Cancer and Aging America: Valuable Information for Patients and Loved Ones

Cancer and Aging America: Valuable Information for Patients and Loved Ones with Lodovico Balducci, MD, Chat Transcript
Friday, March 10, 2006 2:00 – 3:00 PM ET

Moderator: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net Ask the ASCO Expert chat on Cancer and Aging America: Valuable Information for Patients and Loved Ones, a live question-and-answer session hosted by Lodovico Balducci, MD.

During this hour, Dr. Balducci will answer as many questions as possible. Due to an increasing number of chat participants and number of questions submitted for each chat event, time simply does not allow us to address all of your questions, and we encourage you to consult your doctor and cancer care team.

Some questions may be adapted so that Dr. Balducci's answers can help as many people as possible.

Dr. Balducci will take questions from 2:00 – 3:00 PM ET. As you prepare your questions, please keep in mind that Dr. Balducci is unable to give individual medical advice in this setting, nor is he able to address questions that include information specific to one person's medical profile.

The information presented here is for informational and educational purposes only and is not intended to substitute the professional medical advice or treatment recommendations provided by your doctor.

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Good afternoon and welcome. Thank you for joining us. Dr. Balducci will now begin taking questions.

Lodovico Balducci, MD, is Professor of Medicine and Oncology at the University of South Florida College of Medicine and Division Chief of the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center & Research Institute.

Dr. Balducci's clinical research activities include cancer and aging, management of the frail elderly, assessment of quality of life in the older cancer patient, prognostic assessment of the older cancer patient, and interactions of comorbidity and function in the older cancer patient.

He is currently the Program Leader of the only existing geriatric oncology program in the country and the world. Dr. Balducci has also edited five textbooks on geriatric oncology and published more than 200 articles in various medical journals on the subject of geriatric oncology.

Dr. Balducci, thank you for taking the time to join us today.

Guest0: At what age is a patient considered in the older population or even elderly?

Dr. Balducci: I decline to put an age to establish who is old and who is young. That is because age is not chronology; it is physiology. In other words, a 60-year-old person may feel that they are older than a 90-year-old person. However, we generally refer to an older person as someone older than 70 years old, and that is because the main physiologic changes of aging start occurring after age 70.

I want to make absolutely sure that people realize that aging is not established by the number of years a person has lived, but how long a person is able to tolerate stress.

Guest62: Are there oncologists who specialize in caring for the elderly?

Dr. Balducci: Yes. Thanks for asking this question; it is extremely important. In the last 15 years, a number of centers in the United States have started programs in geriatric oncology. These programs train physicians to become aware of the special problems of the older person and to deal with these problems.

Guest50: My mother is in her 80s and has bladder cancer. Her doctor wants to surgically remove her bladder. What sort of quality of life should she expect after surgery and are there any alternatives to surgery for someone her age?

Dr. Balducci: The standard treatment of bladder cancer is still surgery, when it is feasible. After the bladder is removed, the urine may come out from a conduit through the intestine or a surgeon can build an artificial bladder. Despite the problems that may occur with surgery, I believe that your mother will have a better quality of life if she undergoes surgery. The only alternative would be to treat your mother with a combination of radiation therapy and chemotherapy, but the results of this treatment are probably not as good as surgery.

This treatment will also have a bad impact on her quality of life.

Guest25: My husband is having severe bone pain in his hip due to leuprolide (Lupron). How can I get his doctor to refer him to an orthopedic specialist to see if he needs a hip replacement? I am wondering if there is a reason why his doctor cannot refer him to a specialist to take care of the pain.

Dr. Balducci: Your husband may not need orthopedic surgery. The real issue is whether your husband has pain in his hip from metastases of the cancer or because he has osteoporosis from leuprolide. If he has metastases of cancer, the treatment of choice may be radiation therapy. The only indication for surgery would be a risk that he may break his hip.

Guest105: As cancer is becoming more prevalent in the older generations, what is the economical impact on this population?

Dr. Balducci: Well, the treatment of cancer is expensive. So, certainly, aging of the population is associated with increased cancer and increased costs of treating cancer. However, what would be the alternative? If the cancer treatment is able to prevent disability and to prevent pain and other symptoms, it may be even more cost-effective than not treating the patient.

But, you are right, the aging of the population means an increased cost of health care.

Guest94: I am 72 years old. My husband and I have been diligent about keeping up with screening tests. Are there any special considerations that doctors need to take when performing screening tests for people in our age group?

Dr. Balducci: Cancer screening—that is screening for cancer of the breast or large bowel—may save as many lives in older people as it does in younger people. We recommend that a person with a life expectancy of five years or longer undergo regular screening for these cancers like a younger person.

Unless you are particularly frail or sick, at age 72 your life expectancy is approximately 14 years and your husband's is 10 years. So, screening is definitely indicated in both of your cases.

Guest66: What are your thoughts on the importance of this population being involved in clinical trials?

Dr. Balducci: It is extremely important that older people be part of clinical trials. It is the only way to find out whether cancer treatment is a benefit or risk in this population. And that is particularly true for the adjuvant treatments. For example, we know that adjuvant treatment of lung cancer can save approximately five lives out of 100.

Of course, if the person is likely to die as a result of the treatment, or if the person has other diseases that reduce his or her life expectancy, adjuvant treatment might not be beneficial. In our institution, we are doing a number of clinical trials in older individuals to try to establish some simple parameters—such as daily activity, energy level, etc.—so we can separate patients who benefit from adjuvant treatment and those who don't.

Again, please be aware that an older person in good general condition seems to benefit from treatment to the same extent as a younger person.

Guest107: Is it possible to have cancer and manage it like a chronic disease?

Dr. Balducci: Well, I would say that many cancers have become chronic diseases thanks to the new forms of treatment. For example, a woman with metastatic breast cancer or a man with metastatic prostate cancer, can still live several years.

If the metastases are limited to the bone, that is. But even in the case of colorectal cancer, the median survival is in excess of two years. So, yes, many cancers have become chronic diseases and should be handled as such.

I have a patient with metastatic colon cancer since 1980. In his 26th year, he was treated for prostate cancer and lymphoma, as well. I have a woman with metastatic breast cancer for 22 years, and when she developed angina, I had her undergoing coronary artery surgery, as I knew that she would have died of her heart disease much sooner than of her breast cancer. So, yes, many cancers are chronic diseases and should be treated like that—we should prevent disability and take aggressive care of intercurrent disease, acute diseases that may kill them much sooner than the cancer will.

Guest247: I have read many articles that say elderly people often do not receive full or appropriate treatment for their cancer. How can we advocate for ourselves and assure we get the best and proper treatment?

Dr. Balducci: Excellent question. In the past, there was a concern that older people could not tolerate treatment as well as younger people, and as a result, the doses of chemotherapy were reduced. The patients had a poorer prognosis because they were not adequately treated.

I believe that the majority of the oncologists in the United States are aware of the importance of giving full doses of treatment, and we've got antidotes for treatment toxicity. This is feasible in most older patients. I believe that the best way to advocate for yourself is to express up front to your doctor your concerns.

I believe that most of the doctors nowadays are willing to share treatment-related decisions with the patient and will appreciate if you let them know up front this is your desire.

Moderator: Transcripts of today's chat will be available March 13, 2006, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

BDK: My grandmother has colorectal cancer (a recurrence) that has spread to her liver. She is 89 years old and has decided not to seek treatment. I am afraid for her. Can you shed any light on what the future may hold and how we can help her? Thank you.

Dr. Balducci: The decision whether to receive treatment belongs first of all, to the patient. And it is very reasonable for somebody, whatever the personal reason, to refuse treatment. I would recommend that your grandmother be aware of what options are available.

For example, if she only has one or two metastases to the liver, her life could be prolonged by surgery or even by a much safer procedure, which is called radiofrequency ablation. If, on the other hand, your mother has diffused metastases to the liver, her only option is chemotherapy that at her age, which may include some risk of infection, bleeding, and dehydration.

The chemotherapy under the best of circumstances may prolong her life from nine months to one year. I want to assure you, however, that dying of liver metastases is generally not painful. People go to sleep and die. So, if your grandmother is aware of what options are available and she decides that in her circumstances the best thing is to let the cancer take its course, I would strongly recommend to honor her decision and to try to make her last few months of life as meaningful as possible.

moxen: Can you address the best ways to deal with pain in an older cancer patient? I often find that they are reluctant to mention the pain or seek help to relieve it. Thank you.

Dr. Balducci: You're absolutely right. Older people are generally more reluctant to take pain medication and are more likely to endure pain that may compromise their quality of life and activity.

The American Geriatric Society is very concerned about pain in the elderly because pain, even benign pain (such as due to arthritis), may limit the exercise of older people and compromise their health and survival.

Having said that, I believe it is important to remember that older people are more sensitive to the complications of pain medications. So, probably it is wise to start with a low dose of opioids or morphine-like drugs and increase the dose as needed until the best effect is observed.

A number of procedures right now can minimize the effects of opioids. These include giving pain medication directly into the spinal fluid, but this is an expensive procedure and it is risky unless the continuity of care is very good.

Relieving the cause of pain provides the best relief of pain, and there are a number of ways to do that without using opioids. One is radiation therapy, another is radioisotopes, and in many circumstances, chemotherapy is used for this purpose.

Guest276: Is there any new research relating to treating older people with cancer?

Dr. Balducci: Well, all the cancer research is very consequential for older people because new forms of cancer treatment, which are called targeted therapy, are likely to kill the cancer with minimal effect on normal tissues. The difference between targeted therapy and classical chemotherapy is the same that exists in war between missiles and carpet-bombing.

In addition to that, there is an oncology consortium, the Geriatric Oncology Consortium, whose specific aim is to study ways to minimize toxicity and improve the efficacy of cancer treatment for older people. A recent study showed that growth factors may prevent the risk of infection in more than 50% of individuals age 65 and over treated with chemotherapy.

G-Man: My father has lung cancer and my mother is his primary at-home caregiver. Both are in their 70s and my mother is quickly becoming overwhelmed with her responsibilities. My siblings and I don't live near them but want to find ways to help. Any suggestions?

Dr. Balducci: Thank you for asking this question. This is very critical. The caregiver of the older patient, especially the older cancer patient, is generally an older spouse with health problems of his or her own and whose health may worsen as a result of caregiving.

We don't appreciate enough what these unsung heroes do for the welfare of our society. I've seen women in their 80s who will not take care of breast cancer because they have to take care of their husbands with Alzheimer's disease. What can you do?

It is difficult to make specific recommendations without knowing the situation. I believe that as a general rule, you could make frequent calls to your mother and express your gratitude and support. Also, if your family cannot afford a home caregiver, you and your siblings may try to find a way to provide some respite for your mother.

For example, you could hire a person that could spend a night from time to time with your father, or take turns visiting. Of course, you can talk over the situation with your father's oncologist and ask for his or her suggestions.

Another important aspect we often forget is to try to avoid conflicts within the family and express gratitude and appreciation for what your mother is doing, even if it is not what you would be doing.

Finally, your mother and all of you may benefit from some support groups that may be present in your areas. Oncology social workers are extremely well experienced with these issues and may offer a solution that you have not considered. So, if the social worker is not involved in the care of the lady's father, I would recommend a social worker be consulted as soon as possible.

Guest106: I am a 78-year-old male and was treated for prostate cancer with external-beam radiation therapy. Over the past few years, my PSA has increased from 4.2 to 8.3. I have been advised that my best chance of survival would be to begin hormone therapy. I am very physically active in sports and use the gym at least 3 times per week. What kind of effect will hormone therapy treatment have on my energy, mental alertness, and quality of life?

Dr. Balducci: Hormonal therapy may pose disappearance of your libido (sexual desire), may cause osteoporosis, weakness in your muscles, and hot flashes. However, the level of complication is different in different individuals. If hormonal treatment is necessary, I would recommend that you try one shot. The effect will last three months, and if the effects seem to be too harsh, you can stop the treatment thereafter.

I would like to add that there might be other options in your case, however. You may talk with your doctor about cryosurgery or implants. Without more details, I cannot say for sure that hormonal therapy is your best option.

Guest343: My father is 84 and undergoing treatment for bladder cancer. Recently, he has begun showing signs of dementia. How can we tell if this is a result of the cancer, the cancer treatments, or growing older?

Dr. Balducci: As far as we know, no form of cancer treatment, except for maybe irradiation of the brain, can cause dementia in a short time.

So, I don't think dementia is being caused by treatment. I think what might have happened is that your father already had some cognitive deficits and cancer treatment precipitated the diagnosis of this dementia. People who are demented can usually mask their dementia very well until a trauma of some type affects them. I would strongly recommend that your father have a neuropsychological evaluation to make sure that he has dementia, rather than depression, that in older people may mimic dementia.

I also recommend that if he has dementia, he look for common reversible causes of dementia, such as hypothyroidism or deficit of vitamin B12.

Guest277 :I don’t find much information relating to survivorship of elderly cancer patients. My mother is 69 and undergoing treatment for breast cancer. Fortunately her outlook is good and I want to assure she is prepared for life after treatment. Thank you.

Dr. Balducci: This is an excellent question. The question is absolutely right—there is not a lot of information and it is needed. That is why the National Cancer Institute, ASCO, and the American Cancer Society have become interested in survivorship. We all hope that in the near future, maybe five or 10 years from now, the main role of the oncologist will be to take care of cancer survivors.

In the case of your mother, if she is receiving adjuvant treatment, as I imagine from your description, she should not expect long-term bad effects. We have done a study on women age 70 and older surviving breast cancer and we found that their function and cognition were comparable to those of women of similar age without cancer.

Moderator: The chat is now ending. Thank you for your thoughtful questions.

We hope this discussion has been valuable, and we regret not being able to answer every question. We want to thank Dr. Balducci for lending us his time and expertise.

TRANSCRIPTS: The full text of today's chat will be available on Cancer.Net (www.cancer.net) March 13, 2006, by 12:00 PM ET. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

March Q&A: In March 2006, visit Cancer.Net for a question-and-answer (Q&A) forum on Preventing, Screening, and Treating Colon Cancer.

The featured expert is Robert Mayer, MD, of the Dana-Farber Cancer Institute.

The chat room is now closed. Thanks again for joining us.

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Last Updated: March 13, 2006