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)

Resources

www.vanderbiltREACH.org- website for cancer survivors◦Learn more about Cancer Survivorship

care◦Resources◦Education◦Community events