First Person: Hyman Muss, MD: Geriatric oncology pioneer continues leading efforts to help older patients with cancer.

Abstract

It probably was inevitable that Hyman Muss, MD, would go into medicine. Growing up in a brownstone in Brooklyn, New York, where his father, a dentist, and uncle, a general practitioner, had their practices on the first floor, he was exposed to the field on a daily basis. “It was a very tight neighborhood, and they lived near the patients they served,” Dr. Muss says. “I never much liked dentistry, but I loved what my uncle did. He took me on house calls, and over the years I got more and more interested in medicine.” Dr. Muss, the Mary Jones Hudson Distinguished Professor in Geriatric Oncology at the University of North Carolina (UNC) at Chapel Hill School of Medicine and director of the geriatric oncology program at the UNC Lineberger Comprehensive Cancer Center, looks back on his influential career in geriatric oncology as well as ahead toward what else he can accomplish in the field. “We’re making slow but sure headway in caring for older people with cancer,” Dr. Muss says. “There’s such a shortage of knowledge, yet the average age of a cancer patient in the United States is about 67.” One colleague who praises him is Trevor Jolly, MBBS, codirector of the geriatric oncology clinic at the UNC Lineberger Comprehensive Cancer Center, who Dr. Muss recruited as the first geriatric oncology fellow at UNC. Not only has Dr. Muss led some of the major clinical trials in the field and developed a strong program at UNC, but he is a “triple threat,” excelling in research, education, and the clinic, says Dr. Jolly. “It’s hard to find a physician who is intelligent, has great clinical skills, and also has an outstanding bedside manner—especially in the oncology field, which is so busy and has so many demands,” he says. “I suspect he has a clone somewhere working while he sleeps.” Dr. Jolly adds, “All his patients love him. He hugs all of them, which is something I’ve acquired and started doing myself.” Nor is he any less skilled as an educator, according to Dr. Jolly, who says Dr. Muss is never too busy for his fellows. “He has a wealth of knowledge,” he says. “I’ll present a challenging case, and he always has some paper he’ll pull out” to address the problem. A breast cancer specialist who has focused extensively on geriatric oncology for the past 20 years, Dr. Muss did not always know he wanted to be an oncologist. He earned his medical degree in 1968 from the State University of New York Downstate Medical Center in Brooklyn, which he describes as “a terrific education at virtually no cost—$800-a-year tuition.” He completed his residency at Brigham and Women’s Hospital (then Peter Bent Brigham Hospital) in Boston, Massachusetts, and then enlisted and served for a year as a physician during the Vietnam War. Returning to Boston, Dr. Muss completed a fellowship in hematology/oncology in 1974. At the time, he worked with all types of patients with cancer, but as knowledge in the field grew, he specialized in breast cancer. In that area, his major interests are the treatment of both early-stage and late-stage disease, treatment outcomes, and optimizing care for older women with breast cancer. For example, in 2009, The New England Journal of Medicine published the results of the first chemotherapy trial in older patients with early-stage breast cancer developed by Dr. Muss, who served as the study chair, and colleagues through the National Cancer Institute (NCI)’s Cancer and Leukemia Group B.1 The study was prompted because women aged 65 years and older were underrepresented in clinical trials. Researchers compared capecitabine with standard adjuvant chemotherapy in more than 600 patients in this age group. They found that older patients did better in terms of survival and disease recurrence with the standard chemotherapy and experienced tolerable side effects. That study is just one example of Dr. Muss’ efforts to improve cancer care for older adults. Noting that the average patient in clinical trials is between 55 and 60 years old, he says that although age discrimination in research is no longer allowed, there still is plenty of age bias among clinicians. His interest in geriatric oncology first was sparked in the 1980s and 1990s while he served as associate director of clinical research at Wake Forest University in Winston-Salem, North Carolina. Dr. Muss was encouraged by William R. Hazzard, MD, one of the leaders in geriatrics, to compare younger patients with breast cancer to older patients with breast cancer who received chemotherapy. After that study was published, colleagues suddenly began asking him questions about their older patients, and he soon found himself becoming an authority in the area even though he is not double-boarded. “I’ve learned so much from working with geriatricians,” he says. “Many practicing oncologists have no training in geriatrics, and although they treat older people, those patients are less likely to be offered clinical trials even though they’re eligible,” he says, adding that many older patients already have other chronic conditions when they receive a cancer diagnosis. In particular, Dr. Muss points out, there is a lack of data regarding how older patients respond to the newer biologic cancer treatments. As a result, he and his colleagues are working on ways to overcome barriers to geriatric assessments, educate clinicians, and leave the door open to accrue more older patients onto clinical trials. Another challenge is training. Many medical/hematologic oncologists are reluctant to do yet another year of training in a geriatrics fellowship. “We know there will never be enough double-boarded people to care for all the older people with cancer in the United States,” Dr. Muss says. For that reason, he and others in the field persist in their efforts to encourage education in geriatrics. At press time, Dr. Muss’s group at UNC had applied for a National Institutes of Health (NIH) training grant to support further training in geriatric oncology for surgeons, radiation oncologists, and others. In addition to building a strong geriatric oncology research program at UNC Lineberger Comprehensive Cancer Center, Dr. Muss has published numerous articles regarding treatment side effects in older patients with cancer and on the importance of conducting geriatric assessments that ask questions regarding issues such as social support and nutritional status. He and his colleagues also have encouraged the American Board of Internal Medicine to include questions regarding cancer care among older individuals in the examination. Serving on an American Society of Clinical Oncology (ASCO) subcommittee, he coauthored the organization’s statement concerning the importance of improving the evidence base for treating older adults with cancer.2 Dr. Muss and his colleagues currently are conducting what he calls “an exciting avenue of research to determine whether walking and simple exercise can help to reduce the aging effects of chemotherapy. Previously, he worked with Norman Sharpless, MD, currently director of the NCI, to demonstrate that adjuvant chemotherapy for breast cancer accelerates molecular aging.3 “If you’re 70 and have a new diagnosis of breast cancer and we’re treating you with chemotherapy, we measure your biomarkers of aging, do a geriatric assessment, give you a Fitbit, have you walk, and teach you some strengthening exercises,” he says. Researchers then will assess whether exercise reduces the side effects of chemotherapy and biomarkers of aging. Dr. Muss attributes much of his success in the field to a host of mentors, including William C. Moloney, MD, and Emil “Tom” Frei III, MD, at Harvard University in Boston; Harvey J. Cohen, MD, at Duke University in Durham, North Carolina; Larry Norton, MD, at Memorial Sloan Kettering Cancer Center in New York City; Arti Hurria, MD, at City of Hope in Duarte, California; William R. Hazzard, MD, and Charles L. Spurr, MD, at Wake Forest University; and Lodovico Balducci, MD, at Moffitt Cancer Center in Tampa, Florida. Despite all his many achievements, Dr. Muss considers his proudest accomplishment “marrying my wife, Loretta, of 48 years—mother to my children and grandmother to my grandchildren.” The two enjoy visiting their family as well as taking bike trips, hiking, and other outdoor activities.