Cancer Survivorship: How To Manage Treatment-Related Risks and Problems Outside of the Oncology Setting Tracy A.

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Transcript Cancer Survivorship: How To Manage Treatment-Related Risks and Problems Outside of the Oncology Setting Tracy A.

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 Continuum

from Canadian Strategy for Cancer Control, 2005

      Prevention Screening Diagnosis Treatment Survivorship Follow-Up Care Palliative 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 Problems Hearing loss Thyroid problems     Secondary cancers Depression, anxiety Memory problems Sexual 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/Wellness

 Encourage 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

Resources

      NCI Office of Cancer Survivorship: http://survivorship.cancer.gov

American 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.com

REACH for Survivorship Program: http://www.vanderbiltreach.org

Resources

 www.nccn.com

treatments – Clinical guidelines for cancer ◦ 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