Cancer Survivorship in Primary Care

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Cancer Survivorshipin Primary Care

• Arlene ORourke N.P.

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1971-3 million 2012-13.7 million 2020-18 million
Approximately 15 of the 13.7 million estimated
cancer survivors were diagnosed 20 or more years
ago 67 of patients treated now will be alive in
5 years 75 of childhood cancer survivors will
be alive in 10 years Most common cancer
sites-female breast-22, prostate-20,
colorectal-9, gynecologic-8
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History of the Development of Cancer Survivorship

• 1985 Fitzhugh Mullen first describes Cancer
  survivorship
• 1986-NCCS
• 1996-NCI establishes the office of Cancer
  Survivorship
• 2004-Presidents Cancer Panel
• 2005-IOM-
• 2006-From Cancer patient to cancer survivorLost
  in Transition

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Definitions
An individual is considered to be a cancer
survivor from the time of diagnosis through the
balance of his or her life. Family members,
friends and caregivers are also affected by the
survivorship experience and therefore are
included in this definition.
NCCS,IOM

2005
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Definitions

• 5 years after diagnosis without recurrence
• Living with, through and beyond a diagnosis of
  cancer
• Death by other morbidity other then cancer
• Rejection of the term survivor

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DefinitionIOM Recommendation

• Recognize cancer survivorship as a distinct phase
  of care
• Patients completing primary treatment should be
  provided with a comprehensive care summary and
  follow up plan
• Begins at the end of primary treatment with
  intention to cure and lasting until a recurrence,
  a secondary cancer or death. It may include
  ongoing treatment.

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Seasons of Survival

• Acute survival
• Extended survival
• Permanent Survival

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Acute Survival

• Time of diagnosis
• Diagnostics, therapeutics,
• Fear/anxiety
• Disruption of family and social roles
• Financial issues
• Fear of death

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Extended SurvivalTransitional Fallow up

• Treatment completion- uncertainty of treatment
  outcome
• Watchful waiting
• Periodic examinations
• Consolidation/intermittent therapies/hormonal
  therapies
• Fear of recurrence/death
• Fatigue/physical limitations/lingering side
  effects

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Permanent SurvivalExtended follow up

• Cure
• Late effects of treatment may impact QOL, family,
  workplace and financial areas
• Ability to return to normal
• Lasting impact of cancer
• Development of self confidence and self trust

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Goals of Survivorship care

• Preventing recurrence and secondary cancers
• Promoting appropriate disease management
  following diagnosis and treatment to ensure the
  maximum number of years of a healthy life
• Minimizing preventable pain, disability, and
  psychosocial distress
• Assisting cancer survivors to access family,
  peer, community, and other resources they need to
  cope with their disease.

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Goals of Survivorship Care

• Empower survivors and families
• Provide enhanced and better coordination of
  communication around survivorship care
• Improve quality of life

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Focus of Survivorship Care

• Surveillance
• Prevention
• Intervention
• Coordination

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Surveillance

• Recurrent cancer and late effects
• Guidelines
• Based on type of cancer, stage at diagnosis,
  tumor characteristics,related risk of recurrence

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Prevention

• New cancers
• Recurrent cancer
• Late effects
• Guidelines

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Interventions

• Managing long term and late effects of
  treatment-organ dysfunction, mobility, fatigue,
  lymphedema, hormone/sexuality/fertility,
  secondary cancers
• Improve medical and psychosocial outcomes.

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Coordination

• Improve communication between providers to
  promote best practice
• Subspecialty referrals
• Psychosocial referrals
• Resources to support patient and family

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Quality of lifePhysical well being

• Functional activities
• Strength/fatigue
• Sleep and Rest
• overal physical health
• Fertility
• Pain

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Quality of LifePsychosocial

• Control
• Anxiety
• Depression
• Enjoyment/Leisure
• Cognition/attention
• Distress of diagnosis
• Fear of recurrence
• Control of treatment

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Quality of LifeSocial well being

• Family distress
• Roles and relationships
• Affection/sexual function
• Appearance
• Enjoyment
• Isolation
• Finances
• Work

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Quality of LifeSpiritual well being

• Meaning of illness
• Religiosity
• Transcendence
• Hope
• Uncertainty
• Inner strength

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Treatment related ToxicitiesLong term and Late
effects

• Long term-effects that persist after completion
  of treatment
• Late-occur after treatment has completed
• Long and late effects can be tumor, treatment or
  host related.

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Late effects

• Occur months to years following treatment
• Related to organ injury that occurred from
  treatment
• Failure of repair mechanisms over time and organ
  age
• More prevalent as treatments have become more
  complex.

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Tumor Related Factors

• Direct tissue effects
• Tumor related organ dysfunction
• Mechanical effects

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Treatment Related Factors

• Chemotherapy-agent, dose schedule and intensity
• Radiation Therapy-Total dose and fraction size,
  radiated field
• surgery-site and technique

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Host Related Factors

• Genetic predisposition
• Inherent tissue sensitivities and capacity for
  normal tissue repair
• Function of organs not effected by treatment
• Co-morbid conditions
• Pre treatment psychosocial status

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Surgery

• organ impairment
• Secondary side effects
• loss of function

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Chemotherapy

• Effects all organs- systemic therapy
• Most side effects can resolve within 3-6 months
  of completing therapy
• Cardiotoxicity
• Neuropathy
• Fatigue
• Pain
• Sexual dysfunction
• Fertility
• Blood dyscrasia
• Pulmonary Toxicity
• Bone Loss
• Cognitive dysfunction
• Liver dysfunction
• Secondary Malignancy

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Chemotherapy Cardiac Toxicity

• Anthracyclines-adriamycin-diastolic dysfunction
• Platinums-cisplatin-artherosclerosis, endothelial
  damage
• Her-2neu agents-Trastuzumab(Herceptin)-cardiac
  receptors-CHF/Cardiomyopathy
• Antiangiogenesis agents-Bevacizumaub(Avastin)-CHF/
  Acute coronary Syndrome

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ChemotherapyCardiotoxicity

• 1st manifests as diastolic dysfunction 5 years
  after treatment completion
• CHF/Cardiomyopathy
• High risk lt18 gt65, pre-existing cardiac disease,
  pregnancy, extreme sports/exercise
• Leads to increased morbidity and mortality

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Chemotherapy Cardiotoxicity

• Early intervention can improve LVEF
• If left untreated for more then 6 months
  subclinical LV dysfunction is irreversible.

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Pulmonary Toxicity

• Chemotherapy and xRT toxicity
• Lung, BMT, Hodgkins lymphoma, testicular
• Bleomycin,Gemcitiabine,BCNU, Mtx,
• Interstitial pneumonitis,scarring, inflammation
• Not reversible

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Neuropathy

• Vinca Alkaloids
• Taxanes-may be reversible
• Platinums-tinnitus/hearing loss
• numbness/tingling/pain
• Foot Drop
• Parasthesias
• Weakness
• Decreased reflexes

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Neuropathy

• Baseline exam- previous or current neurological
  diagnosis
• Initiate therapy with Vitamin B therapy and
  Glutamine
• PT/OT/Acupuncture
• Neurontin/Cymbalta

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Bone Loss

• Steroids, hormone therapies-aromatase inhibitors
  androgen deprivation, Ovarian failure, radiation
  therapy
• Baseline bone density, vit D therapy, weight
  bearing exercises, biophosphatase therapy

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Radiation Therapy

• Field/total dose
• Breast, Hodgkins, prostate, lung,colorectal,
  bone mets, BMT
• Incidence-10-30 within 5-10yrs post treatment
• Latent- 10-20yrs post treatment
• Vascular-Reynauds, artherosclerosis
• Skin changes
• Heart-valve dysfunction, myocardial/pericardial
  changes, electrical conduction disruption
• Thyroid changes
• Dental changes
• GI changes

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Cancer Survivors have a 14 higher risk of
secondary malignancies
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Secondary Malignancies

• Prior therapy exposures
• Cancer syndromes- genetic
• Host environment-lifestyle choices

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Psychosocial ImpactRisk factors
Pre-treatment risk factors- pre-existing mental
health diagnosis number of life stress
events Post treatment risk factors- Decreased
physical function Decreased cognitive
function 40 of oncologists and 50 0f PCPs
feel confident to manage psychosocial distress









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Interventions to decrease Psychosocial distress

• Rehabilitation
• Education
• Therapy- group or individual
• Support groups
• Events
• Exercise

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Demands of Cancer Survivorship

• Average of 3 specialists per patient
• Treatments may be inpatient and outpatient
• Time intensive and in specialized treatment
  facilities
• Cancer treatment usually occurs in isolation from
  primary health care - communication, multiple
  medical records

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Oncologists Challenges

• 2001-2007-total patients increased by 6
• Continuing patients 93 increase
• New patients up by 23- breast cancer
  patients-continuing - 126!!

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Supply and Demand

• Oncologists struggle with competing needs of
  patients undergoing active treatment and
  essentially well cancer survivors.
• Growing shortage of PCPs will be faced with an
  aging population with acute needs who will
  compete with essentially well appearing cancer
  survivors

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Supply and Demand

• 2010-43 million supply/47 million demand
• 2015-45 million supply/55 million demand

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Challenges of the Primary Care Provider

• Inadequate information about the cancer and
  treatment
• Some cancers are rarely seen in the primary care
  setting
• lack of knowledge and confidence about
  survivorship care
• Patients lack of confidence in the knowledge of
  the primary care provider
• Competing demands of time

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Co-morbidities/Chronic illness 60 of cancer
survivors have at least 1 co-morbid condition vs
45 without cancer Worse
oncologic outcomes with poorly managed
co-morbidities 1PCP per 10,000 decreases
mortality rate in a community by 5.3 85 o f
cancer care is provided in community
settings Higher rate of screening and
vaccinations in cancer survivors with PCP
care More Primary Care Providers Better cancer
Survivor care
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Models of Care

• Shared care
• Risk based follow up
• Disease specific clinics
• Institution based programs

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Shared Care

• Proven to improve outcomes
• PCP/Oncologist share care
• Rule of thirds
• Common with other specialties in mamagement of
  co-morbidities

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Primary Care Support

• Surveillance plan
• Risk based cancer screening
• Prevention
• Genetics
• Resources
• Coordination of care

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Survivorship Care Plans

• Demographics
• Treatment Summary
• Follow up Care Plan

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Guidelines

• NCCN-www.nccn.org
• ASCO-www.asco.org
• Livestrong-www.livestrongcareplan.org
• Journey Forward-www.journeyforward.org

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Barriers to Survivorship care

• Finances
• Educated and dedicated providers
• Lack of acceptance and/or integration with
  disease based or general oncology programs
• Space
• Complexity of survivorship care
• Lack of clear, evidence based guidelines on
  proper management
• Limited knowledge of evolving management of
  co-morbidities

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Next Steps...

• Coordination of care
• Medical Home
• EHR
• Education
• Research