Transcript Treatment
The Young Adult Cured of Cancer in Childhood Melissa M. Hudson, M.D. After Completion of Therapy Clinic St. Jude Children’s Research Hospital Transition of Care After Pediatric Cancer Cancer Diagnosis Pediatric Health Care Primary Prevention Risk-adapted therapy Favorable: Reduce therapy Unfavorable: Intensify therapy Long-Term Survival Adult Health Care Secondary Prevention Health education Cancer screening Therapeutic interventions Health & Resilience Optimal Care After Cancer Longitudinal care from diagnosis to death. Comprehensive care including preventive measures to reduce morbidity and mortality. Coordination of care by provider knowledgeable about cancer-related risks working with multidisciplinary team. Health care sensitive to cultural and spiritual values and issues of the cancer experience Challenges to Providing Care Evolving therapies and late effects. Long latency to evaluate health outcomes. Multiple factors contributing to cancer-related health risks. Unknown effects of aging on many treatment sequelae. Lack of consensus regarding screening guidelines and risk reduction methods. Challenges to Providing Care Transitioning from oncology to primary care. Transitioning from pediatric to adult care. Lack of knowledge by primary care providers: Cancer-related health risks Risk-reduction methods. Lack of support from healthcare system for specialized survivor care, e.g., long-term follow-up programs. Goals of After Therapy Care To maintain cancer-free survival. To detect cancer-related complications at early stages. To prevent, reduce, or correct cancer-related complications. To optimize health and resilience. Prevention of Morbidity Identify factors predisposing to cancerrelated morbidity. Identify factors modifying cancer-related health risks. Provide interventions to prevent, reduce, correct cancer-related morbidity. Factors Contributing to Morbidity Premorbid conditions Host Factors BRCA, ATM, p53 polymorphisms Age Gender Race Tumor Factors Cancer-Related Morbidity Health Behaviors Tobacco Diet Alcohol Exercise Sun Genetic Treatment Factors Aging ????? Treatment Events Relapse Vital Organ Toxicity Surgery Radiation Chemotherapy Histology Site Biology Response Risk-Based Care Screening/prevention plan that integrates cancer experience with health care needs. Considers risk for morbidity related to: Host: sex, race, age at diagnosis & follow-up Cancer: location, treatment modalities Genetic/familial predispositions Lifestyle habits Co-morbid health conditions Case Study: Adult Survivor 25 year-old female patient diagnosed with Hodgkin’s disease at age 15 years Combined modality treatment with COPP/ABV and mantle (21 Gy) radiation Family history: Mother - breast cancer at 42 years; Father - angioplasty at 44 years Social history: cigarette smoking, tanning bed use; drinks alcohol socially; noncompliant with breast cancer surveillance Review Risk Factors Host: female, pubertal status during treatment, 10 years after therapy Treatment: alkylating agents, anthracycline, bleomycin, chest radiation Familial: pre-menopausal breast cancer, early-onset coronary artery disease Lifestyle: tobacco, tanning, alcohol Assess Late Effects Risks Dental: xerostomia, accelerated dental decay Thyroid: hypothyroidism, thyroid nodules Cardiac: cardiomyopathy, atherosclerosis Pulmonary: restrictive lung disease Gonadal: infertility, early menopause Second malignancy, especially breast cancer Counsel to Promote Health Inform of potential health risks. Address increased vulnerability Provide personalized risk information Establish priority health goals. Discuss benefits of protective behaviors. Discuss barriers to/personal costs Provide follow-up counseling. Educate About Risks Cancer diagnosis and treatment Cancer-related health risks Behavioral factors affecting risk Risk reduction strategies Address Increased Vulnerability Sociodemographic factors Cancer treatment modalities Family history/genetic predisposition Maladaptive behaviors Unknown impact of aging Personalize Health Education Predisposing cancer treatments: Radiation, Adriamycin, bleomycin, alkylators Predisposing family history First-degree relative with breast cancer First-degree relative with early onset CAD Maladaptive lifestyles Smoking, tanning, alcohol use Address also: diet, weight control, exercise Need for early breast cancer surveillance. Encourage Health Goals Stop smoking. Use sun protection measures. Eat a healthy diet. Limit alcohol intake. Adopt a physically active lifestyle. Maintain a healthful weight. Pursue early breast cancer screening. Discuss Benefits Smoking cessation Reduce risk of heart and lung disease. Reduce risk of tobacco-related cancers. Sun protection Reduce risk of premature skin aging. Reduce risk of skin cancer. Discuss Benefits Healthy diet and physical activity Reduce risk of cardiovascular disease. Reduce risk of breast, colon, uterine and other cancers. Limit alcohol consumption Reduce risk of liver disease. Reduce risk of mouth, pharynx, larynx, esophagus, liver, and breast cancer. Discuss Benefits Regular screening examinations Early detection of health problems Prevention of health problems Early intervention to reduce morbidity Address Barriers Appreciate that barriers may be personal, familial, social, economic in etiology. Fear/discomfort with breast screening Insurance denial of clinician/imaging screening Provide information to facilitate behavioral change. Patient education about breast screening Clinician communication with primary care providers or insurance company Health Behavior Counseling Discuss alternative behaviors and choices. Anticipate reactions/responses by family and peers. Challenge survivor (and family) to commit to healthier lifestyle. Provide follow-up counseling. Barriers to Risk-Based Care Clinic environment: work flow impeded with time-consuming counseling Clinical staff: time constraints with patient care and lack of knowledge about cancerrelated health risks Survivors/Family: lack of interest or resistance to counseling efforts Requisites for Success Dedicated time/day for survivor follow-up Dedicated staff with interest in late effects Specialty or advance practice nurse most commonly utilized Multidisciplinary participation Oncologists - Nurse Psychologist - Social worker Allied and subspecialty care providers For Comprehensive Risk-Based Screening Recommendations and Patient Education Materials For complete recommendations: Children’s Oncology Group Long-Term Follow-Up Screening Guidelines http://www.survivorshipguidelines.org Advice to Survivors Know about cancer/cancer-related health risks. Keep a record of medical events. Share record with all providers. Pursue routine medical evaluations. Review lifestyle for methods of risk reduction. Keep informed about late effects research. Taming Anxiety About Late Effects Serious late effects occur in a minority. Late effects are possible only when cancer therapy is successful. Research can reduce and prevent late effects. Knowledge of factors predisposing to late effects can reduce their incidence.