Old Age and Cancer – the Focus of This Doctor

MD Anderson Cancer Center
Date: 11-14-2011


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Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from the University of Texas M.D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin. Today, our guest is Dr. Holly Holmes. She's an Assistant Professor in General Internal Medicine here at M.D. Anderson and a geriatrics expert. We're going to be talking about the elderly and the special issues that they have with cancer treatment and survivorship. Dr. Holmes, first of all, how do you define elderly? What is the age range?

Dr. Holly M. Holmes: That's becoming a more and more difficult question to answer. I think that traditionally we used to think of 65 and older as being elderly, but if you ask your average 65-year old person, they would not call themselves elderly, nor do they have what we commonly think of as geriatric conditions. I think that people who are 75 and older or maybe even 80 and older and as the population ages more healthfully, that will even get pushed older and older, but certainly, people who are 75 and older are more likely to have conditions common to the geriatric population.

Lisa Garvin: And you are a geriatrician.

Dr. Holly M. Holmes: Yes.

Lisa Garvin: Let's talk about the profession.

Dr. Holly M. Holmes: Okay.

Lisa Garvin: It's--yeah, I mean, there aren't that many of you apparently.

Dr. Holly M. Holmes: Right, there aren't that many. It's kind of amazing it's become sort of a cocktail party thing for me that when people ask me what I do, I always answer them with a question. I say, I'm a geriatrician? And then they say, oh, so, you specialize in the nutrition for older people? And I said, well, you know, nutrition is just one of the many things that I do. I don't do nutrition actually particularly well, so I really don't try to claim that, but it's amazing to me, given how much our population is ageing that people don't know what a geriatrician is. I mean, you would think that a geriatrician would be the most prominent physician right now, but it is generally a family practice or internal medicine physician who has then done additional fellowship training specializing in care of people 65 and older traditionally thought of as geriatric who then has board certification in geriatrics to specifically take care of older people.

Lisa Garvin: How many are there in the oncology setting?

Dr. Holly M. Holmes: Very, very few. I mean, there are only around 7,000 or so board-certified geriatricians in the country currently. So, when you think about specialized cancer settings like comprehensive cancer centers such as M.D. Anderson Cancer Center, the number of geriatricians is really just such a small handful. Here at M.D. Anderson, we do have three geriatricians who are in palliative care who do not practice geriatrics, so I'm the only practicing geriatrician at M.D. Anderson. At other cancer centers, there are different varying levels of programs, so there may be a handful of geriatricians that specifically do geriatrics, there might be entire programs focused on oncology in older people, but it's really kind of the exception.

Lisa Garvin: And given that the cancer population just tends to skew 50 and older that's kind of odd.

Dr. Holly M. Holmes: Yes, it's really kind of exciting time. I mean, geriatric oncology is just a growing discipline of very dedicated people who recognize the intersection of ageing and cancer and that we need people who have expertise in both to best determine care as we move forward. It's just a very, you know, ironically young discipline.

Lisa Garvin: Let's talk about the special issues that older cancer patients may face. One of them is that they tend to be on a lot of drugs.

Dr. Holly M. Holmes: Yes, older people with cancer are more likely to have a lot of other chronic medical conditions and with every chronic medical condition comes medications to treat them. So, just by virtue of having other medical problems and being older, it is more likely that they will take high numbers of medications even upwards of eight or nine medications concurrently. And so, these medications already may cause their own problems, you know, adverse drug reactions, drug interactions, side effects, just general effects of taking that many medication. And then when you add on cancer to that, then you're dealing with piling on top of that cancer and its treatment and all the supportive medications that go for cancer. So, really makes it very challenging to try to limit the number of medications in order to limit the toxicity and the side effects.

Lisa Garvin: So is that part of your job to help them manage their medications?

Dr. Holly M. Holmes: One of the things I most commonly get consults for is people who have so-called poly pharmacy, which is sometimes defined as having more drugs than clinically indicated or even just taking nine or more medications a day has sometimes been defined as poly pharmacy. So, I will sometimes get consults specific for this issue and some of that is because I used to be a pharmacist. So, my background as a pharmacist has really helped that. I look through patient's medication regimens and I look for very common medication-related problems and try to reduce those drugs.

Lisa Garvin: Do you also counsel them on non-drug things like supplements and vitamins, do those have an effect?

Dr. Holly M. Holmes: I do. I consider those drugs. So, I do try to change my patient's attitude towards anything that they ingest in order to create an effect, I see that as a drug. So, I do try to kind of change the whole outlook towards everything that should be on your list. A patient's list of medications, number one, when they walk in the door often does not contain these items. So, the first thing we do, get all those over-the-counter medications on that list, get all the herbal medicines and supplements on the list, and make sure that everyone you see related to your oncology care knows about it. Those things may have drug interactions, they may have other effects and they may be specifically contraindicated with other kinds of therapy. So, I do try to limit the use of any kind of unnecessary medication whether it is a supplement or not. I will admit that I often find that the supplements are less necessary than some of the other medications, so I try to reduce those.

Lisa Garvin: And obviously, chemotherapy, well, all cancer treatment is pretty rough on people, do these effects like side effects of radiation and chemotherapy, are they enhanced in the older population?

Dr. Holly M. Holmes: They--to some extent, yes, I mean, we have increasing data that there is unique toxicity in older people or that toxicity is more severe and there are specific chemotherapeutic regimens where we have some data on this. This is not necessarily my direct area of expertise, but this is certainly what geriatric oncologists do. So, people who are dually trained in oncology and geriatrics, one of their main goals is to really understand how toxicity might be different in the elderly and how we could better predict it so that we could say upfront, this is the chemotherapy regimen we recommend for you, but with these kinds of factors that you have on board at your age, we recommend changing the therapy in this way to make it unique for you.

Lisa Garvin: And let's talk about prostate cancer patients. A lot of them tend to be in the age range we're talking about, some of them may not need to be treated. I mean, so in some situations, is active cancer treatment a good idea?

Dr. Holly M. Holmes: That's a very difficult question for a lot of people to answer. There is a really challenging balance between having cancer and wanting to treat it and delaying treatment to avoid side effects knowing that you may have a lot of anxiety related to that. There is a real problem with some of the hormone therapies for prostate cancer that men have long term effects that we kind of consider the frailty syndrome in geriatrics. So, loss of muscle mass, loss of bone mass, also, increased risk of cardiovascular diseases, and diabetes. So, these are very long term effects, but in the short term, it's hard to face that decision, you know, regarding the long term. Of course, you know others have really well described the side effects of surgery and radiation therapy and how that presents some other difficult decisions for older men as well including the effects of incontinence and erectile dysfunction.

Lisa Garvin: What about issues like dementia or Alzheimer's? First of all, do we see a lot of cancer patients with early onset or early stages of these conditions and how does that affect their treatment?

Dr. Holly M. Holmes: I think at M.D. Anderson Cancer Center, because our patient population is quite select and they often will come here after having other treatments at other centers, and it requires quite a bit of resources and were with all to really get here, I think we actually have a population that might be less cognitively impaired than in the community. I think in community settings, this is probably very challenging for oncologists. Older people do have a high prevalence of Alzheimer's disease and other dementias. When you look at people 85 years and older, it's estimated that even up to 40 or even close to 50 percent of people have some level of cognitive impairment. So, if you have that already and then you're facing cancer treatment that might affect your cognition as well, it's a really difficult decision. You really have to know, number one that the person has the cognitive impairment and that's just not a routine part of screening for general oncologists.

Lisa Garvin: Now, there's something that we call chemo brain, which is the cognitive effects of certain chemotherapies, have you done enough study or do you have enough data to know that this might be worse in older patients?

Dr. Holly M. Holmes: Well, that is not really my direct area, I deal with the clinical side, but we do have an amazing neuropsychology group here who specializes in chemo brain. And or, you know, of course they don't really call it chemo brain, but I really think for patients that word really kind of grabs on and it's easy to understand what we are talking about. Certainly, we have some really good studies that have been done here on the effects of chemotherapy on brain function. There are smattering of studies that older patients who present with cancer have higher levels of cognitive impairment than younger patients and that they are very susceptible to the effects of chemotherapy and especially certain kinds of chemotherapy, but it really remains to be seen whether if you took somebody with perfectly normal cognitive function, you know, over time after chemotherapy, is the older person more likely to be at risk than the younger person. The geriatrician in me would say yes, I would suggest that the older person is probably more likely to be at risk just because of normal age related changes in cell function and in brain function, but I don't really know.

Lisa Garvin: What's the oldest person that you've seen here at M.D. Anderson?

Dr. Holly M. Holmes: I think, maybe 97, 98.

Lisa Garvin: Wow, I mean--

Dr. Holly M. Holmes: Yeah.

Lisa Garvin: What--how do you deal with somebody at that age who has cancer?

Dr. Holly M. Holmes: You know, I think, I had to be honest I think it's actually easier to handle the issues of cancer in older people than it is in younger people. I'm biased in saying this, but you know, older people who then are diagnosed with cancer, they have been dealing with lots of other chronic diseases their whole lives. And 90-some-year old has a very low likelihood that they haven't been diagnosed with at least one or two other chronic illnesses. So, being diagnosed with cancer becomes another thing that you have to deal with and as you get older there are so many losses that come and I think that older people cope with cancer quite well. It's really remarkable. So, the discussion becomes more framed around what other conditions do you have, what are the risks to you for having this cancer, how would you have been doing if you hadn't had the cancer. It's really a very global look at how this person is functioning, how the cancer fits into that. The cancer is just one part of a whole list of problems that we deal with.

Lisa Garvin: So, it seems like advice to older cancer patients particularly those over 70 is to really kind of weigh their options, like I said, some diseases like prostate cancer, they may die of old age before they die of prostate cancer. So, what would your advice be to a geriatric cancer patient, what sort of questions should they ask, what should they know?

Dr. Holly M. Holmes: I think one thing that you just said is the most important point that you really want to know what kind of options you have. You want to be able to present it--to be presented with lots of different alternatives, but then to put that into use, you really have to know where am I at, you know, I might have this numeric age, but what's my functional age. Maybe I'm 80, but I'm really a very healthy 80 because I have no other medical problems. So, the question is in the context of your other medical problems, any functional problems, your reserve of social support, your ability to be independent, all of those things have to weigh into your decision for cancer treatment and that you really don't want to base that solely on your numeric age.

Lisa Garvin: As some people age, they may not have as good a relationship with their primary care providers they may have when they were younger, is it important to keep up that relationship?

Dr. Holly M. Holmes: That's a huge part of cancer care is keeping the communication with your primary care provider. You have other medical problems that your oncologist is not going to be able to address, but those things could be worsened by your cancer care. And more importantly, the medical problems you have if they are not well controlled, those could make your cancer care more rocky. So, you really have to have good coordination of care between your primary care physician and your oncology physician.

Lisa Garvin: Great. Thank you Dr. Holmes. If you have questions about anything you've heard today on Cancer Newsline, contact askMDAnderson at 1-877-MDA-6789 or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.