Among the many important research areas of breast cancer and frankly all cancers is what’s called survivorship; quality of life and the ability to live independently. Among older survivors, one area of concern: cognitive decline or memory loss. This is one of the areas that Dr. Arti Hurria studies. Dr. Hurria and her team focus on older, long-term breast cancer survivors looking at memory difference between those who received chemotherapy versus those who did not compared to healthy women of the same age who never had cancer. What might their discoveries offer in terms of predicting potential memory issues among survivors and, importantly, creating interventions to preserve capabilities and the highest possible quality of life?
Chris Riback: Dr. Hurria is director of the Cancer and Aging Research Program at City of Hope. She is also co-leader of their Cancer Control and Population Sciences Program. A medical oncologist, Dr. Hurria recently joined the board of directors for the American Society of Clinical Oncology; the worlds leading professional organization of physicians who provide cancer care. She also has been a BCRF grantee since 2012. Dr. Hurria, thanks for joining me. I would begin with why aging? There are so many areas of cancer research to focus on. What drew you to the intersection of cancer and aging?
Dr. Hurria: Well that’s a wonderful question. First, it’s such an honor to be here and to be with your audience. Thank you so much for the opportunity. The reason for aging is because the vast majority of cancers occur in older adults. So if we look at cancer incidence and cancer mortality or new cases and cancer deaths in general what we know is that about 60% of new cancer cases and 70% of cancer deaths occur in individuals who are over the age of 65. That being said, those individuals have really been underrepresented in cancer research to date. There is a real need to understand the issues they’re facing; older adults with cancer and older cancer survivors, and to specifically focus our resources on their specific needs.
Chris Riback: I got to say in researching for this conversation that really struck me. I mean, to read those statistics around the number of new breast cancer diagnoses. I assume it’s in a range of cancers beyond just breast cancer. You can please correct me on that if I have that wrong. The number of those new diagnoses that occur in women 65 and older and at that same time the limited data that exists to guide chemotherapy treatment recommendations including the side effects and the need for dose adjustments; it felt to me like a massive and important opportunity which I guess is exactly how you see it.
Dr. Hurria: Absolutely and to compound the issue is that right now the population is aging. In the U.S. if we looked at just all cancers, but breast cancer is clearly among those, and we look at new cancer cases that are going to occur in patients age 65 plus … That’s just, by the way, a kind of line in the sand. We use an age of 65 plus because of Medicare benefits at that point but certainly recognize there’s a spectrum of aging. What we see is that there is a rapid growth in this population. We’re going to see a 67% increase in cancer diagnoses from 2010 to 2030. We call it ‘the graying of our waiting rooms’. It’s clearly a populations that is on the rise. Yes, they have been underrepresented in cancer research to date. Unfortunately, when we look at who has been enrolled on the key research studies that define how we practice cancer care, primarily those populations have been younger than the age of the group of individuals who have the disease. Hence, what that does is it creates a dilemma when the doctor and the patient are sitting together and trying to make a treatment decision. The doctor’s often extrapolating some data in a younger patient population and trying to then individualize this treatment to an older adult. This is where BCRF has really been a leader in this area in recognizing that there was a gap in knowledge and being such an incredible supporter of research to help to really close that gap and help older breast cancer survivors.
Chris Riback: Yeah, it’s such an interesting point that you make about the aging population. The phrase that came to my mind is ‘a big problem, getting bigger’ because the problem already existed and then, to your point, we as a society are getting a higher percentage of older folks living longer. You can just see how a big problem would just keep getting bigger. Talk to me then if you would, let’s turn to maybe some of your current work and the memory differences. The study, as I understand it, is looking at memory differences between survivors who receive chemotherapy versus those who did not compared to healthy women of the same age who never had cancer. Take me through, how does the study work? Memory differences is the central component of it. What was it about that aspect of the aging that made this something that you wanted to focus on for this study? What stage are you at and what do you hope to find?
Dr. Hurria: This is a very interesting study that really came out of my time being with patients and sitting with patients. My entire practice is older patients with breast cancer. That’s the group of patients I take care of so I spend a lot of time with this group. What they were telling me was that they noticed that they were experiencing some memory problems after receiving chemotherapy. Because of that experience and also because my background is first in geriatrics I was trained and then in oncology, I had an interest in this area. Certainly, listening to patients about what they were subjectively feeling was very important to me. We banded together, myself at City of Hope and then Timothy at Memorial Sloan Kettering Cancer Center, banded together to really try to understand what it was the patients were experiencing. The story is there have been studies that have looked at changes in memory in patients with cancer but the majority of those studies have been done among younger adults. Which is fascinating because as we age we are more likely to experience memory problems so you would naturally think this would be something that would have been studied in an older patient population. The truth of the matter is that actually the vast majority of studies have been done in younger adults. What those were finding were that yes, there was a group of patients who seemed to be at risk for these memory problems, not everyone. Still, the risk factors or understanding who is at risk is still an area of research that is ongoing and early in development.
What we did was we wrote a grant to the government and we asked to have the opportunity to study breast cancer survivors who were 5-15 years out from diagnosis and who were aged 60 plus at diagnosis. In other words, it was a group who were older breast cancer survivors who had either received chemotherapy or not and then a group of healthy controls. What we’ve had has been a really robust response to participating in this. We are now in the third year of the grant and have several hundred patients across the U.S. who are joining us in this effort of understanding how memory might change over time if you’ve received chemotherapy or not. The hypothesis we have is that it’s not just chemotherapy that might be influencing these changes but it’s really understanding who the whole person is. What are the other medical problems that they might have that might also impact memory? If you compound those together and then give someone chemotherapy then how does that over time influence memory? We’re following these people over a period of time … We’re testing their memory over four time points and looking to see what that trajectory of memory change over time and does it differ if you never had cancer, if you had cancer but just needed endocrine therapy or pills to try to decrease the risk of the cancer coming back that block estrogen production or block the estrogen signaling pathway, or if you needed to receive chemotherapy. I think this is going to be a very exciting set of study results and I hope we will have an answer to it in the next few years.
BCRF has been an incredible supporter because they have let us add a component to this study that I think is very novel but somewhat also I’d say high-risk in thinking a little bit out of the box. BCRF which says “give us your best science” and even if it’s thinking a little out of the box they’re willing to let scientists really study and area and get some pilot data. What BCRF has done has allowed us to add biomarkers, or blood samples that where we are looking at something called allostatic load. Which is trying to understand … It’s looking at a cumulative measure of the body’s stress over time in several different bodily organ systems. We’re trying to see if that composite measure can tell us anything about the risk of memory loss over time. We’ve been able to add that in. We’re also getting samples looking at genetic markers. That’s another thing that we’re working on and …yes, the study is going really well. The thing I’m probably most proud about is that it really is going to help answer a question that patients have on their minds. We’re still looking for individuals to participate. If you are interested certainly contact me and I would be happy to tell an individual more about the study.
Chris Riback: Among the aspects that you were discussing that interest me and make me curious; for someone like me who would potentially know somebody or have a family member and obviously memory loss would be an area of concern. Are the lessons that we would try to get out of your research, you talked about it like we can look at the various treatments and I assume what correlation, you’ll use the proper term, those various treatments might or might not have on memory loss or memory impact. Is there also a component of it where if there … In a sense, what can we learn from, what actionable can we take from it? So when we learn that; yes, you know what memory loss, if the hypothesis works out, that through a series of factors memory loss my end up being something that is related to various aspects of breast cancer treatment, does it them make it easier to include various interventions? Are there then actionable things that people can do? Is that the outcome? Is it more about how we can help address it when it occurs? Is it about how maybe potentially we can help prevent it? What is the range of your goals on this?
Dr. Hurria: Chris, absolutely. That’s exactly the idea which is that what we want to do is understand who is at risk for memory loss. There’s two ways then that we can approach that. Number one, it sets us up for a series of studies where we can actually intervene to try to decrease that risk. For example, if we find out that the person who’s most at risk is someone who has diabetes and is inactive and is now going to receive chemotherapy; so it’s that triad. Let’s just suppose that’s something we find. Then it would mean for that population in particular we should intervene and make sure their blood sugars are well controlled, that we get them on an exercise program and we help to change, we would hope, that trajectory of memory changes over time that they might experience.
Basically what would happen is it would lead to a teachable moment of helping that individual who we hope would be a long-term survivor of breast cancer not have secondary effects as a consequence of their treatment or as a consequence of their other medical problem. As soon as we have this data what we envision is that the next set of studies is going to be exactly what you said which is to set us up for a series of intervention studies. The goal here is that patients will be fully informed about what the risks are and how we can then work to really decrease those risks. The goal is that we certainly want patients to get the treatment they need but we want them to get it with the idea that we’re thinking about the survivorship years together and how we can not only best attack the breast cancer but also help them live with the best type of quality throughout those years of survivorship.
Chris Riback: I’m really struck by that phrase. I’m always struck by that phrase ‘quality of life’ and I’d be interested in … You have met with, spoken with, heard from patients over the years. Is there a wide range of what quality of life means? It seems like it’s such a personal definition. Is it or is there a way that you measure it in some way and institutionalize what it means to achieve quality of life? How do you think about quality of life and how have your experience with patients of the years kind of impacted that understanding?
Dr. Hurria: It is a wonderful question and one that also really has so many layers that we could discuss. Let me take the most simplistic approach first but then I’d like to go deeper. Simplistically we can measure quality of life. There actually are these validated scales that are out there that are a series of questions that we ask the person about their physical well-being and their social well-being and their emotional well-being. It tries to get at … questions that get at quality of life. So yes, you can get a score and that’s often what’s utilized in the research setting actually are these scores. We’re looking at a composite score as well as a score in different domains; function, emotions, spirituality, and so forth. On a deeper level though, quality of life is something that’s probably one of the most fascinating parts of being a doctor and the most wonderful and enriching part which is really sitting with your patient and having that very individual connection with them about what does it mean personally. What brings meaning to them and what things might be getting in the way of obtaining or reaching that personal meaning?
I can tell you in oncology and in particular with older adults, much of my time actually spent with them or really getting to know them and exploring these things together. You’re on a journey with them. You’ve been on a journey with them through a really serious illness then you have the honor of continuing that journey through these years as a survivor and getting to know the patient and their families and their grandkids. There’s a much richer personal definition I think to quality of life comes through that experience between a patient and their oncologist.
Chris Riback: You know, I was struck by this aspect of you earlier in the conversation. You used a phrase when I was asking you about the inspiration, the motivation, and how you got to this thought of really focusing on the aging population and the various aspects. You said ‘it came from listening to your patients’. That really hit me. I was like whoa, you don’t hear researchers and scientists talking often about that being … terrific. I know most, if not all, of them do it but to hear that be such a defining component. Now you talking about the ‘honor’ of continuing with these patients and their families and through their lives. I know your bio talks about you being a compassionate and respectful professional. Which also struck me as a wonderful and unique element to have as part of your professional description. Does this sense of compassion or humanism … It really must inform your work. It really must inform how you study, what you decide to study, how you interpret, how you apply … It’s got to be something that just travels through every aspect of your work to the extent that you feel you’re doing your work well. I assume that really fuels you. Do I have that right?
Dr. Hurria: Absolutely. It’s very interesting. We’ve been so fortunate because our research has gone really well and we’ve been able to garner a number of research grants but the only reason, or the primary reason I think we have that success is because every single research grant that I have written has come from a patient encounter, or several patient encounters where they have told me that there is a problem. Is it memory loss or that they want to maybe understand the risks of therapy better. Every research direction has come from a patient asking me a question where I felt that we could do a better job at answering that patients question. Hence, it’s really the patients that have driven this whole research program of how to best care for older adults with cancer.
As a researcher and as healthcare provider I just can’t think of a better … It is such an honor to take care of these patients and to be a part of their life and to have the opportunity then to listen to them and to translate what they’re saying into a research question and then have the opportunity to go with them on the path of answering it; is just so gratifying. It really brings incredible meaning to me. If our research is successful it is solely because of this partnership we’ve had with patients along the way and the hope that we can make it better for the next generation. It amazes me to see how patients contribute to that mission. They’re so willing to participate and to be a part of this, knowing that they may get nothing in return but it might help that next person down the line. It’s really just inspiring and my hat goes off to them everyday. Patients are making the world better for one another. There’s just nothing like it.
Chris Riback: Yeah, it has to be incredibly inspiring. I mean, they’re opening their lives to you for the betterment they hope, and you hope, of others. Just to close out then and on that note, what’s next? Obviously you have the current research that we discussed. Is that where most of your focus is right now or do you always kind of have an ear out for what potentially might … what you might hear, the question from the patient that you might hear that might lead to the next grant that you think about?
Dr. Hurria: There is so much in the ‘what’s next’ category. I’d say two … which is wonderful and BCRF has supported again some of this work. One of the biggest research directions that we’ve undertaken that now has over a dozen sites across the U.S. participating is a study that is specifically focused on older adults with breast cancer who are getting chemotherapy. It’s asking the question of, it says … This is the question that patients have asked me. They say, “Doctor, personalize the therapy for me. Don’t look at my age but look at who I am and with that help to make the right treatment decision for me”. That was the broad ask from patients and what we’re doing is … so this one has 700 people across the U.S. participating where we are getting to know the patient before they start chemotherapy. We’re looking at what’s their function, what’s their memory, what’s their social support, what’s you nutritional status, what’s your emotional state? We’re also collecting a bunch of blood bio markers as well. The idea is we’re trying to come up with a functional age rather than a past order or chronological age, and utilizing that along with what the patient really wants; their values, their preferences and understanding how they will tolerate chemotherapy based upon their functional age. The idea being then a doctor and a patient could sit in room and the doctor could say, “Here’s the benefits of therapy based upon who you are and here are the potential risks that you might undergo.” Hence, kind of a way, where are they on that spectrum of what risks are they willing to take? The goal being that we pick the right therapy for the right person.
That’s another study that is underway, actually very close to completion. I think we are in the last 75 patients joining that study. That’s very exciting and BCRF supported that work. Lastly is the idea of … Most of our cancer therapies have been studied in younger adults. There’s a real need to study these therapies; how well they’re tolerate, what’s the right dosing in the patients who are going to get the drug. We have several studies that we either have ongoing or launching that are really looking at the newest treatments that are FDA approved and then specifically evaluating them in older adults so that we can provide both doctors and patients with guidance on how to dose the drugs, what are the side effects to expect, and how can we best deliver those treatments to an aging population.
Chris Riback: That’s a fascinating set of questions and important series of research efforts. I guess you’ve left me plenty to ask you about for the next time. I would look forward to that as well. Dr. Arti Hurria is director of the Cancer and Aging Research Program at City of Hope. She is also co-leader of their Cancer Control and Population Sciences Program. She recently joined the board of directors for the American Society of Clinical Oncology and has been a BCRF grantee since 2012. Dr. Hurria, thank you so much for your time. I’m Chris Riback. This is BCRF Conversations.
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