Living & Aging with MBC: Dr. Rachel Freedman & Patient Experiences

This episode of our podcast is about and with a very special group of MBC patients. This group is increasing in numbers, and yet it is underrepresented in clinical research, and its unique needs are not well understood. In fact, we don’t even agree on what to call this group - aging, elderly, older adults, geriatrics. We are talking about those of us who are  living with metastatic breast cancer and are over 65 years old.

Did you know that breast cancer has the highest incidence in the aging population? It is estimated that 21% of newly diagnosed patients are over 70 years old. It has been extensively reported that breast cancer-related mortality increases with age, regardless of disease stage.   Geriatric oncology  is emerging as a subspecialty of cancer care really focused on older patients. In this episode, co-hosts Dr. Ellen Landsberger and Victoria Goldberg  are talking to Dr Rachel Freedman, medical oncologist at Dana Farber about the challenges of caring for older adults

The second part of the episode is a panel discussion about the issues of living and aging with MBC with the members of two MBC support groups at SHARE.

Breast cancer is most common in patients older than 70 years and, as people are now living longer than ever, we anticipate that we will see an increasing number of older patients develop breast cancer.

Overall survival is reduced in patients who are diagnosed when over 55, even when adjusting life expectancy for comorbidities. These findings can be explained by under-/over-treatment, decreased tolerance to standardized therapy and decreased patient compliance. Optimal treatment of this patient group remains unclear, since elderly patients are often excluded from clinical trials. Despite the importance of the issue, there is little solid evidence regarding the management and treatment protocols for this specific group of patients. Treatment of breast cancer in elderly women in clinical practice is mostly based on randomized clinical trials which have actually excluded these patients from the studied population. Furthermore, no specific guidelines were available until 2007, when the International Society of Geriatric Oncology (SIOG) created the first dedicated task force to provide precise recommendations to treat geriatric breast cancer patients. Despite this effort, several issues still remain unsolved. For example, a review on Southwest Oncology Group’s therapeutic trials revealed that in studies about breast cancer, women aged 65 or older constituted only 9% of the enrolled population, despite the fact that 49% of women with breast cancer belongs to this age group. Also, patients over 70 made up only 20% of subjects enrolled in US Food and Drug Administration registration trials from 1995 to 1999, although they made up 46% of the US cancer population in that period.

Program for Older Adults with Breast Cancer (OABC)

The Program for Older Adults with Breast Cancer (OABC) at Dana Farber is focused on the unique needs of older breast cancer patients, providing personalized support throughout each patient’s experience.

Our program aims to improve care for older adults with breast cancer by better understanding the specific needs and concerns of these patients and their loved ones.

This program’s approach to medical care is to use personalized support for the unique needs of older adults and their caregivers.

The program offers dedicated staff and specialized care for older adults, including support for other geriatric and age-related health issues, nutritional support, social workers, financial assistance, integrative therapies, and clinical trials designed specifically for older patients.

Spotlight on Metastatic Breast Cancer in Older People

Geriatric oncology is a specialty that focuses on treating and researching cancer in older people. As we age, our bodies are more likely to develop many different kinds of health issues, from high blood pressure and arthritis to heart disease.

Treating metastatic breast cancer in older patients can mean balancing the side effects of MBC treatments with other illnesses and the medicines needed to manage them.

• In this video from Cancer.Net, Cancer Care for Older Adults – An Introduction, Hyman Muss, MD, gives an overview of the goals of geriatric oncology.

• SHARE: An Unheard Majority: How Older Women Experience a Breast Cancer Diagnosis

What is a Geriatric Assessment?

A geriatric assessment is a tool that doctors use to evaluate a person's health and well-being. It looks at the patient’s physical function, nutrition, other medical conditions, mental health, thinking and attention ability, current medications, and how much social support you have at home.

In cancer care, a geriatric assessment may be used to understand patient’s current health status and discuss treatment options. As we age, our bodies change. People who are 65 years and older may have specific needs that their health care team wants to understand. This tool helps them to recommend the best treatment plan and provide the right amount of support.

A geriatric assessment does not typically include a number score or grade. The results of this assessment are used in making decisions about treatment planning.

For example, older patients with cancer have a higher risk of falls. Falls can lead to life-changing injuries that can make it harder to live alone. In this example PT might be suggested as well as other options.

While it is becoming a more common part of cancer care for adults over age 65, not all patients are asked to complete a geriatric assessment. When  choosing a doctor for cancer care, it might be an important consideration and it is worth asking if they use it in their practice

Questions to ask the health care team

Consider asking the following:

• Why is it important to provide details about my health history after my cancer diagnosis?

• What tests will I need before my cancer treatment planning is complete?

• What is the goal of each treatment you are recommending? Is it to eliminate the cancer, help me feel better, or both?

• What are the expected side effects of each treatment? How can they be managed or relieved?

• How can I keep myself as healthy and independent as possible during cancer treatment?

• Why is it important to prevent falls at home? How can I minimize my risk of falling?

  Question about reduced dosing

  Drug dosing is often developed as the maximum tolerated dose and not the minimum effective dose.

  Dr. Rachel Freedman

  “So we tend to push patients until they tolerate it well, but we probably have room in a lot of places to go down and still be effective. And we see that all the time because people on clinical trials who have dose reductions often continue to benefit as much as others who are on higher doses. I will say that in the world of cdk4/6 inhibitors, which are used all the time in metastatic estrogen liking breast cancers, there have been a number of studies now, even the FDA led one, looking at older adults versus younger adults in these trials and how they're tolerated.

  And the truth is it's pretty similar. They have similar benefits. They have similar tolerability with some differences. But I will tell you in practiceI don't always feel that way. The clinical trial patients obviously are different than your practice patients. Even though we enroll a small amount of older adults on clinical trials, they tend to be the healthiest of older adults.

  And so I think it's not quite extrapolatable into our practice. If I'm worried about a person, I do start lower and then I take it from there. Some people have to stay there. Some people, you can escalate a little bit, but often you're seeing benefit at the low dose and then I don't change it.

  There are trials coming along now, particularly with the cdk4/6 inhibitors and answering this question in a much better way, where we start people and we escalate we start low and escalate rather than start high and deescalate to try to find the right dose. And this is happening with a trial called TRADE, which is coming along which is using abemaciclib, which tends to cause a lot of diarrhea.

  And that's a dosing problem for people. And so that trial is going to look at that question prospectively at our answers. And so I think your point is well taken, and I think we need to do better than, maximum tolerated dose.”

TRADE: Dose Escalation Tolerability of Abemaciclib in HR+ HER2- Early Stage Breast Cancer

ClinicalTrials.gov Identifier: NCT0600176

Sponsor: Dana-Farber Cancer Institute

Collaborator: Eli Lilly and Company

PI: Erica Mayer, MD, MPH, Dana-Farber Cancer Institute

This research study is a prospective, single-arm, open label, phase 2 study designed to evaluate if a dose-increasing strategy for abemaciclib will have less side effects and be better tolerated than the standard dosage of abemaciclib for participants with early-stage high-risk hormone receptor positive breast cancer.

This research study involves adjuvant abemaciclib plus endocrine (anti-hormone) therapy that works to target breast cancer. Adjuvant therapy is treatment given after surgery, chemotherapy, and/or radiation therapy.

The U.S. Food and Drug Administration (FDA) has approved abemaciclib as a treatment option for early-stage high-risk hormone receptor breast cancer. The FDA has also approved hormonal therapies as treatment for hormone receptor positive breast cancer.

The research study procedures include screening for eligibility, study treatment including laboratory evaluations and questionnaires, blood tests, tumor biopsies, and stool collections.

Participation in this research study is expected to last for at least 2 years and up to 5 years.

It is expected that about 90 people will take part in this research study.

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Meet the Guest of the Episode

Rachel Freedman, MD, MPH

Dr. Freedman is a medical oncologist in DFCI's breast oncology program and a clinical researcher.  Her research focuses on improving the care of vulnerable patient populations who are under-represented in clinical trials and who are at risk for poor breast cancer outcomes, including older women and those who face challenges in access to care. In addition, she is interested in novel therapeutics, serving as the Principal Investigator for several clinical trials dedicated to older adults. She is also the founder and director of the Program for Older Adults with Breast Cancer at Dana-Farber. Dr. Freedman joined the faculty at Dana-Farber in 2009. She studied at Georgetown University School of Medicine and obtained her master’s in public health at the Harvard University T.H. Chan School of Public Health. Her research has been funded by Susan G Komen, ACS, NCI, Gateway for Cancer Research, METAvivor, and the Alliance for Clinical Trials Foundation.