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.”
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.
The Influence of a Mentor
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.