cancer survivorship · definition of a cancer survivor (national coalition for cancer survivorship)...
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CANCER
SURVIVORSHIPEXAMPLE: BREAST CANCER
Issam Makhoul, MD
March 14, 2018
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Disclosure
• Company Nature of relationship
• Genentech/Roche - Grant/Clinical Trial Research Support
• New Link – Grant/Clinical Trial Research Support
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Definition of a Cancer Survivor(National Coalition for cancer survivorship)
Anyone with a history of cancer,
from the time of diagnosis and for
the remainder of life, whether that is
days or decades.
1. Rowland JH et al. J Clin Oncol. 2006;24:5101-5104. 2. Clark EJ. You have the right
to be hopeful. 2004. ttp://www.canceradvocacy.org/resources/publications/hopeful.pdf.
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The US population in
2040:
380 millions
1/15
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Focus on Survivorship – Males
American Cancer
Society, 2014a
2014 Prostate
Colorectal
Melanoma
UrinaryBladder
NH*Lymphoma
Testis
Kidney
2024Prostate
Colorectal
Melanoma
UrinaryBladder
NH*Lymphoma
Kidney
Testis
OralCavity/Pharynx
*Non-Hodgkin
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2014 Breast
UterineCorpus
Colorectal
Melanoma
Thyroid
NH*Lymphoma
UterineCervix
Lung/Bronchus
Ovary
Kidney
2024 Breast
Colorectal
UterineCorpus
Melanoma
Thyroid
NH*Lymphoma
Lung/Bronchus
UterineCervix
Ovary
Kidney
Focus on Survivorship – Females
*Non-Hodgkin
American Cancer
Society, 2014a
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Impacts of Cancer Treatment
Individual Effects/Risks
Surgical Side Effects
Chemotherapy Side Effects
Radiation Side Effects
Hormonal Therapy Side
Effects
Non-Treatment-Specific Side
Effects
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Psychological Well-Being
Spiritual Well-Being
• Control
• Anxiety• Depression• Fear of recurrence
• Cognition/attentionQuality of Life
Physical Well-Being
• Functional status
• Fatigue and sleep• Overall physical health• Fertility
• Pain
Social Well-Being
• Family distress
• Roles and relationships• Affection/sexual function• Appearance
• Isolation• Finances/employment
• Meaning of illness
• Religiosity• Transcendence• Hope
• Uncertainty• Inner strength
Cancer Survivor Needs
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Cancer Survivorship Care Guidelines:
Key Areas
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Long-term and Late Effects
• Long-term effects are medical problems that develop
during active treatment and persist after the completion of
treatment
• Late effects are medical problems that develop or
become apparent months or years after treatment is
completed
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Risk Factors for Physical Effects
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Potential Effects of Surgery
long-term effects
• Lack of skin sensitivity
• Body image issues
• Sexual dysfunction
• Numbness
• Pain
• Limited ROM
• Weakness
• Poor cosmesis outcome
LATE EFFects
• Lymphedema
• Neuropathy
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Potential Effects of Radiation Therapy
Long-Term
Effects
Fatigue Poor cosmetic
outcome
Pneumonitis
Skin
sensitivity/pain
Breast
atrophy/asymmetri
cal breast volume
Sexual
dysfunction
Lymphedema
Pain Numbness or
weakness of
upper extremities
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Potential Effects of Radiation Therapy
Late effects
Skin discoloration Lymphedema Numbness or
weakness of the UE
Breast may remain
smaller and firmer
than non-irradiated
breast
Shortness or breath
(lung pneumonitis or
fibrosis)
Secondary cancers
(i.e. soft tissue
sarcomas; lung
cancer)
Skin sensitivity/pain Cardiovascular
disease (i.e.
pericardial effusion,
pericarditis)
Teleangiectasia
Sexual dysfunction
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Chemotherapy
•Alkylating Agents
•Anthracyclines
•Taxanes
•Platinum Agents
•Targeted therapy
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Potential Effects of Chemotherapy
Long-Term Effects
Cognitive
impairment
Infertility Hair loss
Fatigue Weight gain
Ovarian failure
with or w/o
menopausal
symptoms
Obesity
Sexual
dysfunction
Neuropathy
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Potential Effects of Chemotherapy
Late Effects
Osteoporosis/osteopenia
cardiovascular disease with anthracyclines-based
chemotherapy
Leukemia and myelodysplastic syndrome with
alkylating agents and anthracyclines
Long-term Effects: Trastuzumab
Cardiac dysfunction
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Potential Effects of Hormonal Therapy
Long-Term Effects
Tamoxifen Aromatase Inhibitors
Hot flashes Vaginal dryness
Changes in
menstruation
Decreased libido
Increased
triglycerides
MSK symptoms/pain
Mood changes Cholesterol elevation
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Potential Effects of Hormonal Therapy
Late Effects
Tamoxifen Aromatase Inhibitors
Increased risk of
stroke
Increased risk osteoporosis
Increased risk of
endometrial
cancer
Increased risk of fractures
Increased risk of
blood clots
Osteopenia in
pre-menopausal
women
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Cancer Survivorship Care Guidelines:
Key Areas
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First 3 years
• Every 3-6 months
Years 4-5
• Every 6-12 months
5+ years
• Annually
History and Physical Exam
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• Annual mammography
MRI of the breast only if lifetime risk of
secondary breast cancer is more than 20%
• Should NOT offer routine laboratory tests or imaging for detection of recurrence in the absence of symptoms
• Should educate and counsel about signs and symptoms of recurrence
• Should counsel patients to adhere to adjuvant endocrine therapy
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Risk Evaluation and Genetic Counseling
• At least 1 grandparent of Ashkenazi Jewish heritage
• Younger than age 50 at diagnosis (younger than age 60 if
triple negative)
• History of ovarian cancer at any age or in first-degree or
second-degree relative
• First-degree relative who had breast cancer before age 50
• 2+ first- or second-degree relatives diagnosed with breast
cancer at any age
• Diagnosis of bilateral breast cancer
• History of breast cancer in male relative
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Cancer Survivorship Care Guidelines:
Key Areas
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Screening for Second Primary Cancers
(Average Risk Patient)
• Should screen for other cancers similarly to general
population
• Should provide an annual gynecological assessment for
post-menopausal women on selective estrogen receptor
modulator therapies (SERMs), such as tamoxifen
• In absence of abnormal vaginal spotting or
bleeding, periodic imaging is NOT of value
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Cancer Survivorship Care Guidelines:
Key Areas
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Physical and Psychosocial
Long-term and Late Effects • Body imaging concerns
• Lymphedema
• Cardiotoxicity
• Cognitive impairment
• Distress, depression, anxiety
• Fatigue
• Bone health
• Musculoskeletal health
• Infertility
• Sexual health
• Premature menopause and hot flashes
• CINP
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Body Image Concerns
• 31-67% of breast cancer survivors
• Concerns are caused by:- Loss of breast - Scarring and/or lymphedema
- Hair loss - Skin changes
- Sexual dysfunction - Weight gain
- Chemotherapy-related menopause
• Offer option for adaptive devices (e.g. breast prostheses, wigs) and/or surgery
• Refer to psychosocial care as indicated
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Lymphedema
• Over 40% of breast cancer survivors
• Risk related to breast surgery and/or radiation
• Axillary lymph node dissection > sentinel lymph node
biopsy
• ARM: Axillary Reverse Mapping
• Immediate or delayed
• Limited ROM
• Mild discomfort, pain
• Body image concerns
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Lymphedema
• Take good care of skin and nails
• Maintain optimal body weight
• Avoid injury of area at risk
• Avoid tight underwear, clothing, watches and
jewelry
• Wear compression garments, if prescribed
• Undertake exercise/movement and limb elevation
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Lymphedema
• Should counsel survivors on how to
prevent/reduce risk of lymphedema, including
weight loss for those overweight or obese.
• http://www.lymphnet.org/pdfDocs/nlnriskreduction.pdf
• Should refer patient with clinical symptoms or
swelling suggestive of lymphedema to a therapist
knowledgeable about diagnosis and treatment of
lymphedema.
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Cardiotoxicity
• Radiation, chemotherapy or endocrine therapy with
aromatase inhibitors
• Epirubicin; doxorubicin; trastuzumab
• Aromatase inhibitors can raise cholesterol
• Post-menopausal
• Weight gain (HTN and insulin resistance)
• Monitor lipid levels and provide CV monitoring as indicated
• Educate breast cancer survivors on healthy lifestyle
modifications, potential cardiac risk factors , and when to report
relevant symptoms (shortness of breath and fatigue)
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Cognitive Impairment
• Multifactorial (fatigue, insomnia, and depression)
• Problems with concentration, executive function, and
memory
• 75% of breast cancer patients in treatment and 35% after
treatment
• Older adults and/or those with lower cognitive reserves
may be more susceptible
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Cognitive Impairment
• Screen for cognitive problems
• Mini Mental State Assessment (MMSE)
• Functional Assessment for Cancer Therapy Cognitive
(FACT-Cog)
• Refer survivors with signs of cognitive impairment for
neurocognitive assessment and rehabilitation
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Potential Psychosocial Effects
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Distress Thermometer
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Our Three Question-Screening
• Are you having concerns with sadness, worry, family or
support, how you function at home, or financial issues?
• Are you having problems sleeping?
• Would you like to speak to someone about your
concerns?
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Fatigue
28-91% of breast cancer survivors
▪ Treat any causative factors (anemia, thyroid
dysfunction, and cardiac dysfunction)
▪ Offer treatment or referral for factors that may impact
fatigue (e.g., mood disorders, sleep disturbance,
pain)
▪ Counsel to engage in regular physical activity
▪ Refer for cognitive behavioral therapy as appropriate
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Bone Health
• Estimated up to 80% of breast cancer survivors
• Postmenopausal
• Women on an aromatase inhibitor
• Premenopausal women on tamoxifen and/or
gonadotropic-releasing hormone (GnRH) agonists
• Women who have chemotherapy-induced premature
menopause
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The Bikini Test
10- 20 minutes without
sun screen, daily!!!
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Bone Health
DEXA
VIT D
Normal vitamin D level is 30 – 100 ng/ml
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Bone Health-Universal Recs
▪Elemental calcium 1000-1200 mg/day
▪VIT D 1000 - 2000 International units/day
▪Weight-bearing/muscle- strengthening exercises
▪Avoid tobacco
▪Limit alcohol
▪Limit caffeine
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Musculoskeletal Health
• Assess for MSK symptoms, including pain
• Aromatase inhibitors
• Acupunture, physical activity, referral for physical therapy
or rehabilitation
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Infertility
Refer survivors of childbearing age who
experience infertility to a specialist in
reproductive endocrinology and infertility as
soon as possible
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Sexual Health
• Aromatase inhibitor can lead to vaginal dryness,
dyspareunia, menopausal symptoms, and loss of libido
• Radiation/surgery can lead to skin fibrosis, loss of sexual
sensitivity to the skin
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Sexual Health
• Assess for reversible contributing factors
• Offer non-hormonal water-based lubricants and moisturizers for vaginal dryness
• Low dose estrogen vaginal tablets (not recommended on aromatase inhibitors)
• Refer to psychoeducational support, group therapy sexual counseling, marital counseling, or intensive psycho-therapy when appropriate
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What is my Husband PSA?
•What is my husband’s Possibility for
Sexual Activity
•Male sexual dysfunction is the reason
in 20% of the cases
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Premature Menopause and Hot Flashes
• Serotonin and norepinephrine reuptake inhibitors (SNRIs)
• Selective serotonin reuptake inhibitors (SSRIs)
• Gabapentin
• Clonidine
* Some SSRIs are CYP2D6 inhibitors
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Premature Menopause and Hot Flashes
• Acupuncture
• Lifestyle modifications (e.g, rhythmic breathing, exercise,
avoiding spicy food, caffeine and alcohol)
• Enviromental modifications (e.g. cool rooms , dressing in
layers)
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Chemotherapy induced neuropathic pain
• Platinum: cisplatin, carboplatin, and oxaliplatin
• Taxanes: paclitaxel, docetaxel, and cabazitaxel.
• Epothilones: ixabepilone
• Plant alkaloids: vinblastine, vincristine, vinorelbine,
and etoposide.
• Thalidomide, lenalidomide, and pomalidomide.
• Bortezomib and carfilzomib.
• Eribulin .
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Chemotherapy-Induced Peripheral
Neuropathy • Signs and symptoms develop and worsen 2-6 months
post treatment
• Paresthesia
• Pins & needles sensation
• Pressure
• Tingling
• Cold
• Numbness
• Warmth
• Sensory ataxia
• Pain
• Severe numbness
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Neuropathy
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Cancer Survivorship Care Guidelines:
Key Areas
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Health Promotion
Achieve and
maintain a healthy weight
Avoid inactivity
Engage in regular aerobic exercise
and strength training
Achieve a diet high in vegetables, fruits and
whole grains
Avoid/limit alcohol
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Physical Activity
• Aim for at least 150 minutes of moderate or 75 minutes of
vigorous exercise per week
• Include strength training at least 2 days per week
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Cancer Survivorship Care Guidelines:
Key Areas
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PCP’s Role on the Care Team
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ASCO Treatment Plan and Summary
Reproduced with permission from the American Society of Clinical Oncology.
Breast Cancer Adjuvant Treatment Plan and Summary. http://www.asco.org/ASCOv2/Practice+%26+Guidelines/
Quality+Care/Quality+Measurement+%26+Improvement/Chemotherapy+Treatment+Plan+and+Summary. Accessed
June 10, 2009.
◼ Name, age, contact information
◼ Breast cancer diagnosis
◼ Surgery (type/dates)
◼ Patient history, including comorbid conditions
◼ Overview of page 2 (not shown)
– Hormonal therapy (agent, duration, date to be
initiated)
– Trastuzumab (dates, ejection fraction)
– Provider contacts (including referrals)
– Pre- and posttreatment comments (eg, baseline
assessments, patient counseling, follow-up
recommendations)
◼ Adjuvant chemotherapy/radiation therapy (planned
and received)
– Details on agents/doses prescribed (dates
initiated/completed)
– Toxicities (anticipated, experienced)
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ASCO Survivorship Care PlanFollow-Up Care Providers to Contact
Medical history and physical
examination
• First 5 years
• Year 6+
Posttreatment
mammography
• First 5 years
• Year 6+
Breast self-examination • N/A
Pelvic examination Ob/gyn
Coordination of care • First 5 years
• Year 6+
Genetic counseling If indicated, based on risk
factors
Follow-Up Care Visit Frequency
Medical history and physical
examination
• Years 1 to 3: every 3 or 6
months (including key notes for
1st-year visits)
• Years 4 to 5: every 6 or 12
months
Mammography • Every 6 or 12 months as
indicated
Notes • May include any relevant
patient notes and/or
recommendations
N/A=not applicable. Breast Cancer Survivorship Care Plan. v1.0 09/07.
http://www.asco.org/ASCO/Downloads/Cancer%20Policy%20and%20
Clinical%20Affairs/Quality%20of%20Care/
Breast%20Cancer%20Survivorship%20Plan%209.07.doc. Accessed
May 27, 2009.
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Thank You!!!
Questions?