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Secondary Cancers, Health Behaviour and Cancer Screening Adherence in Survivors of Allogeneic Blood and Marrow Transplant

(BMT) in NSW.

Gemma Dyer, MPH, GradCert Onc, BN, RN

eviQ Content Author and MPhil Student (Usyd)

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Overview

› 1. Background› 2. The problem› 3. What we did› 4. What we found out › 5. Implications

BackgroundAllogeneic BMT…

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Proportions of disease indications for an allogeneic HSCT in Europe in 2013

• Worldwide ~ 40,000• Australia = 495 (2013)• NSW = 173 (2013) (35%)

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Background

Haematopoietic cell transplants by year and type

“The Problem”

oMalignant Disease:

• < 16yrs, 51 – 78%

• > 16yrs, 12 – 68%

oNon-malignant Disease:

• < 16yrs, 95%

• > 16yrs, 43-72%

Survival is improving

10-year Survival (ABMTRR 1998 - 2013)

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“The problem” of survival post-BMT› Relapse (15-30%)› cGvHD (40-70%)› Cardio-respiratory disease (20-40%)› Endocrinopathies (>60%)› Infertility (Most)› Eye disease (>60%)› Osteoporosis (>40%)› Anxiety and depression, post-trauma› Social dysfunction› Isolation› Secondary cancers (2-8 x)

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Secondary Cancers and Recommendations for BMT survivors

› 12% cumulative incidence rate at 15 years post BMT

› No plateau

› All cancers have been found to occur post BMT

› Risk Factors:- Young age at BMT

- TBI

- Immunosuppression

- Chronic Graft Versus Host Disease

- Smoking

› International Consensus Guidelines - General population screening

- Healthy lifestyle recommendations

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General population screening guidelines

› Breast Screen Australia

› National Cervical Screening Program

› National Bowel Cancer Screening Program

› Healthy Behaviors- Quit smoking

- Be ‘sun smart’

- Be active

- Healthy diet

- Limit alcohol intake

Aims

1. Rates of secondary cancers 2. Cancer screening adherence 3. Cancer risk behavior (smoking and drinking)4. Identify barriers to adherence 5. Inform practice and educate BMT survivors

Methods› Sampling frame

- Allogeneic transplant survivors, transplanted between Jan 1 2000 and Dec 31 2012 in NSW

› Instruments- Sydney Post BMT Survey (402 questions, 20 sections)

- FACT-BMT

- cGVHD Activity Assessment

- Lee Chronic GVHD symptom scale

- Post traumatic Growth Inventory

- Fear of Recurrence scale

- Depression, Anxiety & Stress Scale (DASS) 21

- Clinical data form (transplant procedure)

Validated instruments

n=1475Allogeneic BMT

2000-2012

n= 669Allogeneic BMT survivors

806 (55%)Deceased/status

unknown

n= 583 survivors (82.7%) contacted, sent survey

n= 443 survivors (66%)Returned Completed questionnaire

86 Unable to be contacted

17 (3%) declined consent123 surveys not returned

Results

asdasdDemographicsSVariable ResultsMedian survival 5 yrs (Range :1 yr 4 months- 22 yrs)

Median age at survey 54 yrs (Range :19 yrs-79 yrs)

Gender 252 (57%) maleCulture/ethnicity 324 (87%) Australian/European

Education Completed High School (23.6%)Completed University (39.1%)Trade/diploma/part high school (37.3%)

Annual Household income Low <$40,000 (36.5%)Middle $40- <$80,000 (29.2%)High >=$80,000 (34.3%)

Residential location 92% major city/inner regional; 8% outer regional/remote

Relationship status 71% married; 8% defacto21% single/separated/divorced

Results

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Secondary Cancers post BMT

› 24.1% reported a diagnosis of at least once cancer following BMT

› 21.2% skin cancer

› 1.6% oral cancers

› 4.4% other cancers - Bladder/prostate (4)

- Breast (2)

- Secondary haematological malignancy (3)

- PTLD (1)

- Bowel (1)

- Ovarian (1)

- Sarcoma (1)

- Not specified (4)

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Health behaviour post BMT

› 7.5% Smokers

› 7.7% Drink alcohol more than recommended amount

› 22.9% Not ‘sun smart’

› 32% Overweight, 16% Obese

› 45.1% Physically active

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Cancer Screening Adherence post BMT

› 52.4% skin cancer check

› 32.3% bowel cancer check

› 63.4% PAP smear

› 53.3% mammogram

› 36.3% prostate cancer check

In the 2 years since BMT:

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Barriers to Cancer Screening Adherence post BMT

› 4.4% no time

› 2% cost

› 26% felt it was not necessary

› 72% Not advised by their treatment team

› Factors which increase adherence - Increased time from BMT

- Older age

- Married or defacto relationship (males)

- Higher Quality of Life

Why not?

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Conclusions

› In BMT survivors in NSW:- secondary cancers are common- health risk behaviour is generally better than the general

Australian population health risk behavior- cancer screening adherence is low for this high risk group

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Implications

› This data should be used develop a Model of Care which is sustainable, cost-effective and consistent with patient needs and preferences:

- Cancer screening needs to be embedded within BMT Long Term Follow Up Care Programs

- This in will hopefully lead to:

- Reduced morbidity and mortality related to secondary cancers post BMT

- Improved Quality of Life post BMT

Acknowledgements› Agency for Clinical Innovation BMT Network › BMT Physicians, Researchers, Data Managers, BMT CNCs at each site: › Primary Research Team: Lisa Brice, Nicky Gilroy, Masura Kabir, Ian

Kerridge› RNS: Matthew Greenwood, Kelly Wong, Julian Lindsay, Jennifer Smith,

Chris Poon, Grace Gifford› StVH: John Moore, Jeff Tan, Karim Ibrahim,› RPA: Stephen Larsen, Ann-Marie Johnston, Paris Manii› Westmead: John Kwan, Mark Hertzberg, Megan Hogg, Gillian Huang,

Mark Schifter› Newcastle: Louisa Brown› Patients

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