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Cancer Survivorship: How To Manage Treatment-Related Risks and Problems
Outside of the Oncology Setting
Tracy A. Johnson, DNP, FNP-BC
Disclosures
No financial relationships to disclose
This CME presentation was developed independent of any commercial influences
Objectives Articulate the purpose and key concepts of cancer survivorship
care
Identify cancer treatment regimens that present potential health risks.
Perform accurate, targeted questioning of patient's medical history to screen for potential issues and risks related to cancer treatment.
Incorporate appropriate diagnostic testing and screenings based on health risks and problems related to cancer treatment.
Identify potential "red flags" in clinical presentation and symptoms of cancer survivors.
Identify online cancer survivorship resources for health care providers and survivors.
What Does It Mean To Be A Cancer Survivor?
Currently 12 million cancer survivors in the United States
NCI SEER data: ◦70% all survivors alive 2 years after
diagnosis◦60% alive 10 years after diagnosis
What Does It Mean To Be A Cancer Survivor?
“Cancer survivor”: at diagnosis or after treatment? (NCCS, NCI)
Enduring and overcoming all aspects of diagnosis and treatment
Includes emotional, social, financial, medical sequelae of treatment
So, What’s The Problem?
Advances in detection + Advances in treatment+ Aging population
Growing number of cancer survivors
(Why is that a problem?)
So, What’s The Problem?Growing number of cancer survivors potentially
with multiple comorbidities◦ Typical aging, lifestyle, late effects from treatment
Increased burden on health care system (cost and volume)
Focus shift from oncology to PCP
PCPs and other health care providers not familiar with consequences of cancer and cancer treatment
Cancer Care Continuumfrom Canadian Strategy for Cancer Control, 2005
PreventionScreeningDiagnosisTreatmentSurvivorship Follow-Up CarePalliative Care
IOM 2005 report: “From Cancer Patient to Cancer Survivor: Lost in Transition” (www.iom.edu)
Identified the need to provide survivorship care as a distinct phase of oncology care
Recommendations for addressing late effects from treatment (holistic)
Recommendations for transition from oncology to primary care
What is Cancer Survivorship?
Assists with transition from cancer treatment to living “a new normal”
Addresses the emotional, practical, and physical effects of cancer treatment
Provides assessment, education, referrals, and resources to meet the individual needs of cancer survivors at any point after completing treatment
What Is A Survivorship Care Plan?
Communication between oncology & PCP
Roadmap for long-term care
Education for survivor, family, and other providers
How To Assess Risks Associated With Cancer Treatment:
Type of cancer (s)
Treatment modalities
Specific treatment agents/fields
Clinical and Psychosocial findings
Types Of Cancer Treatment Presenting Health Risks
Breast
Colon
Prostate
GYN
Leukemia
Lymphoma
Lung
Thyroid
Head & Neck
Skin
Melanoma
Types Of Cancer Treatment Presenting Health Risks
Surgery?
Radiation?
Chemotherapy?
Hormonal therapy?
Transplant?
Types Of Cancer Treatment Presenting Health Risks
Anthracyclines: Adriamycin, Daunomycin, Epirubicin, Idarubicin
Taxanes, Platinums, Vinca Alkaloids: Taxol/Taxotere, Cisplatin/Carboplatin, Vincristine/Vinblastine
Radiation: left chest, mantle, prostate, TBI (total body irradiation)
Monoclonal Antibody: Herceptin, Avastin, Erbitux, Rituxan
Hormonal: Tamoxifen, aromatase inhibitors (Arimidex, Femara, Aromasin)
Transplant: Steroids, Immunosuppression, GVH (graft vs host)
Long Term Impact Of Cancer Treatment
Heart/cardiovascular disease
Peripheral neuropathy
Dental problems
GI problems
Osteopenia
Pain
Menopause
Uterine problems (Tamoxifen)
Long Term Impact Of Cancer Treatment
Skin cancer
Breast cancer
Lymphedema
Functional limitations
Fatigue
Emotional: Depression, Anxiety, PTSD, family, social, body image
Financial: work, insurance
What Are The Long-Term Risks From Treatment ?
Chronic pain: surgery, chemotherapy, radiation, hormonal therapy◦Bone, joints, back, abdominal/GI, surgical site
◦What helps: exercise, PT, nutrition, yoga, acupuncture, massage, medications, education/counseling
What Are The Long-Term Risks From Treatment ?
Dental problems: chemotherapy, head/neck radiation◦Frequent brushing/flossing, regular dental visits, drink/rinse with water often
What Are The Long-Term Risks From Treatment ?
Decreased Bone Density: menopause (by any cause), Arimidex, Aromasin, Femara, high dose steroids, radiation◦Daily calcium 1200-1500mg and vitamin D 800-1000 IU
◦Weight bearing exercise, stop smoking◦Monitor bone density testing and vitamin D levels
What Are The Long-Term Risks From Treatment ?
GI Problems: Vincristine, Vinblastine, abdominal or pelvic surgery/radiation◦Motility problems, scarring, adhesions◦Dietary optimization, hydration, physical
activity◦Referrals
What Are The Long-Term Risks From Treatment ?
Heart Risks: Adriamycin (“Red Devil”), other anthracyclines, Left chest radiation◦Make sure cholesterol levels and blood
pressure are normal, exercise, healthy diet, no smoking
◦EKG, echocardiogram (or MUGA, RVG) post-treatment baseline and every 2-5 years
What Are The Long-Term Risks From Treatment?
Cardiomyopathy
Conduction defects, dysrhythmias
Radiation associated valvular disease
CAD/MI
Other cardiovascular disease
Cancer associated thrombosis
What Are The Long-Term Risks From Treatment ?
Lymphedema, Functional limitations: surgery, radiation
◦Helpful to have evaluation, treatment, and education by physical therapist
◦Lymphedema IS possible if you only had 1-2 lymph nodes removed. Less risk, but not zero risk.
◦Late onset lymphedema IS possible several years after treatment. Less likely, but not zero risk.
What Are The Long-Term Risks From Treatment ?
Lymphedema, Functional limitations: surgery, radiation
◦Will always need to stretch & exercise affected area to maintain function & prevent limitations
◦Refer/evaluate early!
◦Areas to consider: neck; breast/axilla; pelvic/genital; lower extremity
What Are The Long-Term Risks From Treatment ?
Fatigue: surgery, chemotherapy, radiation, hormonal therapy, stress, other medical conditions, LIFE
◦ Healthy lifestyle is very important!
◦ Exercise, weight loss, sleep, good nutrition
◦ Massage, acupuncture
◦ Talk to primary care, oncologist, other medical providers about checking for abnormalities in thyroid, vitamins B & D, iron, anemia, hormonal imbalances
◦ Counseling or wellness coaching for emotional problems, stress, guidance for healthy living
What Are The Long-Term Risks From Treatment ?
Menopausal symptoms: natural or chemotherapy induced menopause, surgical removal of both ovaries, hormonal therapy
◦ Healthy lifestyle is very important!
◦ Exercise, weight loss, sleep, good nutrition
◦ Massage, acupuncture – great for pain and hot flashes
◦ Medications for hot flashes and mood swings
◦ Vaginal dryness – use over the counter daily moisturizers (Replens, olive oil)
What Are The Long-Term Risks From Treatment ?
Peripheral neuropathy: Taxol, Taxotere, Vincristine, Vinblastine, Cisplatin, Carboplatin, Oxaliplatin
◦ May or may not resolve after treatment
◦ Pharmacologic therapy
◦ Nutritional therapy
◦ Acupuncture
◦ Safety
What Are The Long-Term Risks From Treatment ?
Uterine problems: Tamoxifen
◦ Risk only if you still have uterus
◦ Yearly pelvic exam and PAP
◦ Report abnormal vaginal bleeding, pelvic pain
◦ Exams can be done by primary care, GYN, health department
What Are The Long-Term Risks From Treatment ?
Skin cancers: Radiation
◦ Monthly self exams, be sure to look at skin in radiated areas
◦ Report new or changing areas on skin: pigmented, raised, non-pigmented, red, itchy, crusty, ulcerated, etc.
◦ Primary care or dermatology can do simple biopsy if needed
What Are The Long-Term Risks From Treatment ?
Elevated cholesterol
Fertility ProblemsHearing lossThyroid problems
Secondary cancers
Depression, anxiety
Memory problemsSexual
dysfunction
What About Genetics?
Encourage patients to keep a record of family history of cancers, non-cancerous colon polyps, other health problems
Consider genetics evaluation if diagnosed before age 50, family history of breast cancers, or lots of cancers in family
• Other hereditary syndromes besides BRCA
• Recommendations for screening for other cancers
• Recommendations for cancer screenings in family members, children
Red Flags
Fatigue
Palpitations
Dyspnea/SOB/Orthopnea - one of most under-reported by providers
Pelvic pain/vaginal bleeding/prior GYN history
Past medical history – also consider existing health issues with new cancer diagnosis
Red Flags
Edema/functional limitations – arm, lower extremities, abdominal/pelvic
Globus sensation/dysphagia
Past cancer history
Age/Gender
Lifestyle – smoking, alcohol, activity, diet
Family history
Screening Recommendations
Echocardiogram , Cardiac MRI, MUGA, RVG (post-treatment baseline, then every 2-5 years)
EKG
Cholesterol
BNP, Troponin
Coronary screening: ischemic studies, calcium scoring CT, cardiac catheterization
Early detection + early treatment = improved cardiac status & outcomes
Screening Recommendations
Bone Density: high dose steroids, aromatase inhibitors, early menopause
Dental exams: any chemotherapy, head/neck radiation
Eye exams/cataracts: high dose steroids, cranial radiation
Reproductive hormones: cranial or pelvic radiation, alkylating agents (Cytoxan)
Pituitary labs: cranial radiation
Thyroid labs/ultrasound: neck radiation
Doppler ultrasound (carotid, other arterior/venous): radiation
Prevention/WellnessEncourage self care/wellness efforts!
Baby steps • Don’t set goals too high• Start small – easier to achieve, easier to see
progress
Be consistent
Encourage survivors to be own advocate • Ask questions• Take advantage of local and online resources• Write things down
Resources Hewitt, M., Greenfield, S., Stovall, E. (2006). From
Cancer Patient to Cancer Survivor: Lost in Transition. National Academies Press: Washington, DC.
Adler, N. E., Page, A. E. K. (2007). Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Institute of Medicine, National Academies Press, Washington, DC.
Feuerstein, M. (2007). Handbook of Cancer Survivorship. Springer: New York, NY.
Lenihan, D., Cardinale, D., Cipolla, C. (2010). The Compelling Need for a Cardiology and Oncology Partnership and the Birth of the International CardioOncology Society. Progress in Cardiovascular Diseases, 53(2), 88-93. doi 10.1016/j.pcad.2010.06.002
ResourcesNCI Office of Cancer Survivorship:
http://survivorship.cancer.govAmerican Society of Clinical Oncology:
http://www.asco.org/Children’s Oncology Group:
http://www.childrensoncologygroup.org/National Comprehensive Cancer Network:
http://www.nccn.org/ Journal of Cancer Survivorship:
http://springerlink.comREACH for Survivorship Program:
http://www.vanderbiltreach.org
Resources
www.nccn.com – Clinical guidelines for cancer treatments
◦Written for patients
◦Diagnosis, work up, treatment, follow up
◦Updated yearly, most current evidence from research and clinical practice
Resources
http://www.cancer.net/patient/Survivorship - website for cancer survivors◦Information from American Society of
Clinical Oncology (ASCO)