Homing in on the Real Needs of Cancer Patients

Hyman Muss, MD

"When you watch a tv show in the United States about cancer, the patients are always young or middle-aged. In reality, the average age of a person with a cancer diagnosis in this country is around 66 or 67, and the majority of people who die of cancer in the United States do so after age 65, so cancer is a disease of aging,” Hyman B Muss, MD, a 2017 Giants of Cancer Care^® award winner and a pioneer in the treatment of older patients with cancer, said in an interview with OncLive.

At the the recent 2018 Miami Breast Cancer Conference^®, Muss delivered the annual Giants of Cancer Care^® Lecture. His talk was entitled, “Chemotherapy and Aging: Issues and Opportunities.”

The Influence of a Mentor

There is nothing particularly “sexy” about geriatric oncology, but this is where the action is, said Muss. There’s much to be learned from older patients: They could have comorbidities, they may be frail, and they may be taking many medications for a variety of ailments, not all of which are related to cancer. These issues may be complex, but they make oncology interesting and challenging, he said.Muss’s first introduction to the field of geriatric medicine was as a faculty member at Wake Forest School of Medicine in North Carolina, where he was under the mentorship of William Hazzard, MD, then-chair of the Department of Internal Medicine at Wake Forest and a foremost expert in geriatric medicine in the United States. Hazzard is currently a professor of gerontology and geriatric medicine at the Sticht Center on Aging at Wake Forest. He encouraged Muss to study outcomes in breast cancer among older women treated with chemotherapy. The result of that inquiry was a manuscript that so impressed the editors of The Journal of the American Medical Association that they accepted it without revision. “This shocked me,” Muss said.

The effect was to give Muss a reputation in the medical community for knowing more about working with geriatric patients with cancer than he actually did, and people immediately began turning to him for guidance. However, he was willing to accept the responsibility of becoming a leader in this branch of oncology treatment, and he set to work to learn everything he could. “I got interested in the topic, and over the years, I transitioned into geriatric oncology with a focus on breast cancer,” he said.

One of his activities in relation to this was his former cochairmanship of the Cancer in the Elderly Committee of the Alliance for Clinical Trials in Oncology, where he worked closely for 20 years with former committee cochairman Harvey Cohen, MD. In addition, Muss’s collaboration with Arti Hurria, MD, led to development of the Cancer and Aging Group Geriatric Assessment, a brief list of questions that enable clinicians to determine how well older patients can function independently. They demonstrated in the Cancer and Leukemia Group B Clinical Trials Cooperative Group Program that the questions could be used in a clinical trial. “The hope is to develop models that can help determine more objectively who might do well in a clinical trial as well as the likelihood of severe toxicity,” Muss explained.

Clinical trials generally recruit younger patients, which means that the data often are not representative of typically older patients. “My career now is dedicated to looking at ways that we can develop trials, especially trials focusing on the newer biologic agents, to predict functional loss or toxicity with treatment,” Muss said.

At the University of North Carolina Lineberger Comprehensive Cancer Center, Muss is director of the Geriatric Oncology Program. Many oncologists don’t know enough about how to manage the geriatric patients under their care, he said. “Very few doctors have been trained to care for older people. They don’t think about the things that geriatricians see all the time—falls, dementia, polypharmacy, and the need for social support. People in their late 70s and older frequently come in with a lot of other issues that even the best oncologists are relatively unprepared for.”

A seminal moment for Muss was a comparison trial of standard adjuvant chemotherapy versus capecitabine in women 65 years or older with breast cancer. The Cancer and Leukemia Group B/ Cancer Trials Support Unit 49907 trial demonstrated that standard chemotherapy can improve survival in older women patients. This was significant because physicians often try to spare older women the discomforts of chemotherapy and undertreat them, which Muss believes is wrong. “We showed that older women benefited from standard treatment as opposed to oral chemotherapy,” he said.

Newer Agents and Older Patients

The trial also showed how much could be accomplished when clinicians work across disciplines in a spirit of unity. “I saw how important it was to build a team [that includes] social scientists and health service research expertise. We even looked at pharmacology and how people took their pills. By working with the right group of people who have similar interests but are knowledgeable in areas that I’m not, I saw how much we can learn about patients who, in turn, can be used to better inform doctors and patients about the consequences of treatment,” Muss said.Newer drugs—especially immunotherapies—offer such advantages as lower toxicity and less damage to patients’ bodies. Muss is excited about the potential these agents represent but noted that more data are needed on how older patients are affected when they receive these treatments. “That’s an area where we need a lot more research,” he said. Relatively few older patients have been included in studies of ipilimumab (Yervoy) and pembrolizumab (Keytruda), for example. “I suspect there are not going to be dramatic differences in nausea and vomiting, for example, but to take an older patient who is barely making it and add profound fatigue or muscle weakness is going to really change that patient’s life, and we know very little about it,” he explained.

Currently, Muss is working to understand not just the effects of treatment on older patients but also whether simple interventions, such as exercise, can stall the accelerated aging and other damage to the body that result from chemotherapy. “We try to get them into rehabilitation programs that can keep these older people as functional as possible with something that is scalable to their abilities.”

Muss receives high praise from a colleague who has worked with him in the field of geriatric oncology for almost 20 years: Hurria, director of the Center for Cancer and Aging at City of Hope in Duarte, California. Muss has led research that defined the standards of care for how older adults with breast cancer are treated, she said. Hurria described Muss as a humanitarian and a role model whose contributions to the research community have included fostering the careers of a multitude of clinicians. “The fact that he chose to dedicate his career to geriatric oncology was a huge plus for our field because we need role models—people who are successful, people we need to emulate— and when you have giants of oncology go into a field that’s relatively underrepresented and talk passionately about it, it’s a game changer.”

Muss grew up in a traditional brownstone in Brooklyn, New York. He attended Downstate Medical School in Brooklyn and graduated summa cum laude. He obtained his medical degree in 1968 and was drafted during the Vietnam War. He could have served stateside but opted to go to the front. The 27-year-old doctor was assigned to an artillery unit with the rank of captain. Muss survived his 1-year tour of duty unscathed, and in 1972, he entered Brigham and Women’s Hospital in Boston, Massachusetts, for hematology training and, later, the Dana-Farber Cancer Institute.

“I’ve been very happy as an oncologist,” he said. “Cancer is one of the key ailments of mankind. To be able to wake up in the morning and feel, ‘I’m taking good care of my patients, I’m trying to do the best I can, and I’m involved in topquality research both nationally and at a wonderful university’—that’s tough to beat!”