Caring for patients in primary care Caring for patients in primary care after cancer treatments are doneafter cancer treatments are done

Moving Moving Forward Forward after Cancerafter Cancer

Developed by:Developed by:

Brent Kvern MD, CCFP, FCFPBrent Kvern MD, CCFP, FCFPAssociate Professor, Associate Professor, Department of Family Medicine, University of ManitobaDepartment of Family Medicine, University of Manitoba

Jeff Sisler MD, MClSc, CCFP, FCFPJeff Sisler MD, MClSc, CCFP, FCFP

Director - Primary Care Oncology, CCMBDirector - Primary Care Oncology, CCMB

22

Conflict of Interest Disclosure

No consultant or speaker fees

Received a grant from the Canadian Partnership Against Cancer to develop this session

A question…A question…

A 61 year old patient A 61 year old patient of yours who of yours who completed treatment completed treatment for breast cancer 3 for breast cancer 3 months ago is your months ago is your next patient. next patient.

What is on your mental What is on your mental “to-do” and “to-talk-“to-do” and “to-talk-

about” list for this and about” list for this and upcoming visits?upcoming visits?

44

55

• Define survivorship phase of cancer.Define survivorship phase of cancer.

• Apply a new framework to consider the Apply a new framework to consider the care needs of cancer patients in follow-up care needs of cancer patients in follow-up

• Be familiar with important tasks in breast Be familiar with important tasks in breast and colorectal cancer follow-up careand colorectal cancer follow-up care

ObjectivesObjectives

1Bell K, Scalzo K, Stephen J, BC Cancer Agency, 2007 6

Cancer SurvivorshipCancer Survivorship

A distinct phase in the cancer trajectory A distinct phase in the cancer trajectory following primary treatment, lasting until following primary treatment, lasting until recurrent or end-of-life.recurrent or end-of-life.11

The survivorship phaseThe survivorship phase

Number of adult Number of adult cancer survivors cancer survivors is > 1 million and is > 1 million and will double by will double by the year 2050the year 2050

7

Age of cancer survivors2

88

A new perspective A new perspective

Think about patients who’ve finished cancer Think about patients who’ve finished cancer treatment like your patients with a recent MI treatment like your patients with a recent MI

99

A new perspectiveA new perspective

Survived something potentially lethalSurvived something potentially lethal Need close monitoring for recurrence.Need close monitoring for recurrence. Need an aggressive approach to risk reductionNeed an aggressive approach to risk reduction Lifestyle issues very importantLifestyle issues very important Your role as a FP/NP is critical to rehabilitationYour role as a FP/NP is critical to rehabilitation

1010

4 essential physician tasks4 essential physician tasks

Our framework of survivorshipOur framework of survivorship

HEALTH HEALTH PPROMOTION / ROMOTION / PPREVENTIONREVENTION

FFAMILY CANCER AMILY CANCER RIRISKSSKS

CANCER RELATED CANCER RELATED MMONITORINGONITORING

MMANAGEMENTANAGEMENT

PP22FRiMFRiM22

1212

Health Health PPromotionromotionPPreventionrevention

Promotion of healthy behavioursPromotion of healthy behaviours

Screening for new cancersScreening for new cancers

Age appropriate screening for other medical Age appropriate screening for other medical conditionsconditions

1313

FFamily Cancer amily Cancer RiRiskssks

Assessing the risk of family membersAssessing the risk of family members• Modifying THEIR risk factorsModifying THEIR risk factors• Recommending a screening planRecommending a screening plan• Referring for genetic testingReferring for genetic testing

Assessing family and marital health Assessing family and marital health

1414

MMonitoring onitoring

• Watching for recurrence of the primary Watching for recurrence of the primary cancer cancer

• Monitoring for worrisome “late effects”Monitoring for worrisome “late effects”– CardiomyopathyCardiomyopathy

• Monitoring rehabilitation and recoveryMonitoring rehabilitation and recovery

1515

MManagementanagement

Side-effects of cancer treatments Side-effects of cancer treatments • Physical Physical • PsychologicalPsychological• SocialSocial

Ongoing care for any non-cancer conditionsOngoing care for any non-cancer conditions

16

Colorectal CancerColorectal Cancer

Sunga AY, et al. Am Fam Physician, 2005

1717

Most recurrences in the first 3 years • Liver – most common site metastases

o 20% of those with liver metastases are candidates for resection

• 10%- local recurrence at original site• 30% - no rise in CEA

• No delayed / late effects of chemotherapy

Colorectal cancerColorectal cancerBackground informationBackground information

1818

Exercise 4 hours a week of activity associated with 53% reduced recurrence and CRC mortality regardless of stage, age, BMI or previous activity level.

Smoking Cessation

Medications for secondary prevention•No role yet for NSAIDs, ASA

BMD of hip if pelvic radiation therapy given

Colorectal cancerColorectal cancerHealth promotion & preventionHealth promotion & prevention

1919

Colorectal cancerColorectal cancerFamily Cancer Risks Family Cancer Risks

If index patient is diagnosed…

Recommendations

Before age 60 years All asymptomatic 1st degree relatives, starting at age 40 (or 10 years earlier than patients age at diagnosis) need colonoscopy Q5 years

After age 60 years All asymptomatic 1st degree relatives, starting at age 40 yrs are at slightly above average risk. FOBT Q2 years followed by colonoscopy if any one sample if positive.

After age 60 years & another 1st degree relative also has a diagnosis of CRC at any age

All asymptomatic 1st degree relatives, starting at age 40 (or 10 years earlier than patients age at diagnosis) need colonoscopy Q5 years

Family history of known hereditary syndrome

Referral for specialist assessment

2121

Colorectal cancerColorectal cancerMonitoringMonitoring

Monitoring

Visit frequency • Q3 months for 3 years following treatment• Q6 months for next 2 years• Annually thereafter

Test to DO • CEA at each visit for first 3 years • CT chest and abdomen – annually for first 3 years• Colonoscopy – 1 year after initial diagnostic scope, then at 3 years, then every 5 years afterward

Tests NOT TO DO • routine CBC, LFTs• routine CXR• FOBT

2323

Cancer related fatigue• Consider other etiologies• Physical activity works!

Peripheral neuropathy from oxaliplatin Radiation proctitis Diarrhea Sexual dysfunction

Colorectal cancerColorectal cancerManagement Management

2424

Anxiety • Consider possibility PTSD like reaction

Employment difficulties Insurance difficulties Social well-being

• “How are things going between you and your partner?”

Colorectal cancerColorectal cancerManagement Management

2525

Breast CancerBreast Cancer

Sunga AY, et al. Am Fam Physician, 2005

Non survivors 12%

5 year survival rates

All Oral Cancer All Oral Cancer Treatments now fully Treatments now fully

covered!covered! Tamoxifen and AIs free for patients as of Tamoxifen and AIs free for patients as of April 19, 2012April 19, 2012

Existing patients should already be Existing patients should already be identified by the DPIN systemidentified by the DPIN system

Pharmacare registration neededPharmacare registration neededCall the Provincial Drug Program at 786-Call the Provincial Drug Program at 786-

7141 or 1-800-297-80997141 or 1-800-297-8099

Help! ? Call the CCMB Pharmacy at Help! ? Call the CCMB Pharmacy at 787-4591787-4591

2727

Recurrences usually occur within five years.• Peaks at 2nd yr after surgery

o Risk declines with time but continues for at least 20 years.

• Non-specific symptoms are common indicators of relapseo Weight loss / Persistent cough / Breast

changes / Chest wall changes / Adenopathy

• 75% recurrences found by the women themselves

Breast CancerBreast CancerBackground informationBackground information

2828

ExerciseCohort studies suggest a 50% survival advantage for breast cancer survivors over those not physically active

Most beneficial in ER+ tumoursMost beneficial in ER+ tumours Diet

Medications for secondary prevention•Tamoxifen, aromatase inhibitors (AIs)

BMD and/or bisphosphonates if AIs used

Breast cancerBreast cancerHealth promotion & preventionHealth promotion & prevention

2929

Breast cancerBreast cancerFamily Cancer Risks Family Cancer Risks

Inherited Risk for Breast Cancer

Mutations of BRCA1 or BRCA2 cause about 5-10% of breast cancers

• Usually cancer occurs early in life.• Strong family history

Criteria for referral for genetic counselling

• Breast cancer at age <35 yrs• Bilateral breast cancer at age <50 yrs• Ovarian cancer <60 yrs• Breast and ovarian cancer <50 yrs• Two or more ovarian cancers, any age• Male breast cancer• Ashkenazi Jewish or Icelandic descent

If patient BRCA +ve • Family members need to know• Initiate screening at age 25 with MRI (or five years younger than earliest reported cancer in the family)

3131

Breast cancerBreast cancerMonitoring Monitoring

Monitoring

Visit frequency • Careful history and physical exam• Q3 -6 months for 3 years• Q6-12 months for next 2 years• Annually thereafter

Test to DO • Mammograms annually for life.

Tests NOT to do • routine CBC, LFTs• routine CXR• routine bone or liver scans• routine tumour markers

3333

Breast cancer survivors have an increased risk of a second primary cancer• Often involving

ipsilateral breastcontralateral breast colon?

Breast cancerBreast cancerMonitoringMonitoring

MonitoringCongestive Cardiomyopathy

• From anthracyclines (doxorubicin, epirubicin, trastuzumab)• Can present 10-15 years after chemo• Be alert for CHF symptoms

MyelodysplasiaorLeukemia

• Associated with cyclophosphomide• Rare•No screening recommended.

3535

Cancer related fatigue• Rule out other etiologies (drugs, depression,

cardiac, thyroid, anemia)• Physical activity, yoga

Menopause• Related to chemotherapy• Retrospective studies have not shown harm with

HRT • no RCT has been performed to allow confident

use Osteoporosis

• Check for AI use

Breast cancerBreast cancerManagementManagement

Tamoxifen •Hot flashes and night sweats•SSRIs can partially alleviate•Avoid paroxetine, fluoxetine, bupropion • Venlafaxine drug of choice

Aromatase inhibitors

AnastrozoleLetrozoleExemestane

• Post-menopausal women only

• Arthralgias and aches: NSAIDs, time

• Switch to a different AI or Tam if not tolerable

3737

Peripheral neuropathy If treated with taxanes (docetaxel) Use gabapentin*, pregabalin, tricyclics*

Post treatment cognitive impairment or “Brain fog”• Rule out or address other aetiologies (drugs, depression)

Chronic Pain

Breast cancerBreast cancerManagementManagement

BreastBreast cancer cancerManagementManagement

Sexual dysfunction Anxiety

Fear of recurrence: Consider CBT

Employment and insurance difficulties Social wellbeing

“How are things going between you and your partner?”

3939

In closing:In closing:Caring for Cancer SurvivorsCaring for Cancer Survivors

A distinct phase in the cancer continuum.

Increasingly a responsibility of primary care

Cancer survivors are at increased risk – think of them like post-MI patients

4040

4 essential physician tasks4 essential physician tasks

Our framework of survivorshipOur framework of survivorship

HEALTH HEALTH PPROMOTION / ROMOTION / PPREVENTIONREVENTION

FFAMILY CANCER AMILY CANCER RIRISKSSKS

CANCER RELATED CANCER RELATED MMONITORINGONITORING

MMANAGEMENTANAGEMENT

PP22FRiMFRiM22

Dr Jeff SislerDr Jeff Sislerjeff.sisler@cancercare.mb.caQuestions? Questions? Call the Call the UPCON Helpline UPCON Helpline at (204) 226-2262at (204) 226-2262

Moving Moving Forward Forward after Cancerafter Cancer