Transcript Cancer Survivorship Care Why, What, Where

Cancer Survivorship Care
Why, What, Where
Kenneth Miller, M.D.
Sinai Hospital
Baltimore, MD
Changes in long-term survivorship over 3 decades
1980-1985
1990-1995
2000-2005
Estimated Number Cancer Survivors in the United States
from 1971 to 2003
Data source: 2004 Submission. U.S. Estimated Prevalence counts were estimated by applying U.S. populations to SEER 9 and
historical Connecticut Limited Duration Prevalence proportions and adjusted to represent complete prevalence. Populations from
January 2002 were based on the average of the July 2001 and July 2002 population estimates from the U.S. Bureau of Census.
Acute treatment is only a small part
of the seasons of survivorship.
Transitional
Survivorship
“When I was in treatment, I had all the steps
laid out in front of me. I knew what I had to do
to fight this disease. Now, I find myself wanting
to go to clinic, to be getting chemo, to DO
SOMETHING.”
“It has been about four years since I
completed my chemotherapy. There isn’t
a day that I don’t think about cancer
though it is not hourly!”
“Cancer is just one of many issues that I have faced “.
“Cancer helped me; I love more, I care more, my life
means more to me”
Living With cancer
NED
Copyright © 2013 by American Society of Clinical Oncology
Use of the Word
“Cure” in Oncology
Follow-up Care at 20 years
Follow-up after 20 years was recommended
by oncologists for patients with a history of
Breast- 50%
Colon- 28%
Lung- 36%
Lymphoma- 40%
Most oncologists thought that the residual
risk of recurrence was 0%
So who are we seeing as
cancer survivors for
follow-up care?
Distribution of Care at a Major
Cancer Center
•
•
383 patient visits from one week were analyzed
243 were actively receiving treatment 63%
•
81
<=5 years post-tx
•
11
6-10 years post-tx 3%
•
4
>10 years
21%
1%
Who are We Caring For?
Data re: 18,000 visits to a CCC
What problems are we seeing in cancer
survivors?
LLE that I most clearly remember
in my patients in 25 years
1) Steve died of a secondary leukemia after
treatment of Stage III HD
2) Mary developed significant CHF after tx
with CHOP for NHL.
3) Mark developed carotid artery disease,a
TIA, and hypothyroidism after RT for
SCCHN
Why So Small a Group?
• Are my patients unusually
fortunate?
• Have I been treating
patients less aggressively?
• Is it possible that I am not
seeing my patients for
long-term follow-up?
• Am I unusually good?
Allogeneic BMT
Autologous BMT
NHL, Testicular
Breast
DCIS, Prostate
What LLE are We Seeing?
What we are noting and what patients are
experiencing may be different
We reviewed office notes from visits for
cancer survivors at
6-10 years
>10 years
LLTE at >10 years
Cardiovascular
Musculoskeletal
Hypothyroid
Fatigue
Sexual Health
Lymphedema
6%
6%
6%
3%
2%
2%
So For example; Cardiac disease for
survivors at 10+ years is 6% of the 1%
of the total visits = <<1%
How about for Adult Cancer
Survivors?
Emotional
Medical
Financial
Spiritual
Age
Gender
Genetics
CHEMOTHERAPY
RADIATION
SURGERY
RISK OF LONG TERM AND LATE EFFECTS
What Care Was Provided for
Cancer Survivors at >10 years?
Surveillance
100%
Prevention
13%
Coordination
11%
Survivorship Is
a ‘teachable and a learnable
moment’
• Healthy behaviors
(e.g., diet, exercise, healthy weight,
sunscreen use, immunizations, smoking
cessation, osteoporosis prevention)
• Preventive care and treatment of comorbid conditions
BMI
MEAN
STD.DV.S
PRE
POST
31.22
5.91
Post-Pre
30.91 -0.31
International Physical Activity Questionnaire – Impact of
intervention
IPAQ Continuous Scoring
Mean
Std Dev
PostPre
Post
Pre
2525.8
1062.8
1
3588.65 3
2940.1
1526.7
7
4466.89 2
Sitting
Mean
169.60 300.63
Std Dev
154.91 123.31
131.03
Many of our patients are cured!
The value of surveillance at 20
years is limited
The risk of LLE is relatively small
The need for secondary prevention
is great!
History
Exam
Medical Decision Making
Time
Nurse Practitioner Visits
250/year @ $220 = $55,000 in charges=$27,000 collected
20% of FTE for these= $30,000
Downstream charges = $200,000
PCP Visits
Integrate survivorship care with other health care
Stressing Secondary Prevention