am 11.30 grunfeld
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Care of the Cancer Survivor
Eva Grunfeld, MD, DPhil, FCFP
Ontario Institute for Cancer Research, andDept of Family and Community Medicine,
University of Toronto
No conflicts of interest
Objectives of the Presentation
1. Definition and epidemiology of cancer survivors
2. Overview of cancer-related healthcare needs of cancer survivors
3. Overview of general medical and preventive healthcare needs of cancer survivors.
4. Review the role of PCPs and survivorship care plans
5. Conclusions
Objectives of the Presentation
1. Definition and epidemiology of cancer survivors
2. Overview of cancer-related care needs of cancer survivors
3. Overview of general medical and preventive care needs of cancer survivors.
4. Review the role of PCP and survivorship care plans
5. Conclusions
Definitions of Survivorship
From the time of diagnosis through the remaining years of life.
National Action Plan for Cancer Survivorship, Centers for Disease Control and Lance Armstrong Foundation,
USA, 2004
versus The period following first diagnosis
and treatment and prior to the development of a recurrence of cancer or death.
Source: From Cancer Patient to Cancer Survivor,
Institute of Medicine, USA, 2006
Cancer Care Trajectory
Source: IOM, 2006
Source: J. Natl. Cancer Inst. 2008 100:236; doi:10.1093/jnci/djn018
Breast Cancer:Conditional relative
survival
Source: IOM Report, 2006
Colorectal Cancer: Conditional relative survival
Source: IOM Report, 2006
Summary
50% of cancer patients will be long-term survivors
Breast and colorectal are among the most prevalent cancers
Between 60 to 80% are long-term survivors
approximately 3% of the population are cancer survivors
most are elderly and most have multiple comorbidities
Objectives of the Presentation
1. Definition and epidemiology of cancer survivors
2. Overview of cancer-related healthcare needs of cancer survivors (focus on breast and colorectal cancers)
3. Overview of general medical and preventive healthcare needs of cancer survivors.
4. Review the role of PCP and survivorship care plans
5. Conclusions
Case : Breast Cancer
Your patient is a 48 y.o. with T2N1M0 carcinoma of the left breast. Primary treatment consisted of lumpectomy, chemotherapy, and radiotherapy. She is on extended adjuvant treatment with an aromatase inhibitor.
Now what?Her oncologist recommends the following protocol for
follow-up:Visits every 3-4 months for 10 yearsAnnual CT and bone scanCBC, LFTs each visitTumour markers (CA-15, CA-27, CEA) each visitBilateral mammogram biennially (as per screening
recommendations) Do you agree?
Survivorship Issues
Routine follow-up care Surveillance for recurrence Surveillance for late effects of treatment Surveillance for new primary cancer Psychosocial issues Special concerns
(social/economic/occupational)
General medical and preventive care
Special Issues
Ongoing adjuvant hormonal therapy
Weight control Lymphoedema Menopausal Symptoms Osteoporosis Cognitive functioning Psychosocial functioning
Breast Cancer: surveillance for recurrence
Distant recurrences occur within 5 yearscan occur 10 years
Most frequent sites of recurrence:breast, bone, liver, lungs
69% of recurrences are interval events and present with signs or symptoms, not routine tests Source: Grunfeld et al., BMJ, 1996
Diagnosis of RecurrenceInterval or symptomatic (%)
Tomlin 1987 64 Zwaveling 1987 73 Rutgers 1989 77 (distant) Ciatto 1985 58 Ormistan 1985 78 Valagussa 1981 78 Stierer 1989 40 (distant) Pandya 1985 54 Scanton 1980 73 Winchester 1979 91 Grunfeld 1997 69* Woster 1995 77* Donnelly 2002 74* te Boekhorst 2001 63
* Identified as interval event Source: Tomiak, Ann Oncol, 1993
Adjuvant hormonal treatment
Extended adjuvant treatment with Aromatase Inhibitors (AI) and/or Tamoxifen (for hormone receptor +ve)
Several scenarios: immediate Tam (maximum of 5 years) immediate AI (maximum of 5 years) AI after 2 to 3 years, or after 5 years of
Tamoxifen AI followed by 2nd AI AI for postmenopausal only s/e = loss of BMD, fracture (2-4%), bone/joint pain
Tam for pre, peri, or postmenopausal s/e = uterine cancer (1%), hot flashes, DVTs (1-2%)
Source: Burstein, J Clin Oncol, 2010
Breast Cancer:ASCO Guidelines for Follow-
Up History and physical, including breast
examEvery 3 to 6 months for Years 1-3Every 6-12 months for Years 4-5Annually thereafter
Annual mammogram, unless otherwise indicated
Other lab tests and scans NOT recommended in asymptomatic patients
Source: Khatcheressian et al., JCO, 2006
Surveillance Mammography
PurposeDetection of ipsilateral recurrenceDetection of contralateral new primary
RCTs of follow-up regimens control for mammography
Guidelines recommend annual
Source: Grunfeld, Noorani et al., The Breast, 2002
Prevalence of Late Toxicities
Common Less Common
Premature menopause
Depends on age and regimen; 70% of women over 40 CMF
Cardiovascular Disease
CHF 1-5%
Hot flashes 40-50% Second Primaries
Leukemia 1-2%
Weight gain 50% gain 6-11 lbs; Endometrial cancer <1%
Fatigue 30% 1-5 yrs Sarcoma <1%
Cognitive Impairment
30% Bone health 2% fracture on AI
Lymphedema 12-35% Blood clots 1-3%
From Cancer Patient to Cancer Survivor, IOM Report 2006
Outcomes related to exercise
in breast cancer survivors
Level of Exercise (MET hours/week)
Source: Adapted from Holmes et al., 2005
Outcomes related to weight gain
in breast cancer survivors
Change in Body Mass Index (BMI)
Source: Adapted from Kroenke et al., 2005
Case: Colon Cancer
Your patient is a 65 year old otherwise healthy woman who has just completed adjuvant chemotherapy for Duke’s C colon cancer.
She wants to know what happens now. She asks you:- how often do I need to see the doctor?- do I not to go to the oncologist or my PCP?- what kind of regular tests do I need?- what problems should concern me?
What do you tell her?
Colorectal Cancer: surveillance for recurrence
early stage – 90% 5 year survival Stage III – 65% 90% of recurrences in first 5 years most common sites
liver, lung, local, abdomen Metachronous new primary
3 to 5% in first five years Meta-analysis of RCTs show that
intensive follow-up results in improved survival
Colorectal Cancer:ASCO Guidelines for
Follow-upASCO 2005 update
History and physical: - q 3 to 6 months x3 years; q 6 months years 4+5 CEA
- q 3 months ≥ 3years; if stage II or III, eligible for Sx or CTx
LFTS, FOBT, CBC - no CT chest and abdo; CT pelvis for rectal cancer - annual if eligible for Sx or CTx Colonoscopy - perioperative; year 3; year 5; more frequently if polyps
Objectives of the Presentation
1. Definition and epidemiology of cancer survivors
2. Overview of cancer-related care needs of cancer survivors
3. Overview of general medical and preventive care needs of cancer survivors.
4. Review the role of PCP and survivorship care plans
5. Conclusions
Cancer prevalence by age
0.6% 0.9% 1.4%2.2%
3.5%
5.4%
8.0%
11.3%
14.8%
17.8%
19.3%18.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Percentage
30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Age
Number of comorbidities by age
6.4 4.6
21.1
13.68.8
22.5
19.2
15
18.4
20.1
16.9
12.7
12.5
16.4
16.1
12.824.3
38.6
55-64 65-74 75+Age
Percentage
0 1 2 3 4 5
Severity of comorbidity by cancer site
45.5
55.3 53.6 52.246
3831.2 30.6
29.8
31.627.6 27.3
29.8
32.9
29.328.6
17.3
10.313.3 16.1
17.320
25.4 28.8
7.42.9 5.5 4.4 6.8 9
14.2 14.1
All PatientsProstate
Breast
GynecologicalHead and NeckDigestive System
Lung
Urinary System
Percentage
None
Mild
Moderate
Severe
Competing Causes of Death
Yancik, R. et al. JAMA 2001;285:885-892. Source: Yancik et al., JAMA, 2001p 30 months
General Medical and Preventive Care
Management of comorbid conditions heart disease, diabetes
Early diagnosis of chronic diseases Preventive health care
Screening for other primary cancersnew breast primary, colorectal cancer,
ovarian cancer
Screening for other chronic diseasesosteoporosis, hypertension,
hyperlipedemia
Never screened over 4 years
1. Females age 50-69
2. Females age 20+
3. Age 50 to 74; FOBT, Barium enema, sigmoidoscopy or colonoscopy
4. Size of sample varies based on age/sex eligibility for screening modality
Source: Grunfeld et al., Can Fam Phys In Press
Screening
Index Cancer 4 %
Breast (n=11,219 )
Hodgkin’s Lymphoma (n=2,322)
Endometrial (n=3,473)
Colorectal (n=1,833)
Mammogram 1 - 36.6 24.4 38.4
Pap2 50.7 37.0 - 63.2
Colorectal cancer 3
65.3 76.1 65.6 -
Summary
Cancer survivors are at risk for late complications
Complex interactions between late effects of treatment, other medical conditions, and cancer
Focus on medical care for conditions other than the index cancer is crucial, particularly for older cancer survivors
Objectives of the Presentation
1. Definition and epidemiology of cancer survivors
2. Overview of cancer-related care needs of cancer survivors
3. Overview of general medical and preventive care needs of cancer survivors.
4. Review the role of PCP and survivorship care plans
5. Conclusions
Breast cancer patients: mix of physician visits
Follow -up Year
% of patients with at least one visit Physician Specialty
Year 2 (n=11,219)
Year 3 (n=10,026)
Year 4 (n=9,297)
Year 5 (n=8,624)
Primary Care Only * 8.0 12.3 17.3 23.0
Oncology Only* 8.8 7.7 7.5 6.4
Multiple 4.9 3.6 3.0 2.2
PCP and Onc ology* 81.1 77.0 71.8 66.6
PCP and Medical 11.3 16.5 18.4 17.6
PCP and Radiation 7.5 8.2 9.2 9.3
PCP and Surgical 13.1 13.9 14.7 15.9
PCP and Multiple 49.2 38.4 29.5 23.8
* P < 0.001 Source: Grunfeld, J Oncol Pract, 2010
Mix of Physician Specialties Visited:
Breast Cancer Survivors
0
10
20
30
40
50
60
70
Both PCP Only OncologistOnly
Neither
Year 1
Year 2Year 3
Year 4Year 5
*p<0.0001 for change over timeSource: Snyder et al., JGIM, 2009
Testing a Primary Care Model of
Breast Cancer Follow-up CareSTUDY YEARS METHODS SUBJECTS
Phase I
1991-1992 Focus Groups Patients (England)
1992-1993 Focus Groups Patients (England)
1992-1993 Survey FPs (England)
1992-1993 Survey Specialists (England)
Phase II 1993-1994 RCT (n=296) English Patients
Phase III 1997-2003 RCT (n=968) Canadian Patients
Phase IV 2007-2011 RCT (n=400) Canadian Patients
Testing a Primary Care Model of Breast Cancer Follow-up CareSTUDY YEARS METHODS SUBJECTS
Phase I
1991-1992 Focus Groups Patients (England)
1992-1993 Focus Groups Patients (England)
1992-1993 Survey PCPs (England)
1992-1993 Survey Specialists (England)
Phase II 1993-1994 RCT (n=296) English Patients
Phase III 1997-2003 RCT (n=968) Canadian Patients
Phase IV 2007-2011 RCT (n=400) Canadian Patients
Randomized Trial(18 months follow-up)
Trial GroupDifference
(95%CI) PCP
n = 148
Specialist
n = 141
Time to diagnosis of recurrence (days)
22 days 21 days 1.5 (-13 to 22)
Total time with the patient (min)
35.6 20.7 14.9* (11.3 to18.4)
Cost per patient (£s) 65 195 - 130 * (-149 to -112)
Time cost to the patient (min) 53 82 - 29 * (-37 to -23)
No difference in health-related quality of life over time No difference in anxiety or depression over time PCP patients more satisfied
Results – Phase II
*p<0.001 Source: Grunfeld et al., BMJ, 1996
Testing a Primary Care Model of Breast Cancer Follow-up CareSTUDY YEARS METHODS SUBJECTS
Phase I
1991-1992 Focus Groups Patients (England)
1992-1993 Focus Groups Patients (England)
1992-1993 Survey PCPs (England)
1992-1993 Survey Specialists (England)
Phase II 1993-1994 RCT (n=296) English Patients
Phase III 1997-2003 RCT (n=968) Canadian Patients
Phase IV 2007-2011 RCT (n=400) Canadian Patients
Follow-Up Guideline Sentto Primary Care Physicians
Outcome Event
Family Physician
(FP) Group(n=483)
Cancer Centre
(CC) Group(n=485)
Risk Difference
CC – FP(95% CI)
Number of Patients (%)
RecurrenceDistanta
Locala
Contralaterala
54 (11.2%)361011
64 (13.2%)381215
2.02% (-2.13, 6.16)
Death (All Causes) 29 (6.0%) 30 (6.2%) 0.18% (-2.90, 3.26)
Serious Clinical Events
17 (3.5%) 18 (3.7%) 0.19% (-2.26, 2.65)
Spinal Cord compressionb
Pathological fractureb
Uncontrolled local recurrenceb
KPS ≤ 70b
Brachial plexopathyb
Hypercalcemiab
0321402
1801802
Testing a Primary Care Model of Breast Cancer Follow-up CareSTUDY YEARS METHODS SUBJECTS
Phase I
1991-1992 Focus Groups Patients (England)
1992-1993 Focus Groups Patients (England)
1992-1993 Survey FPs (England)
1992-1993 Survey Specialists (England)
Phase II 1993-1994 RCT (n=296) English Patients
Phase III 1997-2003 RCT (n=968) Canadian Patients
Phase IV 2007-2011 RCT (n=400) Canadian Patients
Evaluating a survivorship care plan
Overall Objective:To determine if a survivorship care plan
and educational intervention for breast cancer survivors ready for transition from specialist care to primary care improves patient and health service outcomes
From Cancer Patient to Cancer From Cancer Patient to Cancer Survivor: Lost in TransitionSurvivor: Lost in Transition
Institute of Medicine, 2006
Recommendation 2:
Patients completing primary treatment should be provided with a comprehensive care summary and follow-up plan that is clearly and effectively explained. This “Survivorship Care Plan” should be written by the principal provider who coordinated oncology treatment.
What is a care plan
Identifying information (patient and provider)
Cancer treatment summary Diagnostic tests completed Risk of recurrence Signs and symptoms Recommended surveillance
guidelines Potential late effects Preventive care recommendations
Design and SettingDesign and Setting
Design: Multicenter randomized
controlled trial
Setting: 400 breast cancer patients on
active follow-up through tertiary cancer centers throughout Canada
Study InterventionStudy Intervention
All Patients Received:
Transfer to patients’ own FP for exclusive follow-up (i.e., all oncology providers agree to transfer)
Discharge visit with oncologist according to usual practice
Patients and FPs instructed to schedule the first follow-up visit in approximately 3 months
Statement that follow-up now provided by FP
Study InterventionStudy Intervention
Intervention Group Only Received:
Patient received:30 minute educational session with nurseSurvivorship care plan
Patient’s FP received:Survivorship care planGuideline on follow-upUser friendly abbreviated versionReminder table of visits and tests
Survivorship Care PlanSurvivorship Care Plan
Red dashed line = SCP, Black solid line = No SCP
Patient-reported Outcomes: Change Scores over Time
Source:Grunfeld, J Clin Oncol, 2011
Who should provide long-term care?
ASCO guideline - 2005 updateBased on two RCTs .. follow-up by a PCP appears to lead to the same health outcomes as specialist follow-up with good patient satisfaction. There is no reason to think that US patients will be any different.
Canadian guideline - 2005“responsibility for follow-up should be formally allocated to a single physician, with the patient participating as much as possible”
Percent willing to provide exclusive cancer follow-up: results from a Canadian national
survey of FPs1
Cancer 2yrs
3 to 5 yrs 10+ or never
Prostate 55.3 35.4 8.1
Colorectal 49.8 33.4 15.4
Breast 50.0 40.5 7.7
Lymphoma 42.0 41.6 15.4
1. Current experience providing exclusive follow-up most significant predictor of willingness. Source: Del Giudice, Grunfeld, et al,, J Clin Oncol, 2009
Usefulness of various modalities to help PCPs provide exclusive
cancer follow-upRan
kModality %
1 Patient-specific standardized letter with guidelines
95.4
2 Printed guidelines 91.8
3 Expedited rates of re-referral 92.7
4 Expedited access to test for suspected recurrence
91.1
5 Ability to telephone\email specialist for advice
86.1
Source: Del Giudice, Grunfeld, et al J Clin Oncol, 2009
Objectives of the Presentation
1. Definition and epidemiology of cancer survivors
2. Overview of cancer-related care needs of cancer survivors
3. Overview of general medical and preventive care needs of cancer survivors.
4. Review the role of PCP and survivorship care plans
5. Conclusions
Conclusions
Growing prevalence of cancer survivors Change in perspective from acute life threatening
disease to chronic disease Growing body of research shows that PCPs can,
are, & wish to play a key role in post-treatment cancer care
For breast cancer patients, a standard discharge visit with the oncologist achieved similar results as a survivorship care plan and educational session
Quality of general preventive care is a concern Involvement of PCPs in post-treatment cancer care
is essential but need guidelines, access, and education
Niagara Falls, CanadaNiagara Falls, Canada