Transcript Survivorship for “cured” Hodgkin patients – How should we

Survivorship for “cured” Hodgkin
patients – How should we be following
them?
Carrie Thompson, MD
Mayo Clinic
Lymphoma & Myeloma 2014
©2014 MFMER | slide-1
Disclosures
• I have nothing to disclose
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Outline
• Surveillance for relapse
• Screening for late effects
• Cardiovascular disease
• Secondary malignancies
• Psychosocial issues
• Care models
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Background: Survivorship
• 13.7 million cancer survivors in the US
• ~200,000 survivors of HL
• Decreased survival compared to general pop
SEER Cancer Statistics Review, 1975-2008, NCI.
JCO 2003; 21:3431-9
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Do surveillance scans improve outcomes in
HL?
Cancer 2014;120:2122-9
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Surveillance for relapse
• Negatives of routine scans
• Radiation exposure
• False positives
• Anxiety
• Cost
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Surveillance guidelines
• Physical examination, history, and clinical judgement
are the cornerstone of followup
• Q 3 mos years 1-2, q 4 mos year 3, then q 6 mos
years 4-5
• Imaging studies
• NCCN
• CXR or CT chest and CT A/P q 6-12 mos x 2 yrs
• Lugano Classification
• Routine scans are discouraged
• Scans prompted by clinical indications
NCCN.org Version 2.2014
JCO 2014; 32:3059-67
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Monitoring for Late Effects
• Cardiovascular disease
• Secondary malignancies
• Psychosocial issues
• Other
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Congestive heart failure: chemotherapy
agents
• Cytotoxic agents
• Doxorubicin, cyclophosphamide,
ifosfamide, cisplatin, fluorouracil, paclitaxel
• Targeted agents
• mTOR inhibitors
• PI3 kinase inhibitors
• Trastuzumab
• Bevacizumab
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Congestive heart failure in HL
• Subclinical (asymptomatic, echo abnormal)
• 27.6% in lymphoma survivors1
• Do not know if this will lead to clinical CHF
• Clinical CHF
• 7.2% incidence with 6 year followup2
• May become evident during times of
increased cardiac workload
• Pregnancy, anesthesia, BMT, illness
1JCO
1998; 16:3502-8 2Ryberg 1998
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Coronary artery disease in HL
• Caused by radiation therapy
• Prospective study in 294 survivors of HL
• ≥35 Gy to mediastinum
• Excluded patients with known CVD
• Nuclear study and stress test
• 40 patients (14%) underwent coronary
angiography
• Coronary artery stenosis >50% in 22 patients
• 7.4% of those screened
JCO 2007; 25:43-9
Blood 2007; 109:1878-86
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CAD in HL
• Coronary CT angiography in 31 adult survivors
of childhood HL with hx radiation therapy
• ECG, treadmill stress test, echo
• 12 (39%) patients with coronary lesions
• 3 (10%) with obstructing lesions on coronary
angiogram
• 2 of these 3 died from CVD
• All had abnormal ECG, 1 abnormal treadmill,
0 abnormal echo
Cancer 2014; Jul 16 Epub
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Other cardiac diseases
• Valvular disease
• Predominantly mitral and aortic valves
affected
• Pericardial disease
• Historically most commonly affected cardiac
structure
• Conduction system
• Arrhythmias and QT prolongation
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Cardiac Follow-Up Expert Guidelines
JCO 2011; 29:1885-1892
©2011
Annals Onc 2012; 23:Suppl 7
MFMER |
JASE 2014;27:911-39 ©2014 MFMER | slide-14
slide-14
Screening Recommendations: CVD
• Annual physical exam
• BP check
• Lipids every 3-5 years
• Glucose annually
• Particularly if hx paraaortic LN xrt
• Treat cardiac risk factors
• Lifestyle modifications
JCO 2009; 27:5383-89
JCO 2014; 32 ©2014
Epub
MFMER
| slide-15
Benefits of exercise
JCO 2014; 32 Epub
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Screening Recommendations: CVD
• Post-radiation therapy
• If >30 Gy to mediastinum
• Stress test (exercise stress echo) starting
5-10 years post therapy then q 5 years
• Post anthracycline chemotherapy
• If >240 mg/m2 doxorubicin
• Echo starting 5 years after treatment then
q 5 years
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For female cancer survivors contemplating
pregnancy
• Refer to cardiology if…
• >240 mg/m2 anthracycline dose
• >30 Gy radiation to the heart or surrounding
tissue
• Any combination of the above with high-dose
cyclophosphamide
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Late Effects: Secondary Malignancies
• Breast cancer
• In those treated for childhood HL, estimated
incidence of breast cancer 20% at age 45
• Thyroid cancer
• Lung cancer
• Risk significantly increases in those who
smoke after radiation therapy
• Gastric/colorectal cancers
• Sarcoma
JCO 2007; 25:1489-97
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Types of secondary cancers, continued
• AML/MDS
• Mostly due to chemotherapy (alkylators)
• NHL
• ~5% lifetime risk in those treated for Hodgkin
lymphoma
• Skin cancers
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Recommendations for those at risk
• Annual skin exam in irradiated field
• Annual mammogram (+/- MRI) 8 years after
radiation or at age 40, whichever is earlier
• Colonoscopy 15 years after pelvic, abdominal,
spinal irradiation or at age 35
• Tobacco cessation
• ?low dose CT scan chest
• ?EGD
• Life-long surveillance
Am J Med 2011; 12:1606-12
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Fertility Issues
• Very important issue
• ABVD does not affect fertility
• Fertility preservation pre-treatment
• Wait 2 years post-treatment to have children
• No increase in birth defects, miscarriage,
cancer in offspring compared to general
population
www.fertilehope.org
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Fatigue
• 26% of survivors of Hodgkin lymphoma have
significant fatigue
• Higher than general population, other cancer
types
• Fatigue associated with higher symptoms of
anxiety and PTSD and lower QOL
• Unclear etiology, literature suggests may be
related to long term health complications
JCO 1999; 17:253-61, JCO 2005; 23:6587-95,
Thompson 2009
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Loss of Immunity: for all HL survivors
• NO live vaccines
• No shingles vaccine, influenza vaccine live
• Influenza vaccine annually
• Tdap/Td q 10 years
• HPV vaccine if <age 26
• Pneumococcal vaccine
• PCV-13 followed by PPV26 8 weeks later,
second dose PPV26 5 years later
• If <age 60, PPV26 at age 65
http://www.cdc.gov/vaccines/schedules/
hcp/imz/adult-conditions.html
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Loss of Immunity
• If splenectomy or splenic RT
• Meningococcus, HIB, PCV13 at time of
treatment
• PPV23 8 weeks later then 5 years later
• Meningococcus q 5 years
• If hematopoietic stem cell recipient
• More complicated revaccination schedule
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Depression and Anxiety in Cancer
Survivors
• Depression higher than
general population in 1st 2
years after diagnosis, then
no different
• Anxiety levels higher than
general population and
tend to persist
Lancet Oncology 2013; 14:721-32
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Anxiety in Lymphoma Survivors and
Spouses
Lancet Oncology 2013; 14:721-32
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Survivorship Care Models
• Primary care providers not trained in care of
long-term cancer survivors
• Communication and coordination of care is key
• Survivorship care plan
• Treatment summary
• Follow-up care plan
JOP 2014; Epub 10/14/14
www.asco.org
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Does education and screening for late
effects decrease QOL?
Int J Rad Onc Biol Phy 2014; 90:164-71
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Summary
• Surveillance for relapse
• Physical examination, history, and clinical
judgement are the cornerstone of followup
• Late effects
• Cardiovascular disease, secondary
malignancies, fatigue, fertility, loss of
immunity, psychosocial issues
• Coordinated care
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Thank you!
[email protected]
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