DR. JULIA USATINSKYDR. NIJAL PATEL

Empowering primary care physicians to handle survivorship needs

Who are the survivors?

A cancer survivor is an individual from the time of cancer diagnosis, through the balance of his/her life

National Cancer Institute definition

Epidemiology

Epidemiology of Breast Cancer

An estimated 226,870 new cases of invasive breast cancer are expected to occur among women in the US during 2012; about 2,190 new cases are expected in men.

Excluding cancers of the skin, breast cancer is the most frequently diagnosed cancer in women.

The breast cancer incidence rate began to decline in 2000 after peaking at 142 per 100,000 women in 1999.

The dramatic decrease of almost 7% from 2002 to 2003 has been attributed to reductions in the use of hormone therapy

Epidemiology of Breast Cancer

The 5-year relative survival rate for female breast cancer patients has improved from 63% in the early 1960s to 90% today.

The 5-year relative survival for women diagnosed with localized breast cancer is 99%; if the cancer has spread to nearby lymph nodes (regional stage) or distant lymph nodes or organs (distant stage), the survival rate falls to 84% or 23%, respectively.

For all stages combined, relative survival rates at 10 and 15 years after diagnosis are 82% and 77%, respectively

Epidemiology of Colon Cancer

An estimated 103,170 cases of colon and 40,290 cases of rectal cancer are expected to occur in 2012.

The third most common cancer in both men and women.

Incidence rates have been decreasing for most of the past two decades, which has largely been attributed to increases in the use of screening tests that allow the detection and removal of polyps before they progress to cancer.

Epidemiology of Colon Cancer

The 1- and 5-year relative survival rates for

persons with colorectal cancer are 83% and 64%, respectively.

When colorectal cancers are detected at an early, localized stage, the 5-year survival is 90%

Cancer Survivors

Distribution of cancer survivors in the U.S. by site, 2002.

Survivors

. The number of cancer survivors in the United

States increased steadily during the past three decades:

CDC/NCI. MMWR 2004;53:526-529.

Increased from 3.0 million (1.5% of the U.S. population) in 1971 to 9.8 million (3.5%) in 2001, and expected to double by 2050

CDC. Cancer Survivorship–United States 1971-2001. MMWR. 2004: 53:526-529

Survivorship Care

…increasing (survivors) population combined with predicted shortages of PCPs and oncologists will present unique challenges to making sure that cancer survivors receive high-quality cancer survivorship care.”

~Katherine Virgo, PhD, MBA, managing director of health services research at the American Cancer Society's

Survivorship Care

“People with histories of cancer have the right to continued medical follow-up with basic standards of care that include the specific needs of long-term survivors.” (Principle 6)

~National Coalition for Cancer Survivorship, 12 principles

What are the needs of the survivors?

Monitor for early complications after treatment

Detect late effects of treatmentDetect recurrences earlyAddress general health issues (might

have higher propensity for other health-related issues)

Address psychological health Health maintenance

Some other areas

Care for the family membersEnsure compliance with adjuvant

therapiesDirect exercise and nutritionAddress quality-of-life issues

Most importantly: return to normal life

Who should follow?

Journal of Clinical Oncology, 2009: PCPs are willing to assume exclusive responsibility for routine follow-up care after completion of active treatment.

The following modalities were felt to be most useful to assist PCPs in assuming responsibilities:

A patient-specific letter from the specialist Available guidelines Expedited routes of referral and access to

investigations for suspected recurrence

Who does better job?

Lack of evidence supporting advantages of long-term follow-up care in Oncology clinics

No significant difference in: Time to detection of disease recurrence Frequency of serious clinical events related to

recurrence Health-related quality of life of cancer survivors

Data from BMJ, J Clin Oncol, Br J Cancer, Eur J Cancer Prev

What are the barriers?

“Inadequate training” and “uncertainty” who is providing what care are concerns Journal of General Internal Medicine, 2011 (breast, colon)

“CME initiatives” and “an enhanced cooperative effort between those delivering and coordinating…care” are needed Supportive Care in Cancer, 2010

“Inadequate preparation and lack of formal training” Cancer, 2009 (any cancer)

What do our patients think?

Survey of 300 breast cancer survivors:

PCPs do great job at general care, psychosocial support, and health promotion

However:Knowledgeable about cancer follow-up- 50%PCPs and oncologists communicate well- 28%

Journal of Clinical Oncology, 2009

Common themes:

Fragmentation of care

Fragmentation of care

One major barrier to successful transition is fragmentation of care

Many cancer patients choose to receive treatment at hospitals where their primary care physicians aren't affiliated.

Cancer center may not be coordinated electronically with the PCP’s office

Fragmentation of care

An average of 3 specialists/patient, with treatments across time and space…outpatient, inpatient, specialized treatment facilities….

Increasing with aging of the population

Limited communication among treating physicians, multiple medical records

Common themes:

Lack of adequate knowledge/training

Not enough training for PCPs in Medical School

Cancer survivorship has yet to be well represented in undergraduate medical school curriculum and only a few schools currently offer courses or clerkships pertaining to cancer survivorship

Not enough training!

Pheochromocytoma: annual incidence is approximately 0.8 per 100,000 person years Hours of medical school and residency curriculum Oddly dominates lectures on hypertension

Cancer survivor: one in every 25 Americans Review of curriculum guidelines of internal medicine

and family medicine found a lack of mention of cancer survivorship

Not enough guidelines for PCP

Many guidelines address only the first five years post-treatment when patients are followed by their oncologist, but not for the period after that, when patients are being returned to their primary care physicians

What do we do to fix it?

Overcoming barriers

Patients can be given a comprehensive care summary and follow-up plan that is clearly and effectively explained

Frequent communication between the oncologist and PCP

Cancer Treatment Plan and Summary

Follow up care plan

Overcoming barriers

Improving medical schools/residency curricula

Including cancer survivors as “standardized patients” by some medical schools

Developing integrated curriculum on cancer survivorship Problem-based learning cases Multimedia web-based problems

Introducing various CMEs for practicing physicians

Overcoming Barriers

Educating primary care physicians and oncology providers, as well as empowering patients, are key components

Increasing the availability of evidence-based guidelines on cancer survivorship; existing guidelines should be refined

Follow up guidelines

Breast Cancer Follow Up

Breast Cancer Follow Up

Breast Cancer Follow Up

Breast Cancer Surveillance Not Recommended

Routine Blood Tests CBC and LFTS not recommended

Imaging Studies CXR, Bone scans, liver U/S, CT scans, PET scans and Breast MRI not recommended

Tumor Markers CA 15-3, CA 27.29 and CEA are not recommended

Colon Cancer

Lung Cancer

CXR or CT is recommended every 6 months for 2 years and then annually

Use of blood tests, PET scan, sputum cytology, tumor markers, and fluorescence bronchoscopy is not currently recommended for surveillance

Patients who smoke should be strongly encouraged to stop smoking

ACS Guidelines on Nutrition andPhysical Activity for Cancer Survivors

Achieve and maintain a healthy weight.•If overweight or obese, limit consumption of high-calorie foods and beverages and increase physical activity to promote weight loss.

Engage in regular physical activity.•Avoid inactivity and return to normal daily activities as soon as possiblefollowing diagnosis.•Aim to exercise at least 150 minutes per week.•Include strength training exercises at least 2 days per week.

Achieve a dietary pattern that is high in vegetables, fruits, and whole grains.• Follow the American Cancer Society Guidelines on Nutrition and PhysicalActivity for Cancer Prevention.

Use of Supplements

All attempts should be made to obtain needed nutrients through dietary sources.

It may be counterproductive take folate supplements when receiving

antifolate therapies such as methotrexate.

When to supplement

Only if a nutrient deficiency biochemically (eg, low plasma vitamin D levels,

B12 deficiency) clinically (eg, low bone density)

If nutrient intakes fall persistently below two-thirds of the recommended intake levels Consult a registered dietitian avoid ingesting supplements that exceed more

than 100% of the Daily Value

CASE

Clinical Case

AR is a 40 year old female with history of left sided breast cancer in which per patient she received chemotherapy and radiation and had a lumpectomy. Further information is unknown as patient just moved from out of state and her oncologist is retired, and she is unsure what hospital he was affiliated with.

CC- progressively worsening SOB over the last 2 weeks

PMH- breast cancer, HTN, and hyperlipidemiaSH- not currently working, denies alcohol, smoking

and drugsPE- Bibasilar crackles, 2+ lower extremity edema,

lymphedema of the left arm

Issues for the Patient

Did my cancer spread to my lungs

How do I make sure my 3 daughters and 2 sisters do not have breast cancer

What further tests need to be done to make sure I do not have another cancer Colonoscopy Pap Smear Lung Cancer Skin Cancer

Issues for the PCP

Is this SOB secondary to CHF from Previous medical problems Radiation Chemotherapy

Anthracycline, traztuzamab

What chemotherapy regimen did the patient receive

What follow up tests have been done for the patient and what needs to be done

Possible Answers for Patients Issues

Cancer spread to lungs- Unlikely because symptoms most consistent with CHF

Genetics- Need to go over the recommendations for genetic referral

Other cancers- Patient needs to be screened as any other patient; close monitoring of skin for malignancy

Possible Answers for PCP issues

Why SOB- will need further testing including ECHO, CXR to look for cause of SOB

What regimen- not available at this point but this is where summary is helpful

What tests need to be done- CHF workup, mammogram

Conclusions

With improvements in medical education and coordination of care, primary care will offer a safe, cost-effective method in providing routine (and often exclusive) follow-up care for cancer survivors

Discharging cancer survivors from oncology programs will reduce the load of well patients on already busy cancer clinics

Refining guidelines, risk-stratifying patients, as well as providing patients with follow-up care plans, will make this process better structured and coordinated.

Available Resources

Available resources

Up to Date- now a small section on cancer survivorship, and more chapters are being written focusing on the topic

ACP's online decision support tool, PIER (Physicians' Information and Education Resource) includes information on follow-up care organized by type of cancer

The American Society of Clinical Oncology houses information on cancer survivorship on its website

The American Cancer Society and the National Cancer Institute jointly co-sponsor a cancer survivorship conference every two years that allows the research community to come together to discuss the issue

Questions?

Thank You!