• Paths of Progress Fall/Winter 2013

    Cancer

    An age-old challenge
    by Saul Wisnia

    Rabbi Marc SamuelsRabbi Marc Samuels is one of a growing number of Americans age 65 and older who face a diagnosis of cancer.  

    Amidst all the talk of genetic risk for developing cancer, it's easy to overlook an important fact: The single biggest risk factor for developing cancer today is aging. In fact, more than 60 percent of all cases in the U.S. occur in people age 65 and older. Research over the past 20 years shows that genetic disparities can affect how cancer impacts different age groups, and that certain forms of the disease — including blood cancers like leukemia and other bone marrow disorders — are particularly prevalent in older individuals.

    The Older Adult Leukemia Program at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) addresses this problem. It features weekly clinics with oncologists, physician assistants, and nurse practitioners who specialize in leukemia care, as well as social workers and geriatricians with decades of experience.

    "Leukemia and myelodysplastic syndrome [a pre-leukemia condition] are diseases of older people; children can get them, but the second peak is in people in their 70s, 80s, and beyond," says Jane Ann Driver, MD, MPH, who leads the Older Adult Leukemia Program with Gabriela Motyckova, MD, PhD. "We want to help improve their outcomes and quality of life as much as possible."

    Jane Ann Driver, MD, MPH and Gabriela Motyckova, MD, PhDJane Ann Driver, MD, MPH (left), and Gabriela Motyckova, MD, PhD, often work in tandem to treat older patients, adjusting chemotherapy and other treatments based on accompanying conditions.  

    Driver and Motyckova complement each other well. Motyckova is a hematologist/oncologist who focuses on the clinical aspects of treatment, while Driver is both an oncologist and a geriatrician who goes beyond cancer to assess each patient's overall medical condition, cognitive functioning, and social supports.

    "It's helpful to put the entire picture together," says Motyckova, who first studied the unique needs of older patients as a Dana-Farber/ Harvard Cancer Center fellow. "In a traditional oncology setting, we focus initially on cancer, but there are a lot of primary care and medical issues that can have a profound impact on an older individual's care. Having Dr. Driver to coordinate and manage such issues, and also assess the current functional status of a patient, can help us make the best choices for each stage of care."

    Although an elderly patient may seem cognitively competent in the presence of a spouse, child, or other caregiver, keeping quiet or simply answering "yes" to every question, Driver probes deeper to assess cognitive capabilities.

    In one test, Driver measures attention, memory, and coordination; in another, she determines energy level to gauge the patient's ability to withstand the rigors of chemotherapy or a bone marrow transplant. One 70-year-old may have a much lower "functional age" than another.

    "I'm not only interested in the details of the malignancy or the bone marrow, I'm also looking at the person as a whole — their cognitive abilities, social supports, the ease with which they can get around their home," says Driver. "If a person can't remember and repeat five items, will he or she remember to take needed pills? If they don't have a caretaker who can give them rides to appointments and bring them in if they develop a fever, is it safe to administer more intensive therapy?"

    A Growing Resistance

    Researchers are working to understand the genetic roots of the increased incidences of cancer in older individuals. Richard Stone, MD, director of the Adult Leukemia Program at DF/BWCC, says researchers have long known that elderly patients with acute myeloid leukemia (AML) fare much worse when given the same therapy for what appears to be the same disease treated effectively in children.

    Rabbi Marc Samuels with his wifeRabbi Marc Samuels (with his wife, Carole) benefits from a patient-centered program that addresses all aspects of his care beyond cancer.  

    "We have begun to understand recently that the chromosomal changes or abnormalities that we use to classify leukemias are different in older adults — making for a more resistant disease," says Stone.

    Recognizing these genetic abnormalities is the first step to undermining them. One way is through stem cell transplants; the development in the last decade of "mini transplants" that use lower, less toxic doses of chemotherapy and/or radiation has made the life-saving process an option for patients up to 75 years old with a variety of cancers — including AML.

    Stone points to a study led by Timothy Ley, MD, of the University of Washington at St. Louis as a big step forward in AML genetic analysis. Ley's team studied the genomes of 200 adult AML patients and found at least one potential driver mutation (the type that causes tumor growth) in nearly all the samples. A database formed from their findings will help researchers at DF/BWCC and elsewhere further seek the genetic causes of acute leukemia.

    While this work is underway, Stone says, geriatric assessments will continue to play a key role in helping older patients fight leukemia and other cancers.

    "In our field, especially in a place like Boston, an older adult with multiple medical problems may see several different specialists, each of whom has them on a different medicine," Stone attests. "Many patients have internists, but these doctors may not be focused on geriatrics because they have busy clinics and may only see each patient once or twice a year. Having the extra set of eyes that a geriatrician provides is invaluable."

    Amy Emmert, vice president for Hematopoietic Stem Cell Transplantation and Cellular Therapies at DF/BWCC, agrees. "We are looking for those cases where a patient might need additional clinical support from social workers or other caregivers," says Emmert. "People who are 35 can better handle the many challenges of cancer than seniors — who often come from a different educational background and have a different understanding of medicine."

    Close Bonds

    In some cases, due to the frequent visits that often accompany cancer care, a DF/BWCC geriatrician can take over as the primary physician for patients in his or her care.

    This was the case with Marc Samuels, an 85-year-old rabbi and survivor of the Auschwitz concentration camp. The soft-spoken Samuels, who says he feels like a celebrity during his weekly visits to DF/BWCC for injections to combat myelodysplastic syndrome, has developed a special relationship with Driver, whom he calls "more my friend than just my doctor." The geriatrician once even made a house call to the Brookline apartment of Samuels and his wife of 56 years, Carole.

    There are practical advantages to such closely-watched care. When Samuels fell and broke his pelvis last spring, Driver was able to connect him with an orthopedist right next door to Dana-Farber, at Brigham and Women's Hospital. Within weeks, Samuels was back at his regular oncology appointments with a cane and a smile.

    Eventually, Driver and Motyckova hope that Samuels and other older patients will have the opportunity to participate in a variety of clinical trials at Dana-Farber that focus on areas including chemotherapy tolerance, symptom management, fatigue, and support systems. "Geriatricians have their expertise, oncologists have theirs, and it's a wonderful combination for these patients to have access to both in one place," says Driver.

    Paths of Progress Fall/Winter 2013 Table of Contents 

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