A group of cancer experts is pushing a new line on treating the disease: Age is not what it used to be, as far as a barrier to aggressive cancer treatment is concerned.
The development could have major implications for healthcare costs.
Whether the cancer is in the breast or in the lungs, age by itself no longer should preclude treatments such as chemotherapy, said Dr. Corey Langer, medical director of thoracic oncology at the Fox Chase Cancer Center in Philadelphia. Langer and a handful of other researchers are presenting the argument this week at the American Society of Clinical Oncology meeting in Chicago.
Langer told meeting attendees the nation is facing not only a growing elderly population, but also a growing population of "fit-elderly. These are people who are playing tennis into their 70s. They are working out, trying to stay fit."
Analyzing data from a non-small-cell-lung cancer study, in which patients were randomized to four "state-of-the-art" combination chemotherapy regimens, Langer and colleagues found patients ages 70 to 80 did as well as patients younger than 70, regardless of treatment, he told United Press International.
The National Cancer Institute study enrolled 1,139 patients with advanced lung cancer. Of those patients, 227 were 70 or older, Langer said. There was no age-related difference in response to treatment -- about one-third of the patients responded -- or in ability to complete the treatment, he said.
Dr. Hyman Muss, a professor of medicine at the University of Vermont, in Burlington, said the story is much the same in breast cancer. About half of new diagnoses are made in women age 65 or older. When breast cancer spreads to the lymph nodes, the standard therapy for younger women is surgical removal of the tumor, followed by chemotherapy to kill any remaining cancer cells.
Muss told UPI that women 65 and older respond to chemotherapy "just as well as younger women," but the problem is often they are not offered chemotherapy because they are considered too old.
"In the United States, if a woman is healthy at age 65, she can expect to live for 20 years, at 75 she can expect to live for 12 years, at 80 for six years," he said. "With chemotherapy, the response rate is about 60 percent, meaning six of every 10 women will be cancer-free for 10 years."
For a 75-year-old woman, "she can live the years she was expected to live," he said.
Even bone marrow transplants, which though risky are considered effective treatment for leukemia and other blood cancers, should be offered to elderly patients, said Dr. Michael Friedman, president and chief medical officer at the City of Hope National Medical Center and Beckman Research Institute in Duarte, Calif.
Friedman said 23 leukemia patients, ages 60 or older, including "a patient who was over 80," underwent a new, less-toxic bone marrow transplant procedure and "13 of those patients are currently in remission."
Before patients undergo the procedure, they are given both radiation and chemotherapy to destroy leukemia cells in the bone marrow in order to make room for the new, healthy transplanted cells.
The therapy phase of the treatment is very toxic and many cancer experts have considered it too severe for elderly patients to tolerate. But by adjusting the procedure and using a newer, less-toxic immuno-suppressant drug called Cellcept in combination with traditional drugs, the technique can be used on both elderly patients and young children. "Our youngest patients were 12-month-old twins," Friedman noted.
Elderly patients often are eager for treatment because "they value the years at the end-of-life as much as the years at the beginning of life," he added.
Although good response rates comprise the upside to treating elderly patients, paying for those treatments -- which previously were not considered an option for the elderly -- portends a major new financial burden for an already strapped Medicare system.
Therefore, Medicare officials are responding cautiously. In the past, Medicare would approve payment for any new drug approved by the Food and Drug Administration -- but no more.
Two weeks ago, Dr. Sean Tunis, medical director at the Centers for Medicare and Medicaid Services, signaled the change in a speech at a meeting of North American Society of Pacing and Electrophysiology. Medicare is rethinking all payment decisions, Tunis said, and one of the guiding principles in that process will be a requirement that new therapies must demonstrate superiority to existing drugs.
This new attitude is surprising, because the FDA only requires new drugs to demonstrate equivalence in order to be approved, said Terry Coleman, of Ropes and Gray, a Washington lobbying firm that represents ASCO.
Coleman said the CMS published regulations last year declaring it has reserved the right to ask for additional review of "novel, complex or controversial (new therapies) that would be costly to Medicare and which could be subject to over use or misuse."
The agency did just that with oxaliplatin, a new drug FDA had approved for colorectal cancer. Last February, CMS notified its carriers it was reviewing oxaliplatin, a decision that essentially stopped its use in Medicare patients. Last month, however, after a barrage of criticism, CMS softened its stance on oxaliplatin and the drug now has entered the Medicare pipeline.
Medicare is not alone in raising concerns about high-cost, high-risk cancer treatment in elderly patients.
Dr. Craig Earle, assistant professor of medicine at Harvard Medical School in Cambridge, Mass., and colleagues from the Dana-Farber Cancer Institute in Boston, reviewed medical records from almost 29,000 Medicare patients who died within a year of being diagnosed with lung, breast, colorectal or other gastrointestinal cancers.
Earle said the use of chemotherapy has increased to 29.5 percent from 27.9 percent among elderly patients. But that increase, he said, does not necessarily reflect good medical practice. For example, 18.5 percent of the patients received chemotherapy within two weeks of dying, he noted.
"I have argued as much as anyone against ageism in cancer treatment, but there is a time to stop," Earle told UPI. "Since we have developed second, third and fourth line therapies, we might find it difficult to stop, but we shouldn't be starting third line treatment in the last few weeks of life."
