Transcript Oncology for Family Medicine Residents. Module 4: Survivorship Care

Oncology for Family
Medicine Residents
Anna N Wilkinson, MD, MSc, CCFP
Objectives
1. Work up of suspected malignancies
2. Oncology Basics
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Chemotherapy and Radiation Therapy
3. Oncology Emergencies
4. Survivorship care
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Ongoing monitoring of patients and management
of sfx treatment and longer term drugs
4. Survivorship Care
Case 1
 Mrs XX, is returned to your care after treatment for
her breast cancer. She received FEC-D chemotherapy,
radiation therapy, herceptin, and is now mantained
on Femara. She is discharged from the cancer clinic.
 What do you need to monitor??
What Is Survivorship Care?
 Well follow-up care and rehabilitation following cancer
treatment and lasting until recurrence or death from other
causes
 Usually co-managed by oncologist and family physician
 5-year relative survival rate (RSR)
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Breast: 88%
Lung: 17%
Colorectal: 64%
Prostate: 96%
Survivorship Care
 All cancer survivors are at increased risk for
 New primary cancers
 Recurrent cancer
 Long-term and late-onset effects from both the cancer
and its treatment
 Many face an increased risk for other co- morbidities
(DM, CV disease)
Survivorship Care
 A cancer diagnosis can provide physicians with the
opportunity of a "teachable moment”
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Healthy diet
Smoking
ETOH consumption
Exercise
Surveillance
 Screen for depression and anxiety or cancer-related
fatigue
 Screen for local recurrence or metastatic disease
 Screen for new cancers
Surveillance
 Symptoms suggestive of distant metastases
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Bone pain
Cough
Shortness of breath
Chest pain
Abdominal pain
Nausea
Weight loss
Headaches
Confusion
Breast Cancer
Breast Cancer
 Local recurrence in the ipsilateral breast is expected to
occur in ~1% of women annually
 New cancer in the contralateral breast is expected to occur
in 15% of women within 20 years
Surveillance Schedule for Breast
Cancer
 Physical Exam
 Include breasts, chest wall, axillae, regional nodes,
abdomen, pelvis
Period Post Tx
Frequency
Year 1,2,3
Every 3-6 months
Year 4,5
Every 6-12 months
After 5 years
Annually
 Mammography
 Begin 6-12 months post treatment, not sooner
 Annually thereafter
Testing NOT recommended for
Breast Ca Surveillance
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Ultrasound of the liver
CT scanning
FDG-PET scanning
Breast MRI
Use of CA 15-3 or CA 27.29
CEA testing
Blood work
Chest x-rays
Bone scans
Treatment Side Effects:
Breast Cancer
 Chemotherapy
 Ovarian Failure
 30% of woman <25 yrs
 90% of woman >35 yrs
 Menopausal sx, increased
risk osteoporosis
 Infertility
 Cardiac dysfunction
 Especially with
anthracyclines and
herceptin
 “Chemo Fog”
 Fatigue
 Secondary malignancies
 Leukemias
 Radiation
 Skin Cancers
 Pulmonary Fibrosis
 Cardiac Dysfunction
Treatment Side Effects: Breast
Cancer
 Hormonal therapy
 Tamoxifen
 Increased risk
endometrial ca
 Increased risk VTE
 Vaginal d/c
 Flushing and sweating
 Positive effect on lipid
profile and bone density
 Aromatase Inhibitors
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Osteoporosis
Arthritis
Arthralgia/Myalgias
Hyperlipidemia
Treatment Side Effects: Breast
Cancer
 Lymphedema
 Affects 20-30% of woman with axillary dissection
 Especially in those woman who received radiation therapy
 Rates improving with sentinel node
Colorectal Cancer
Colorectal Cancer
 80% recurrences occur within the first 2 years
 Local recurrence occurs in only 10% of cases
 Liver and lungs are the most common sites for
metastases to occur
Surveillance Schedule for Colorectal
Cancer
Test
Recommendation
Colonoscopy
As soon as possible after cancer
treatment if complete colonoscopy
NOT done at time of dx
1 yr after diagnosis, then in 3 yrs,
then q5 yrs
CT scan
Chest, Abdomen +/- Pelvis annually
for 3 yrs
CEA
Every 3-6 months for at least 5 years
Sigmoidoscopy
Every 6 months if rectal ca and no
RT
CEA
 Expect to see elevated CEA values immediately
following surgery and during chemo
 CEA returns to normal within 4-6 weeks of successful
surgery
Testing NOT recommended for routine
colorectal cancer surveillance
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Chest x-ray
PET scans
Ultrasound
Blood work
FOBT
Symptoms suggestive of recurrence
of Colon/Rectal ca
 Abdominal pain,
particularly RUQ
 Dry cough
 Constitutional symptoms
 Fatigue
 Nausea
 Unexplained weight
loss
 Signs and/or symptoms
specific to rectal cancer
 Pelvic pain
 Sciatica
 Difficulty with
urination or
defecation
Treatment Side Effects: Colon/Rectal
Ca
 General
 Fatigue
 Anxiety, depression
 Chemotherapy
 Peripheral neuropathy
 “Chemo brain”
 Surgery
 Frequent and/or urgent bowel
movements or loose bowels
(may improve)
 Gas and/or bloating
 Incisional hernia
 Increased risk of bowel
obstruction
 Adjustment to ostomy (if
present)
Treatment Side Effects: Colon/Rectal
Ca
 Radiation
 Localized skin changes
 Rectal ulceration and/or
bleeding (radiation colitis)
 Incontinence
 Bowel obstruction (from
unintended small bowel
scarring)
 Infertility
 Sexuality dysfunction (e.g.,
vaginal dryness, erectile
dysfunction, retrograde
ejaculation)
 Second primary cancers in
the radiation field (typically
about seven years after
radiotherapy)
 Bone fracture (e.g., sacral)
Lung Cancer
Surveillance schedule for Lung
Cancer
Period post treatment History and Physical Imaging
Year 1, 2
Q 3months
• CT at 3,6,12,18, 24 months
• CXR all other visits
Year 3
Q 6 months
• CT annually
• CXR all other visits
Year 4+
Annually
• CT annually
 Smoking Cessation!!!
Symptoms suggestive of recurrence of
Lung ca
 Constitutional symptoms
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Dysphagia
Fatigue (new onset)
Nausea or vomiting (unexplained)
New finger clubbing
Suspicious lymphadenopathy
Sweats (unexplained)
Thrombosis
Weight loss or loss of appetite
Symptoms suggestive of recurrence
of Lung ca
 Pain
 Bone pain
 Chest pain
 Shoulder pain not related to trauma
 Neurological symptoms
 Persistent Headaches
 New neurological signs suggestive of brain metastasis or
cord compression such as leg
 Weakness or speech changes
 Headache or focal neurological symptoms
Symptoms suggestive of recurrence
of Lung Ca
 Respiratory symptoms:
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Cough (despite use of antibiotics)
Dyspnea
Hemoptysis
Hoarseness
Signs of superior vena cava obstruction
Stridor
 If disease recurrence is suspected, CT Chest with contrast
including upper abdomen should be done.
Treatment Side Effects: Lung Ca
 Constitutional Issues
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Anxiety
Cough
Decline in appetite
Decrease in general health
Depression
Dysphagia
Esophageal stricture
Fatigue
Pain
 Physical ability restrictions
 Reduced sleep quality
 Shortness of breath
 Long -Term Chemotherapy
Effects
 Hearing loss
 Neuropathies
 Renal impairment
Treatment Side Effects: Lung Ca
 Long-Term Radiation
Effects
 Breathing complications
(fibrosis, strictures)
 Breathlessness/Dyspnea
 Long-Term Surgery
Effects
 Empyema
 Oxygen dependence
 Post-thoracotomy pain
syndrome
 Reduced exercise
tolerance or activity
limitations
 Shortness of breath
Prostate Cancer
PSA Monitoring
Type of Treatment
PSA
Surgery
Every 3 months in year 1
Every 6 months in year 2
Annually thereafter
XRT
6 months after treatment completion
Every 6 months until end of year 5
Annually thereafter
• Use discretion in discontinuing monitoring for those patients who would
not be appropriate for further treatment
• More frequent monitoring required if PSA becomes detectable
PSA
 Radical prostatectomy
 PSA should decline to zero within 3-6 weeks
 External Beam XRT
 PSA should drop to a “nadir” level, generally between
0.2ng/mL and 0.5 ng/mL
 3 months post XRT, PSA should be half of pretreatment level
 It can take as long as 18 to 36 months to reach the nadir
 Nadir level is predictive of treatment success
 A “PSA Bounce” can be seen: as much as 5% increase in PSA in
up to 30% of patients, as long as 60 months after treatment
PSA Kinetics
 Increasing PSA after curative treatment, without any
evidence of recurrent disease is called a “Biochemical
Recurrence (BCR)”
 Not all men with BCR will go on to develop metastatic
disease
 The velocity at which the PSA rises “PSA doubling time
(PSADT)” is one of the best predictors of mortality
 PSADT >12 months: likely local recurrence
 PSADT <6 months: likely metastatic disease
 Bone Mets are rarely present with PSA<20
Workup with biochemical recurrence
 Bone Scan
 CT
 ??MRI?? – only if local salvage planned after previous
radiotherapy
Symptoms suggestive of Prostate Ca
recurrence
 Severe and progressive
axioskeletal bone pain
 Weight loss
 Leg Edema
 New Urinary symptoms
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Hematuria
Incontinence
Urgency
Obstructive symptoms
Voiding discomfort
Nocturia
 New Bowel Symptoms
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Rectal bleeding
Rectal pain
Urgency
Change in bowel
movement
 Fatigue
 Tiredness unrelated to
sleep disturbance
 Physical, emotional and/or
cognitive exhaustion
Treatment Side Effects: Prostate Ca
 Sexual Dysfunction
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Erectile Dysfunction
Loss of Libido
Anorgasmia
Dry Ejaculate
Penile shortening or
curvature
 Infertility
 Urinary Dysfunction
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Obstructive sx
Urgency
Hematuria
Incontinence
Treatment Side Effects: Prostate Ca
 Bowel Dysfunction (RT)
 Rectal Bleeding
 Urgency and frequency
 General
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Anemia
Fatigue
Gynecomastia
Hot flushes
Osteoporosis
Depression/anxiety
Cognitive slowing
Worsening of lipid profile
Case 1
 Mrs. XX post breast cancer tx
 Surveillance for dz recurrence
 Surveillance for sfx of tx
 Cardiotoxicity
 Lymphedema
 Depression/anxiety/fatigue
 Surveillance for sfx of ongoing tx
 BMD
 Lipid profiles
PGY-3 FP-Onc program
 6 month FP Oncology program
 Rotations in
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Palliative care
Medical oncology inpatients
Medical oncology outpatients
Gyne oncology
Hematology
Radiation oncology
References
 Cancer Care Ontario
 https://www.cancercare.on.ca/
 National Comprehensive Cancer Network
 http://www.nccn.org/
 Wilkinson et al, Can Fam Physician. 2008 Feb; 54(2):
204–210