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

1. Cancer Survivorship: How To Manage Treatment-Related Risks and Problems Outside of the Oncology Setting Tracy A. Johnson, DNP, FNP-BC

2. Disclosures • No financial relationships to disclose • This CME presentation was developed independent of any commercial influences

3. 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.

4. 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

5. 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

6. So, What’s The Problem? Advances in detection + Advances in treatment + Aging population Growing number of cancer survivors (Why is that a problem?)

7. 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

8. Cancer Care Continuumfrom Canadian Strategy for Cancer Control, 2005 • Prevention • Screening • Diagnosis • Treatment • Survivorship Follow-Up Care • Palliative Care

9. 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

10. 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

11. What Is A Survivorship Care Plan? • Communication between oncology & PCP • Roadmap for long-term care • Education for survivor, family, and other providers

12. How To Assess Risks Associated With Cancer Treatment: • Type of cancer (s) • Treatment modalities • Specific treatment agents/fields • Clinical and Psychosocial findings

13. Types Of Cancer Treatment Presenting Health Risks • Breast • Colon • Prostate • GYN • Leukemia • Lymphoma • Lung • Thyroid • Head & Neck • Skin • Melanoma

14. Types Of Cancer Treatment Presenting Health Risks • Surgery? • Radiation? • Chemotherapy? • Hormonal therapy? • Transplant?

15. 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)

16. Long Term Impact Of Cancer Treatment • Heart/cardiovascular disease • Peripheral neuropathy • Dental problems • GI problems • Osteopenia • Pain • Menopause • Uterine problems (Tamoxifen)

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. What Are The Long-Term Risks From Treatment? • Cardiomyopathy • Conduction defects, dysrhythmias • Radiation associated valvular disease • CAD/MI • Other cardiovascular disease • Cancer associated thrombosis

24. 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.

25. 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

26. 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

27. 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)

28. 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

29. 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

30. 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

31. What Are The Long-Term Risks From Treatment ? • Elevated cholesterol • Fertility Problems • Hearing loss • Thyroid problems • Secondary cancers • Depression, anxiety • Memory problems • Sexual dysfunction

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Resources • www.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

41. Resources • http://www.cancer.net/patient/Survivorship - website for cancer survivors • Information from American Society of Clinical Oncology (ASCO)

42. Resources • www.vanderbiltREACH.org- website for cancer survivors • Learn more about Cancer Survivorship care • Resources • Education • Community events