Treating Elderly Patients with Cancer

Oct 29, 2012

Oncologists work to improve care for this vulnerable patient population

  Arti Hurria, MD, FASCO

Member since: 2001

Institution: City of Hope Comprehensive Cancer Center

Specialties: Breast cancer, geriatrics oncology

Education: Medical degree: Northwestern Medical School; residency and fellowships: Beth Israel Deaconess Medical Center, Harvard Geriatrics Fellowship, Memorial Sloan-Kettering Cancer Center, Joan and Sanford I. Weill Medical College

From partnering with caretakers and family, to the lack of representation of elderly patients in clinical trials, caring for geriatric patients with cancer comes with a unique set of challenges but also exceptional rewards. Arti Hurria, MD, FASCO, Director of the Cancer and Aging Research Program at City of Hope Comprehensive Cancer Center,is a geriatric oncologist working to help elderly patients with cancer and their loved ones navigate the often tumultuous treatment period. In the following interview, Dr. Hurria discusses thespecial needs of patients with cancer age 65 and older and how caring for these patients has been, at times, inspirational.

AC: What drew you to oncology and working with elderly patients?

Dr. Hurria: I love the chronic care of patients. I love the ongoing relationship you develop with people. It’s an incredibly vulnerable time in a person’s life, and if you can take the time and use both medical knowledge and compassion, you can really make a difference for someone. What I realized when I did a geriatric fellowship before I became an oncologist was that older adults were a vulnerable population because they had been so unrepresented in clinical trials. When you tried to make treatment decisions with them, you were often looking at data derived from younger patients. [For her geriatric oncology research, Dr. Hurria received a Conquer Cancer Foundation of ASCO Young Investigator Award in 2002 and a jointly supported Career Development Award in 2005.]

AC: So you saw there was a need, and you wanted to step in?

Dr. Hurria: That’s exactly right. Older patients come with this wealth of knowledge. A clinic visit is always incredibly interesting, just hearing about their lives, what factors they are putting into a decision, and why they are making the decisions they feel are best for them. It’s a very rich experience for me to get to know these individuals and figure out how to optimize their remaining days of life and do it in a way where we feel like, whatever our goals of treatment, they are in agreement with what the patient wants.

AC: How do you go about establishing a treatment goal with patients?

Dr. Hurria: If the patient has the capacity to make a decision, then it’s a decision that’s made between the patient and the oncology team. It’s making sure the patient understands what their options are and how they weigh the risks and benefits within the context of who they are.

AC: What happens if you have a patient who doesn’t have the capacity to make decisions?

Dr. Hurria: It’s a little bit more complex because you have to establish that they really don’t have the capacity to make a decision. And if they don’t, then you’re looking toward who has been established as the person who can make the decision for them. You’d be working with a proxy and looking at what prior documentation the patient provided regarding their wishes and beliefs.

AC: How has the under-representation of elderly patients in clinical trials affected care?

Dr. Hurria: It has a huge impact because if the treatment hasn’t been studied within the age range or the functional status of the patient you have in front of you, it can be very hard to extrapolate the risks and benefits of that therapy. We’ve been working very hard to improve the amount of research being done in older patients.

AC: Are you currently involved in any research projects?

Dr. Hurria: We have a very active research program in cancer and aging, and there’s a consortium of investigators across the United States who collaborate with us called the Cancer and Aging Research Group []. We have studies looking at how you assess the functional age of a patient and how you identify which individual is at increased risk for toxicity from chemotherapy. Another thing we’re focused on is looking at specific therapeutics in older adults. Although most drugs approved by the U.S. Food and Drug Administration undergo a very rigorous drug-approval process, there’s often very little information included on the geriatric-usage section. The goal of these studies is to look at specific therapeutics in older adults, how they are tolerating the therapies, and what the specific side effects are. A third area we’re exploring is understanding the needs of the caregiver. How do we best support not only the patient but also the caregiver through this extensive journey?

AC: Can you provide examples of patient relationships that have stuck with you?

Dr. Hurria: There are so many. One was a woman who was socially isolated. She was single, previously divorced, and had very few friends. She lived alone, was in her late 80s, and had maintained her independence through that time. When she saw me, she had inflammatory breast cancer, but it hadn’t spread yet. I took care of her over the next two-and-a-half years until she passed away. The goal of treatment was always for her to maintain her independence, maintain her function.

In getting to know this woman, we found out that she was a prominent person during the civil rights movement. She was so humble, but she was this incredible advocate and individual. She probably joined every one of the research studies we had. Everyone just adored her. She’s an example of how the medical and research team can become a patient’s social support sometimes. We were it. She taught us so much about what was important to older adults. She was just this amazing person and had so much wisdom on so many different levels. She was, for me personally, someone who inspired me.

The other thing I’ve seen again and again is the incredible love family members have for these patients and the challenges of an aging spouse who has cancer. One husband [of a patient with cancer] was here every visit; there was nothing the wife did alone. It was a partnership. Geriatric oncology is about not only taking care of the patient but taking care of the whole family. It’s recognizing even when we lose a patient, their family has a connection with us. And how do we continue to make sure the family is okay?

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