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