By Inside Jersey Staff NJ.com, June 2012
John Munson, photographer
(photo) Milton Steinhorn, 86, is a retired dentist from Middletown, who beat lymphoma last year after 6 chemo treatments.
By Sarah Golin
When Milton Steinhorn was diagnosed with lymphoma last year, he didn’t know what to expect. He had beaten bladder cancer and prostate cancer a decade earlier, with surgery and radiation. And he was hoping to have successful treatment of this illness, as well. But it would be his first experience with chemotherapy, and at age 85, he wondered how it would work out.
His doctor recommended six rounds of chemotherapy over several months. He took the diagnosis and recommended treatment in stride.
“They grade the cancer — I think mine was grade four — and then they say, ‘Okay, for this we use that,’ and then they go to work,” says the retired dentist who lives in Middletown.
It didn’t occur to him that his treatment should be, or could be, different because of his age.
“I don’t think my age mattered,” says Steinhorn, who otherwise was in good physical shape.
Stories like Steinhorn’s are remarkable for how common they have become. As recently as a decade ago, many elderly cancer patients were routinely discouraged from pursuing chemotherapy or other advanced medical treatments. Some weren’t even offered the option.
But things have changed dramatically.
“This has really been a big part of the oncology care in the last decade,” says James Salwitz, an oncologist with the Central Jersey Oncology Center and a professor at Robert Wood Johnson Medical School in New Brunswick. “We just weren’t doing it well.”
Until recently, clinical studies on cancer treatments did not allow patients older than 65 or 70 to participate. This resulted in scarce information for oncologists on how cancer treatments affect the elderly. But, similar to how medical studies once excluded women and minorities, the practice is changing.
The National Cancer Institute is ensuring that patients older than 65 and 70 are recruited for clinical trials and studies. It also is funding studies on the disparate care for older cancer patients, including examining whether they are offered all available treatment options. Worta McCaskill-Stevens, acting chief of the community clinical oncology program at the institute, says elderly patients continue to be underrepresented in clinical trials and the NCI is doing something about it. Along with funding geriatric oncology research, there has been a push to make doctors use standard protocols for all cancer patients, regardless of age.
Salwitz says that while parity in cancer care for older patients is improving, cure rates among the elderly are not. He notes that while 50 percent of cancer patients are diagnosed after age 65, 70 percent of cancer deaths occur after age 65.
Stuart Leitner, an oncologist with St. Barnabas Medical Center in Livingston, recently did his own informal survey of chemotherapy among the very old.
“Last year, I reached out to each one of my partners to find out how old was the oldest person they had treated with chemo. Each one had at least one (patient) over age 90 in chemo,” he says.
One of Leitner’s own patients, a 94-year-old with advanced bladder cancer, did remarkably well on chemotherapy, with an abdominal mass entirely eliminated, he says. The man lived another two years after chemotherapy.
Despite individual success stories, the overall picture of chemotherapy for the very old is unclear, says Leitner. “We really, really don’t have good scientific information for people in that age range.”
As Baby Boomers age, the number of cancer patients older than 70, and the percentage of patients who fall into that category, will grow dramatically. Cancer doctors say this means research on elderly patients needs to catch up quickly.
In 2000, there were 1.4 million New Jerseyans 60 and older, but by 2030, that number will rise to 2.5 million, according to the Center for Health Statistics of the state Department of Health and Senior Services. And the percentage of people age 60 and older will grow from 17 percent to more than 25 percent of the population by 2030.
Among seniors, the fastest-growing age category will be those older than 85. And many will need cancer care.
For Paul Chung, head of oncology at Southern Ocean Medical Center in Manahawkin, the future is already here. His office could be considered a preview of what cancer doctors can expect in the future. His practice is located amid the Jersey Shore retirement communities, where people 60 and older account for more than 25 percent of the Ocean County population.
“Almost all of my patients are over age 70, and many are well over 80,” says Chung. His approach to treating the elderly is the same as treating any patient — follow the standard protocols whenever possible.
“We give them the national standard guidelines. We don’t discriminate based on age. We don’t change based on age. And almost with quite certainty, I can guarantee that many, many do well,” he says.
But he notes that, like any patient, you have to consider the older person’s medical history and condition. For those who are fit and active, the standard treatment may be well tolerated.
“I had this interesting gentleman who was 89 with stage 4 lung cancer,” says Chung. “He used to row a boat every day on Barneget Bay for exercise. What he did every day, I couldn’t do.”
Despite the patient’s age and advanced illness, chemotherapy was recommended.
“He did chemo for two years, and he beat every statistic,” Chung says. “He finally died at 92 from the cancer. It is not only how strong you are but also how motivated you are. At 92, he finally said, ‘You know what? I had three great years, and I did the chemo, but I think I’m done.’”
For many oncologists today, a person’s chronological age is no longer the key factor in deciding treatment.
“When you see a patient, you are treating a person not a patient,” says Leitner of St. Barnabas. “The main thing I am thinking about is what is their real physiological age? What is their overall functional status? It is more than just a number.”
A patient’s ability to tolerate treatment — and to enjoy a healthy life after treatment — can be determined more by underlying medical conditions than by the cancer itself.
“You could have a 95-year-old man who plays golf and walks everywhere, compared with a 70-year-old who is sedentary and has other medical problems,” says Peter Yi, an oncologist at Princeton Medical Center, who also treats a large elderly population in his practice.
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Drug interactions are another significant issue, Yi says. “Some (elderly) patients take so many medications, 10 or 20 different medications. Chemotherapy can have lots of drug interactions,” he says.
Older patients should undergo a comprehensive geriatric assessment, a battery of tests that helps determine the patient’s true functioning, says Salwitz. Kidney and liver functioning are important, he says, because these organs are key in handling toxic chemotherapy. “Their functioning naturally declines with the aging process, without any disease,” he says.
Yi notes that when treating elderly cancer patients, you have to anticipate the “what if” complications — what if the stress of the treatment induces heart trouble, what if chemotherapy affects the blood sugar, and so on.
“You have to think of these things very carefully and tailor them to the individual,” says Yi.
Most crucial is for patients and their doctors to clearly understanding the goal of any treatment. This is true with any cancer patient, but is even more critical with the elderly.
“Even if it is somebody who is in their 80s, if they think they will live to 90, we will look for a cure,” says Leitner. “You have to balance a person’s status and function with their goals.”
Because the results of advanced cancer treatment in the very old are not well documented, doctors say, it should be assumed that a treatment won’t work.
“Sometimes I will have a patient say to me, ‘I am over 80, I don’t want chemotherapy,’” says Yi of Princeton Medical Center. “I say, ‘Let’s sit down and discuss this. What are our goals? Are we going for a cure? Are we going for palliative treatment?’ The goal has to be clearly defined.”
Any discussion of goals and treatment, also must include a review of possible side effects.
While the side effects of chemotherapy in the elderly are not well researched, it is accepted that they are more even in healthy, vital people of advanced age. Fatigue and weakness often are worse for older patients, and the chance of infection is higher. Older patients also are more likely to end up in the hospital during treatment, doctors say.
Milton Steinhorn’s treatment was very difficult but manageable, he says.
“I had six chemo treatments. After the first one, I was fine, and after the last one, I was fine. But after (treatments) two, three, four and five, I ended up in the hospital,” he says.
Steinhorn had seven blood transfusions during three hospitalizations, but he remained optimistic that the treatment would work, he says. After his fourth round of chemo, a PET scan declared him clear of the lymphoma. So, bolstered by that good news, he knew he would be able to tolerate the last two rounds.
Along with the infections and hospitalizations, the biggest side effect Steinhorn experienced was extreme fatigue.
“It was debilitating. It took all my energy to get up in the morning and get dressed and have breakfast,” he says. Then he might spend the rest of the day dozing in a chair.
“I had a physical therapist come by and show me some exercises to do, so I would try to do that every day. The exercises were so your muscles don’t just disintegrate during treatment.”
Steinhorn was lucky, in one sense. Although he had lymphoma and a rigorous chemo treatment, he also had help. Although a widower, Steinhorn has two grown children and a significant other with whom he lived throughout his chemotherapy treatment. Her care played a big role in his recovery.
“To face this thing alone would be very, very tough,” he says.
And this is another obstacle many older cancer patients face. Social supports can weaken with age, as friends and relatives die or become infirm themselves. Patients may not have a spouse to drive them to radiation treatment every day for six weeks, or someone at home to help them get dressed and make them food when they are weakened by chemotherapy.
Allowing friends and family to help shoulder the stress and burden of treatment can make a big difference, doctors say.
“I had a couple I was treating, both 90 years old, and both have had some very impressive, very serious complications from their treatment,” Salwitz recalls. “But they have each other, and they support each other and genuinely help each other, and they have made it through. I have seen several patients, much younger than that, who without the support, can’t tolerate the (complications).”
That is why many oncologists recommend that their older patients get family members involved. Bring an adult child or other family member to doctor appointments, and let them take notes and ask questions.
Other recommendations for older cancer patients include checking out information from the National Cancer Institute and the American Cancer Society, including looking at standard treatment guidelines. It can be a good place to start a discussion about treatment options.
Chung also tells people to make sure they are seeing a board-certified oncologist, and to carefully follow the doctor’s instructions.
There is inspiration to be found among patients in their 70s, 80s and 90s who have been treated and cured.
“Often people can do just fine,” says Yi of Princeton. “I had a patient who I did not expect to tolerate chemo very well (due to liver and kidney issues). This person did so well, she went into complete remission. The person was 83 years old, with advanced colon cancer. Most patients like that don’t survive a year or two. This person has been cured and continues to live independently. She’s got arthritis and some other conditions, but generally is doing very well. She has been in recovery for six years now, and she is 89.”
Milton Steinhorn recommends patience — and time in the sun — to aid recovery. He spent 2 months in California over the winter after his treatment ended.
“The sun does wonderful things for you,” he says.
Slowly, Steinhorn has been able to regain the life he had before lymphoma. He’ back to playing golf three times a week and makes occasional trips to the gym to work out.
He emphasizes, however, that his recovery didn’t happen all at once, like a miracle cure. “I just would think, ‘I did this, and I wasn’t tired. I walked up the stairs and I wasn’t tired,’” he says. “It took a while to get the strength back.”
June, 2012
Inside Jersey Magazine