds Foundation. They also offer tools for clinicians to help their patients make better treatment decisions.
The co-authors propose three high priority research needs for elders. First: developing clinical trials that focus on elders to discern the risks and benefits of systemic therapy. Second: accurately estimating life expectancy in older patients with cancer, since elder patients may have comorbidities, loss of function, cognitive loss and/or poor social support. Third: expanding research on biomarkers of aging that might predict both short- and long-term toxicities. Muss and Busby-Whitehead conclude that, “all of us must be strong advocates for the highest quality care for our expanding numbers of elders with cancer.”