Curing Patients with Cancer, But At What Cost: The Double- edged Sword of Cancer Therapy --- May the...
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Transcript of Curing Patients with Cancer, But At What Cost: The Double- edged Sword of Cancer Therapy --- May the...
Curing Patients with Cancer,But At What Cost: The Double-
edged Sword of Cancer Therapy ---
May the best of what we have done in the past, be the worst of what we will do in the
future
Louis S. Constine, MD, FASTROProfessor of Radiation Oncology and Pediatrics
Cancer Incidence – Distribution by Site SEER Program, 2006
PercentTotal invasive cancers: 129,552
0.20%
0.50%
0.60%
0.60%
0.60%
1.20%
0.80%
0.70%
1.00%
1.20%
1.30%
2.20%
1.30%
2.10%
2.30%
2.50%
3.50%
3.70%
3.30%
9.80%
12.20%
14.60%
17.70%
7.90%
Multiple primary cancersProstate
BreastLung and bronchus
Colon /rectumUrinary bladder
Melanomas of the skinNon-Hodgkin lymphoma
Uterine corpusKidney
PancreasOvary
ThyroidStomach
Brain & CNSMultiple myeloma
CervixEsophagus
Liver Larynx
Hodgkin lymphomaTestis
Soft tissue including heartBone and joint
0 2 4 6 8 10 12 14 16 18
5-Year Survival of Patients with Cancer by Era, SEER, 1975-1998
Age at Diagnosis (Years)
40
50
60
70
80
0 10 20 30 40 50 60 70
Year of Diagnosis
1993-98
1987-92
1981-86
1975-80
Su
rviv
al (
%)
Peak to Valley Transformation
2004Projected
In patients diagnosed with cancer before age 15, the 5-year survival rate improved from
58% in 1975 to 80% in 1997
--- an average annual change of 1.68%
Less well known is the remarkable improvement in prolonging survival in adult patients, especially those between 50 and 80 years of age
Estimated Number of Cancer Survivors in the United States Over Time
12.1 Million Cancer SurvivorsUnited States: 2007
Source: http://dccps.nci.nih.gov/ocs/prevalence/prevalence.html. Last accessed Oct. 2009
Cancer Survivorship
U.S.: 12 million cancer survivors• 3.5% population• Impact on public health
Increases in cancer survival• Earlier diagnosis (screening)• More effective treatment• Prevention of secondary disease• Decreases in mortality from other causes
Caring for Cancer Survivors
Do you care for survivors in your practice?
Always 264 (31.4%)
Sometimes 408 (48.6%)
Rarely 126 (15.0%)
Not at all 36 (4.3%)
Do not care for survivors 6 (0.7%)
Are you comfortable providing this care?
Yes 512 (61.2%)
No 213 (25.5%)
Do not provide 111 (13.3%)
ASCO Prevention Survey, 2004
Essential Elements Of Survivorship Care
• Education of the cancer survivor, family, health care providers – Care plan based on future health risks
– Promotion of healthy lifestyles
– Possible genetic predispositions for counseling
• Surveillance for cancer spread, recurrence, or second cancers and for long-term adverse physical, psychosocial, socioeconomic effects
• Intervention to prevent or treat consequences of cancer or therapy
• Communication between specialists and primary care providers to ensure that the survivor’s health needs are met
• Research focused on understanding, preventing, treating adverse consequences of cancer or its therapy
• Patient advocacy to address problems related to employment, insurance, and disability
Components of Treatment Summary
• Contact information for key individual providers • Dates of treatment initiation and completion • Diagnostic tests and results• Tumor characteristics • Therapies provided, including specific agents, title of
clinical trials (if any), treatment response, and toxicities experienced
• Psychosocial and nutritional services provided • Identification of a coordinator of continuing care
Components of Care Plan
• Likely course of recovery from treatment • Recommended surveillance• Possible long-term effects of treatment and symptoms • Possible signs of recurrence and second tumors • Possible effects of cancer on daily life (personal
relationships, work, mental health) and available resources for support
• Potential insurance, employment, and financial consequences of cancer and referrals to counseling, legal aid, and financial assistance if needed
Treatment Summary Concordance with IOM
Concordance with IOM recommendations N=65 TSs/13 sites (for each domain)
No. of sites achieving adequate (≥75%) concordance
Descriptive statistics Mean SD Range N (%)
Diagnosis 0.46 0.31 0.00–1.00 2 (15.4)
Staging and tumor characteristics 0.65 0.35 0.00–1.00 9 (69.2)
Surgery 0.73 0.22 0.38–0.98 7 (53.8)
Treating physician contact information 0.33 0.30 0.00–0.75 1 (7.7)
Clinical trials 0.18 0.25 0.00–0.60 0 (0.0)
Chemotherapy 0.52 0.24 0.10–0.83 3 (23.1)
Radiotherapy 0.55 0.19 0.26–0.80 2 (15.4)
Hormonal therapy 0.79 0.20 0.40–1.00 7 (53.8)
Targeted therapy 0.34 0.38 0.00–1.00 3 (23.1)
Toxicity 0.52 0.48 0.00–1.00 7 (53.8)
Genetic testing 0.26 0.24 0.00–0.60 0 (0.0)
Supportive therapy 0.03 0.08 0.00–0.27 0 (0.0)
Follow-up care contacts 0.08 0.18 0.00–0.50 0 (0.0)
TS Total 0.46 0.19 0.14–0.70 0 (0.0)
Survivorship Care Plan concordance with IOM
Concordance with IOM recommendations N=65 TSs/13 sites (for each domain)
No. of sites achieving adequate (≥75%) concordance
Descriptive statistics Mean SD Range N (%)
Toxicities and late effects 0.98 0.07 0.75–1.00 13 (100)
Breast cancer surveillance 0.82 0.11 0.67–1.00 8 (61.5)
Cancer surveillance 0.43 0.35 0.00–1.00 3 (23.1)
Non-cancer surveillance 0.77 0.21 0.33–1.00 6 (46.2)
Signs of cancer (recurrent and second) 0.32 0.27 0.00–1.00 1 (7.7)
Psychosocial effects 0.52 0.35 0.00–0.86 6 (46.2)
Referrals and resources 0.62 0.35 0.00–1.00 8 (61.5)
Prevention/health promotion 0.46 0.14 0.00–0.50 0 (0.0)
Genetic testing recommendations 0.62 0.51 0.00–1.00 8 (61.5)
Relatives’ cancer risk 0.01 0.03 0.00–0.10 0 (0.0)
SCP total 0.59 0.16 0.37–0.83 2 (15.4)
Survivorship Program Components Across Four Health Care Organizations
Organization Type Survivorship Program Providers Partnerships
Academic medical center
In-person clinical evaluation with multidisciplinary team
Medical oncologist, nurse practitioner, psychologist, social worker
Faculty practice medical group
Community hospital
Nurse-led, telephone-based program; survivors also receive mailings and follow- up calls
Oncology-certified registered nurse
Local physician-owned oncology network
County hospital
Nurse-practitioner–led clinical program; survivors assessed, followed and primary care needs addressed
Nurse practitioner
In-house Navigation Program
Primary-care medical group
Social worker–led, telephone- based program; survivors also receive mailings and follow-up calls
Licensed clinical social worker
Oncology medical groups contracted to provide services to plan members
SCP Components Across Four Health Care Organizations
Organization Type SCP Completed ByTreatment History
Components Received By
Academic medical center
Multidisciplinary survivorship team: oncologist, nurse practitioner, psychologist
Detailed summary of radiation, chemotherapy, surgeries, hormonal treatment
Patient copy, provider copy (PCP, oncologist, ob/gyn, etc), paper chart, and EMR
Community hospital Patient, with telephone assistance from survivorship oncology nurse
General summary of radiation, chemotherapy, surgeries, hormonal treatment
Patient keeps own copy and distributes to oncology care team and primary care
County hospital Survivorship nurse practitioner
Detailed summary of radiation, chemotherapy, surgeries, hormonal treatment
Patient copy, copy in paper chart, and copy scanned into EMR (electronic template in progress)
Primary-care medical group
Contracted oncology group physicians and staff, with assistance from survivorship social worker
Detailed summary of radiation, chemotherapy, surgeries, hormonal treatment
Scanned into EMR (electronic template in progress) and in oncology group paper chartAbbreviations: SCP, survivorship care plan, EMR, electronic medical record; PCP, primary care provider; ob/gyn, obstetrician/gynecologist
Survivorship begins at diagnosis!
Health &Quality of
Life
Long-Term Survival
Cancer Diagnosis &Treatment
What are the physical What are the physical costs of survivorship?costs of survivorship?
General Considerations
• Risk of late effects depends on the tissue and age of patient at time of treatment
• Late effects are dose and modality specific (e.g., surgery, radiation, chemotherapy)
• Combined modality therapy can have additive risks
Tissues at Risk for Late Toxicity
• Bone/soft tissues
• Cardiovascular
• Dental
• Endocrine
• Gastrointestinal
• Hepatic
• Hematological
• Immune system
• Nervous system
• Neuropsychologic
• Ophthalmologic
• Pulmonary
• Renal
• Reproductive
Factors Contributing to Morbidity
Cancer-Related Morbidity
Premorbid Conditions
Treatment Events
Aging
Host Factors
AgeGenderRace
HistologySiteBiologyResponse
Tumor Factors
Treatment Factors
SurgeryChemotherapyRadiation therapy
Health Behaviors
TobaccoDietAlcoholExerciseSun
Genetic
BRCA, ATM, p53polymorphisms
Why, a four-year old child could understand this.
Someone get me a four-year old child!
-- Groucho Marx
Radiation therapy is getting complicatedRadiation therapy is getting complicated
Tables and data and lines, oh my...Tables and data and lines, oh my...
Know Your Cancer-Related Health Risks
• After removal of one of paired organs, the remaining organ usually maintains function:
– Enucleation (removal of eye)– Nephrectomy (removal of kidney)– Oophorectomy (removal of ovary)– Orchiectomy (removal of testes)
• It’s important to take precautions to preserve the health of the remaining organ
Surgery for Solid Tumors
Know Your Cancer-Related Health Risks
• Surgery to remove tumors of bones or soft tissue may affect strength, function, mobility
• These surgeries may also cause chronic pain that limits activity
• Examples include:– Amputation– Limb-sparing surgery
Surgery for Solid Tumors
Bleomycin, BCNU, CCNU, and busulfan
can cause lung scarring
Anthracyclines (drugs like doxorubicin and daunorubicin) affect
heart muscle function
Prednisone and Methotrexate affect
bone strength
Know Your Cancer-Related Health Risks
Chemotherapy for Cancer
Cisplatin, carboplatin and ifosfamide can
affect kidney function
Know Your Cancer-Related Health RisksChemotherapy for Cancer
Cyclophosphamide can cause injury to the bladder lining
Cisplatin and carboplatin can cause hearing loss
Know Your Cancer-Related Health RisksChemotherapy for Cancer
Vincristine and cisplatin can affect nerve function
Know Your Cancer-Related Health RisksChemotherapy for Cancer
Methotrexate and Cytarabine (Ara C) given by vein or into the spinal fluid can affect learning, concentration and memory
Know Your Cancer-Related Health RisksChemotherapy for Cancer
Alkylating agents chemotherapy affects testicular and ovarian function• Risk of injury is related to total dose of medication received• Alkylating agents most often used for childhood cancer:
cyclophosphamide, procarbazine, nitrogen mustard, ifosfamide
Know Your Cancer-Related Health RisksRadiation for Cancer
Brain radiation can affect learning & memory, motor
function and sensation
Endocrine gland radiation can affect growth, metabolism, and reproduction
Radiation for Cancer
Scarring from radiation can affect heart rhythms, heart
muscle and valve function and blood vessel flow
Lung scarring from radiation leads to stiff lungs that restrict air flow during
breathing
Know Your Cancer-Related Health Risks
Know Your Cancer-Related Health RisksRadiation for Cancer
Radiation cause kidney damage and bladder scarring
Some of the signs of radiation injury of the urinary tract are:
• High blood pressure• Blood in urine• Incontinence • Problems voiding
Know Your Cancer-Related Health RisksRadiation for Cancer
• Decreased testosterone• Decreased, damaged or
absent sperm• Damage to duct system to
transport sperm• Sexual dysfunction from
damage to pelvic nerves
Know Your Cancer-Related Health RisksRadiation for Cancer
• Decreased estrogen• Damage or depletion of
eggs in ovaries• Scarring of lining of the
uterus (womb)• Scarring of blood supply
to uterus
Multiple Primary Cancers
Etiologic Factors
Cancer
#1
Cancer
#2
Treatment
Lifestyle
• Tobacco• Alcohol• Diet• Other
Environment
• Contaminants• Occupation• Viruses• Other
Host factors
• Age and gender• Genetics• Immune function• Hormonal, other
Interactions andother influences
• Gene-environment• Gene-gene
Modified from Travis LB. Acta Oncologica 2002; 323-333.
Subsequent Malignant NeoplasmsDCCPS and DCEG
Who is at risk? When to worry?
• Age at treatment• Sex/race of survivor• Type/strength of
therapy– Chemotherapy
– Radiation therapy
– Transplant
• Time from treatment• Type of cancer• History of relapse• Family history• Health habits
Age at Treatment Matters…
• Learning problems after brain radiation– Younger patients at higher risk compared
to older patients• Infertility after alkylating chemotherapy
– Older females at highest risk compared to younger females
Chemotherapy Dose Matters…
Heart muscle problems after anthracyclines
Risk Anthracycline dose
Low Less than 100 mg/m2
Medium Between 100 and 300 mg/m2
High More than 300 mg/m2
Combination of Treatments Matters…
• Chest radiation: scarring of heart lining, heart valves, or blood vessels
• Anthracycline chemotherapy: weakening of the heart muscle
Risk of heart problems is greater if cancer treatments have similar risks
for health problems.
Health habits matter…
• Lung scarring can occur after chest radiation and bleomycin
• Stiff lungs restrict air flow during breathing
• Thick scarred air sacs do not release oxygen to the tissues as well
• Smoking increases the risk of lung injury
Genes & Family History Matter…
• Heart disease• High cholesterol• High blood pressure• Diabetes
• Arthritis• Osteoporosis• Kidney problems• Cancer
Cancer treatment may result in an earlier onset of diseases that “run” in families, especially
those that usually present in adulthood
Important Facts About Late Effects
• The chances of having late effects after cancer is high• The chance of having serious or life-threatening late
effects after modern cancer therapy is low• Knowing your cancer history and possible health risks can
help you and your doctorwork together to prevent late effects or diagnose health problems early
• Regular check-ups are needed to diagnose and prevent late effects
What Doctors Can Do…
• Design cancer treatments to reduce the risk of late effects
• Develop therapies to protect normal tissues
• Monitor childhood cancer patients for late effects
• Prescribe corrective therapy
What Survivors Can Do…
• Have regular check-ups so late effects can be prevented or detected in earlier stages
• Follow doctor’s advice about medications and other interventions that can reduce the risk of late effects
• Practice health behaviors that reduce the risk of late effects
Habits that affect risk
• Smoking• Sun
exposure• Diet• Physical
activity• Alcohol
intake
Tobacco Use
• Don’t smoke. If you do smoke, QUIT!• Don’t use any tobacco products• Avoid smoke-filled rooms• Exercise regularly to keep your lungs fit• Check out:
1.877.4SJ.QUIT
Preventing Skin Cancer
• Do not tan.• When outdoors, stay
in the shade.• Limit sun exposure
from 10-4.• Practice sun
protection measures.– Sunscreen Apply frequently!– Wide brim hat– Long-sleeve shirt– Sun glasses with UV
absorption
A Healthy Diet
• Eat a variety of healthful foods, with an emphasis on plant sourcesEat > 5 vegetables and fruits servings each day.Choose whole, rather than processed, grains Limit consumption of red meatsChoose foods to maintain a healthful weight
• Check out:
Physical Activity and Weight
• Adopt a physically active lifestyleModerate activity for > 30 minutes on > 5 daysModerate-to-vigorous activity for > 45 minutes on
> 5 days may further reduce breast and colon cancer risks
Balance caloric intake with physical activity• Check out:
http://www.cdc.gov/healthyweight/http://www.mypyramidtracker.gov/
Maintain a Healthy Weight
• Body mass indexWeight (kg) divided by
height (cm)2
• Normal weight = BMI 18.5-25• Overweight = BMI 25-30• Obese = BMI > 30
Check out: http://www.cdc.gov/healthyweight
Alcohol and Health
• Alcohol increases risk of cancer of the mouth, throat, voice box, esophagus, liver, and breast
• Alcohol may also increase the risk of colon cancer
• Alcohol increases risk of liver injury in people with chronic hepatitis and other liver disease
• Alcohol may have some benefit in preventing cardiovascular disease
Guidelines for Alcohol Intake
• If you drink, limit alcohol drinks to less than two drinks a day for men and one for women
• A drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80 proof distilled spirits
Just remember, only one
or two!
Good Health Habits…
• Lower cancer risk• Lower cardiovascular disease risk• Lower bone and muscle problems• Improve energy level and mood• Improve productivity• Lower late effects risks in
cancer survivors
Specific f/u recommendations for Hodgkin Lymphoma, part 1
• Annual visit to health care provider for prevention and age appropriates screening
• Annual physical exam including thyroid and breast exam for women
• Consider low dose CT in patients at high risk for lung cancer
• Thyroid function tests annually in pts after neck/chest RT
Specific f/u recommendations for Hodgkin Lymphoma part 2
• Vaccinations q 6 years in patients after splenectomy
• Lipid screening q 1-3 years (LDL <100)• CAD risk factor modification• Women after chest RT treated at age <35 y:
– Yearly mammogram 8 years after RT or age 40
– Consider breast MR
Specific f/u recommendations for Hodgkin Lymphoma - part 3
• Cardiac work up with EKG, echo, stress test; consider visit with a cardiologist at 10 years
• Skin check annually• Baseline vitamin D level• Consider a screening colonoscopy prior to
age 50 if prior abdominal radiation
We Are Working Hard:
»To cure patients with cancer
»To minimize late effects
And we are making progress!