Tracy A. Johnson, DNP, FNP-BC
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Transcript of Tracy A. Johnson, DNP, FNP-BC
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Cancer Survivorship: How To Manage Treatment-Related Risks and Problems
Outside of the Oncology Setting
Tracy A. Johnson, DNP, FNP-BC
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DisclosuresNo financial relationships to disclose
This CME presentation was developed independent of any commercial influences
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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.
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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
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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
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So, What’s The Problem? Advances in detection + Advances in treatment+ Aging population
Growing number of cancer survivors
(Why is that a problem?)
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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 PCPPCPs and other health care providers not familiar
with consequences of cancer and cancer treatment
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Cancer Care Continuumfrom Canadian Strategy for Cancer Control, 2005
PreventionScreeningDiagnosisTreatmentSurvivorship Follow-Up CarePalliative Care
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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
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What is Cancer Survivorship?Assists with transition from cancer
treatment to living “a new normal”Addresses the emotional, practical, and
physical effects of cancer treatmentProvides assessment, education, referrals,
and resources to meet the individual needs of cancer survivors at any point after completing treatment
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What Is A Survivorship Care Plan?
Communication between oncology & PCP
Roadmap for long-term careEducation for survivor, family, and other providers
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How To Assess Risks Associated With Cancer Treatment:
Type of cancer (s)Treatment modalitiesSpecific treatment agents/fieldsClinical and Psychosocial findings
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Types Of Cancer Treatment Presenting Health Risks
BreastColonProstateGYNLeukemiaLymphoma
LungThyroidHead & NeckSkinMelanoma
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Types Of Cancer Treatment Presenting Health Risks
Surgery?Radiation?Chemotherapy?Hormonal therapy?Transplant?
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Types Of Cancer Treatment Presenting Health RisksAnthracyclines: Adriamycin, Daunomycin, Epirubicin,
IdarubicinTaxanes, Platinums, Vinca Alkaloids: Taxol/Taxotere,
Cisplatin/Carboplatin, Vincristine/VinblastineRadiation: left chest, mantle, prostate, TBI (total body
irradiation)Monoclonal Antibody: Herceptin, Avastin, Erbitux, RituxanHormonal: Tamoxifen, aromatase inhibitors (Arimidex,
Femara, Aromasin)Transplant: Steroids, Immunosuppression, GVH (graft vs
host)
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Long Term Impact Of Cancer Treatment
Heart/cardiovascular disease
Peripheral neuropathy
Dental problemsGI problems
OsteopeniaPainMenopauseUterine problems
(Tamoxifen)
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Long Term Impact Of Cancer Treatment
Skin cancerBreast cancerLymphedemaFunctional limitations
FatigueEmotional: Depression,
Anxiety, PTSD, family, social, body image
Financial: work, insurance
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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
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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
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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
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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
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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
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What Are The Long-Term Risks From Treatment?
Cardiomyopathy Conduction
defects, dysrhythmias
Radiation associated valvular disease
CAD/MIOther
cardiovascular disease
Cancer associated thrombosis
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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.
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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
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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
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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)
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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
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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
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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
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What Are The Long-Term Risks From Treatment ?
Elevated cholesterol
Fertility ProblemsHearing lossThyroid problems
Secondary cancers
Depression, anxiety
Memory problemsSexual
dysfunction
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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
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Red FlagsFatiguePalpitationsDyspnea/SOB/Orthopnea - one of most
under-reported by providers Pelvic pain/vaginal bleeding/prior GYN
historyPast medical history – also consider
existing health issues with new cancer diagnosis
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Red FlagsEdema/functional limitations – arm,
lower extremities, abdominal/pelvicGlobus sensation/dysphagiaPast cancer historyAge/GenderLifestyle – smoking, alcohol, activity, dietFamily history
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Screening RecommendationsEchocardiogram ,
Cardiac MRI, MUGA, RVG (post-treatment baseline, then every 2-5 years)
EKGCholesterolBNP, Troponin
Coronary screening: ischemic studies, calcium scoring CT, cardiac catheterization
Early detection + early treatment = improved cardiac status & outcomes
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Screening RecommendationsBone 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
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Prevention/WellnessEncourage self care/wellness efforts!Baby steps • Don’t set goals too high• Start small – easier to achieve, easier to see
progress
Be consistentEncourage survivors to be own advocate • Ask questions• Take advantage of local and online resources• Write things down
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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
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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
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Resourceswww.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
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Resources
http://www.cancer.net/patient/Survivorship - website for cancer survivors◦Information from American Society of
Clinical Oncology (ASCO)
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Resources
www.vanderbiltREACH.org- website for cancer survivors◦Learn more about Cancer Survivorship
care◦Resources◦Education◦Community events