The Challenges of Surviving Cancer · 14.03.2018 · Cancer Surveillance and Screening...

The Challenges of Surviving Cancer

March 14, 2018

M. Alma Rodriguez, M.D.The University of Texas MD Anderson Cancer CenterVice President – Medical Affairs

Conflict of Interest Disclosures

• No conflicts to disclose in relationship to this presentation.

• Discuss cancer survivorship and what the landscape looks like in the US.

• Review data on current and projected survivors nationally.

• Describe the domains of Cancer Survivorship Care

• Review the risks and late effects of Cancer Survivorship

• Review the social and economic challenges Cancer Survivors face

Presentation Objectives

• Describe current and projected US cancer survivorship statistics

• Discuss Survivorship Care Delivery models

• Articulate the domains of survivorship care and the importance of survivorship care as a distinct phase of the cancer continuum

• Utilize the “take-aways” from lessons learned at MD Anderson to envision/improve the quality of life and care for Arkansas cancer survivors

Learning Objectives

An individual is considered a cancer

survivor from the time of diagnosis,

through the balance of his or her life.

Family members, friends, and

caregivers are also impacted by the

survivorship experience, and therefore

included in this definition.

NCI Office of Cancer Survivorship, 1996

Who is a Cancer Survivor?

18 Million Cancer Survivors Projected in 2022

Acute

Intermediate

Long-Term

de Moor J S et al. Cancer Epidemiol Biomarkers Prev2013;22:561-570

Phases of the Journey

Mullan F., N Engl J Med. 1985 313(4):270

ACUTE INTERMEDIATE LONG TERM

Recovery WellnessRemission

Diagnosis

Active Treatment

Immediate Side Effects

Surveillance

For Recurrence

Rehabilitation

Late Effects of

Treatment:

Physical

Psychosocial

• Persistent symptoms after cancer

treatment

• Health effects of new onset years

after treatment

• Difficulty finding physicians after

treatment

• Lack of communication among

physicians

• Emotional symptoms and

disrupted relationships

2005, National Academies Press; IOM , Wash. D.C.

Survivorship Healthcare

Challenge: Lost in Transition

Consequences of cancer survival

• Physical anatomic or functional changes

• Organ toxicity/morbidities that lead to premature onset of

chronic illnesses

• Psychological disturbances

• Socioeconomic burdens

• Increased risk of second malignancies

• In addition, other health co-morbidities can worsen,

particularly in older cancer patients

Distribution of US Cancer

Survivors by Age Groups

Children & Adolescents

Young Adults

Working

Older

As of January 1, 2016

Children & Adolescents (0-19)Young Adults (20-39)

Working Adults (40-59)

21%

4%

74%

1%

Patient related factors: Cancer

survivors are a growing and aging

population*

• One out of every six persons over 65 is a cancer survivor, and 1.4 million were diagnosed more than 20 years ago.

• 70 % of adults diagnosed with cancer today can expect to be alive in five years (CDC).

• Widespread screening, improved treatment and population aging (especially baby-boomers) will lead to continued growth of this cohort.

• Comorbid conditions can be exacerbated by cancer therapies *IOM/NRC From Cancer Patient to Cancer Survivor 2006

Source: Source: DeSantis C, Chunchieh L, Mariotto AB, et al. Cancer Treatment and Survivorship Statistics 2014. Cancer.

Survivor Populations are Unique by

Treatment, Disease, and Health History

• Surgical interventions, radiation ports and doses, as well as chemotherapeutic interventions are unique for

each of the malignant diseases, and

• Differ as well depending on stages or biological or

hormonal characteristics within each disease,

• Hence, the anticipated or potential side effects (short and long term) of treatments will be unique to the

patient’s initial disease presentation, age and other potential comorbid conditions.

• Detection and treatment of late malignancy recurrence or new second malignancies

Cancer Surveillance and Screening

• Lifestyle changes to prevent cancer and risk assessment

Risk Reduction and Cancer Prevention

• Health maintenance and observation of vital organ function

Late Effects / Side Effects Management

• Psychosocial support services to maintain healthy relationships and restored life

Psychosocial Functioning

Domains of Survivorship Care

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 5 10 15 20 25 30

73.4% with at least

one chronic condition

42.4% with a severe

or life-threateningcondition or death

Cum

ula

tive

Inci

dence

Years since Cancer

Cumulative incidence of chronic physical health conditions among 10,397 young adult survivors of childhood cancer

Childhood Cancer Survivor Study

Oeffinger KC, et al. N Engl J Med, 2006

Cause-Specific Mortality in Early Stage Breast

Cancer Survivors

Breast cancer

Cardiovascular disease

Second malignancy

Hooning MJ, et al. Int J Radiation Oncology Biol Phys, 2006

Beard CJ, et al. Cancer, 2013

Cumulative incidence by causes of death for patients with stage I testicular seminoma

Second cancer

Cardiovascular

disease

Testicular cancer

SEER Registry; N=9193 men, diagnosed 1973-2001

Risk factors for second

malignancies

• Treatment related• Radiation, chemotherapy

• Hereditary• Genetic syndromes

• Environmental• Exposure to harmful conditions

• Type of primary cancer• Some cancers have risk of other second primary cancers for

unknown reasons

• Health related• Infectious agents

• Autoimmune disorders

• Lifestyle factors

Health and Lifestyle

• Smoking: lung, oral cavity

• Obesity: colon, breast, ovarian

Tiers of Medical Risk in Long-term

Survivors

Prevention

Oncology

InternalMedicine

Psychosocial Support/Symptom Management

Tier 3: High risk of relapse; active indolent/controlled disease; intensive chemotherapy/radiation/SCT with high risk of sequelae= SCT, Chronic, & High-Risk Cancers

Tier 2: Patients with complications/risk of treatment or second malignancies = Chemo, Radiation

Tier 1: Very low risk of complications or relapse = Surgery

Algorithm: Domains of Care

Survivorship Care Delivery Models

in the US

Model Examples

Oncology-based• Disease-based programs

• Treatment-based

programs

• Comprehensive stand-

alone programs

• Breast, colorectal, genitourinary cancers

• Hematopoietic stem cell transplant

• All disease type cancer survivors

Shared Care• Shared care between

oncology practice &

primary care provider

• Survivor is seen at cancer center and co-

followed by the community primary care

provider

Community-based• Oncologist, PCP, allied

health professional

• Includes referrals to community providers

such as physical therapist, nutrition

counselors, etc.

Psychological Health

• Anxiety or fear over

relapse

• Depression

• Grief over loss of

health, lifestyle or work

• Body image

• Disrupted relationships

Returning to Life Activities

• Fatigue is a common

complaint – can be

improved by exercise

• Impaired immunity is a

consideration for

travelers

• Gradual integration to

normal prior level of

activity recommended

• Activity is important for

health and weight

management

Sexual Health

• Decreased Libido: consider hormone

levels, thyroid function

• Menopause symptoms

that are uncomfortable

• Psychological factors:

– Anxiety/fear

– Depression

– Body image

Fertility

• Strategies to

preserve fertility prior

to treatment

• Post treatment

evaluation for fertility:

– Sperm counts at

least 6 months

after treatment

– Return of menses

may not always

relate to fertility

Return to Work

• Factors associated with successful return to work are

1. younger age; 2. higher

education level ; 3. employment prior to illness

• (Mosher et al, Psychooncology 2009)

• 84% of those who did not experience relapse of their

primary malignancy were employed at 5 years post SCT.

• (Syrjala et al, JAMA 2004)

Annual Lost Productivity, Adults age 18-64, MEPS, 2008-2010

Presented By Cathy Bradley at 2018 Cancer Survivorship Symposium: Advancing Care and Research

Interference with job tasks


Key findings: Employment & Hours Worked


Key Findings


Key findings: Predictors of poor work outcomes


Economics and Insurance• A study in 10 year HSCT survivors

indicated 24% had experienced denial

of health insurance, and 27 % were

denied life insurance, compared to age

matched cohorts which reported no denials

• Those with health insurance had higher premiums, or lesser coverage which

made health care for late effects difficult

or unaffordable Syrjala KL, et al; JCO 2005.

• A report by the CDC also noted that

cancer survivors had much higher out

of pocket expenses, compared to age

and gender matched cohorts– CDC, Morbidity and Mortality Report, 6/2014

Presented By K Yabroff at 2018 Cancer Survivorship Symposium: Advancing Care and Research

Summary


Strategies for addressing financial hardship


The Challenge of Surviving Cancer

• The challenge in overcoming cancer is not only to find therapies that will prevent or arrest the disease quickly, but also to map the middle ground of survivorship and minimize its medical and social hazards

– Fitzhugh Mullan. Seasons of Survival: Reflections by a Physician with Cancer. NEJM 1985

• Alfano, C. M., Smith, T., de Moor, J. S., Glasgow, R. E., Khoury, M. J., Hawkins, N. A., … Rowland, J. H. (2014). An Action Plan for Translating Cancer Survivorship Research Into Care. JNCI Journal of the National Cancer Institute, 106(11), dju287. http://doi.org/10.1093/jnci/dju287

• Blanch-Hartigan, D., Forsythe, L. P., Alfano, C. M., Smith, T., Nekhlyudov, L., Ganz, P. A., & Rowland, J. H. (2014). Provision and Discussion of Survivorship Care Plans Among Cancer Survivors: Results of a Nationally Representative Survey of Oncologists and Primary Care Physicians. Journal of Clinical Oncology, 32(15), 1578–1585. http://doi.org/10.1200/JCO.2013.51.7540

• Cancer Treatment & Survivorship Fact & Figures 2016-2017https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatment-and-survivorship-facts-and-figures/cancer-treatment-and-survivorship-facts-and-figures-2016-2017.pdf

• Caruso, R., Pasquale, C. D., Lichosik, D., Dellafirore, F., & Pittella, F. (2013). Report on the 2013 European Multidisciplinary Cancer Congress—ECC 17, Amsterdam, 27 September–1 October 2013: nursing highlights. Ecancermedicalscience, 7, 367. http://doi.org/10.3332/ecancer.2013.367

• Catt, S., Starkings, R., Shilling, V., & Fallowfield, L. (2017). Patient-reported outcome measures of the impact of cancer on patients’ everyday lives: a systematic review. Journal of Cancer Survivorship, 11(2), 211–232. http://doi.org/10.1007/s11764-016-0580-1

• de Moor JS, et al. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol. Biomarkers Prev. 2013;22:561–570. doi: 10.1158/1055-9965.EPI-12-1356

• de Moor, J. S., Mariotto, A. B., Parry, C., Alfano, C. M., Padgett, L., Kent, E. E., … Rowland, J. H. (2013). Cancer Survivors in the United States: Prevalence across the Survivorship Trajectory and Implications for Care. Cancer Epidemiology, Biomarkers & Prevention : A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology, 22(4), 561–570. http://doi.org/10.1158/1055-9965.EPI-12-1356

• Halpern, M. T., Viswanathan, M., Evans, T. S., Birken, S. A., Basch, E., & Mayer, D. K. (2015). Models of Cancer Survivorship Care: Overview and Summary of Current Events. Journal of Oncology Practice, e19-e27.

• Kahana, E., Kahana, B., Langendoerfer, K. B., Kahana, B., & Smith-Tran, A. (2016). Elderly Cancer Survivors Reflect on Coping Strategies During the Cancer Journey. Journal of Gerontology & Geriatric Research, 5(5), 337. http://doi.org/10.4172/2167-7182.1000337

• Liu, Q., Leisenring, W. M., Ness, K. K., Robison, L. L., Armstrong, G. T., Yasui, Y., & Bhatia, S. (2016). Racial/Ethnic Differences in Adverse Outcomes Among Childhood Cancer Survivors: The Childhood Cancer Survivor Study. Journal of Clinical Oncology, 34(14), 1634–1643. http://doi.org/10.1200/JCO.2015.66.3567

Suggested Reading

http://doi.org/10.1200/JCO.2013.51.7540

https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatment-and-survivorship-facts-and-figures/cancer-treatment-and-survivorship-facts-and-figures-2016-2017.pdf

http://doi.org/10.1007/s11764-016-0580-1

http://doi.org/10.1158/1055-9965.EPI-12-1356

http://doi.org/10.1200/JCO.2015.66.3567

Suggested Reading

• Nekhlyudov, L., O’Malley, D. M., & Hudson, S. V. (2017). Integrating Primary Care Providers in the Care of Cancer Survivors: Gaps in Evidence and Future Opportunities. The Lancet. Oncology, 18(1), e30–e38. http://doi.org/10.1016/S1470-2045(16)30570-8

• Nekhlyudov, L., Ganz, P. A., Arora, N. K., & Rowland, J. H. (2017). Going Beyond Being Lost in Transition: A Decade of Progress in Cancer Survivorship. Journal of Clinical Oncology, 35(18), 1978–1981. http://doi.org/10.1200/JCO.2016.72.1373

• O’Malley, D., Hudson, S. V., Nekhlyudov, L., Howard, J., Rubinstein, E., Lee, H. S., … Crabtree, B. F. (2017). Learning the Landscape: Implementation Challenges of Primary Care Innovators around Cancer Survivorship Care. Journal of Cancer Survivorship : Research and Practice, 11(1), 13–23. http://doi.org/10.1007/s11764-016-0555-2

• Rowland, J. H., Kent, E. E., Forsythe, L. P., Loge, J. H., Hjorth, L., Glaser, A., … Fosså, S. D. (2013). Cancer Survivorship Research in Europe and the United States: Where have we been, where are we going, and what can we learn from each other? Cancer, 119(0 11), 2094–2108. http://doi.org/10.1002/cncr.28060

• Stone, D. S., Ganz, P. A., Pavlish, C., & Robbins, W. A. (2017). Young adult cancer survivors and work: a systematic review. Journal of Cancer Survivorship, 11(6), 765–781. http://doi.org/10.1007/s11764-017-0614-3

http://doi.org/10.1007/s11764-016-0555-2

http://doi.org/10.1007/s11764-017-0614-3

References


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The Challenges of Surviving Cancer · 14.03.2018 · Cancer Surveillance and Screening...

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