Transcript Clinical Slide Set. Care of the Adult Cancer Survivor

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© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
in the clinic
Care of the Adult
Cancer Suvivor
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What are the essential components
of follow-up care?
 Prevent recurrent and new cancers and other late effects
 Monitor for cancer spread, recurrence, or 2nd cancers
 Assess medical and psychosocial late effects
 Manage consequences of cancer and its treatment
 Coordinate with other doctors so all health needs met
 Provide routine health promotion
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
When should patients transition to
follow-up care?
 Sooner
 If early-stage or low-risk for late effects + recurrence
 Later
 If high risk for late effects + recurrence
 Communication + cooperation is critical
 Oncology team should provide care recommendations
 Primary care doctor should manage comorbid conditions +
provide health maintenance (even if no transition occurs)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Which types of clinicians should
provide follow-up care?
 Historically: oncologists
 Focus on surveillance for disease recurrence
 Newer approach: shared care model
 Oncology and primary care teams work together
 Oncologists lead in coordinating care
 Focus: health promotion + managing comorbid conditions
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What information should clinicians
have when follow-up care begins?
 Treatment summary
 Type and location of cancer and type of surgery
 Drug names and cumulative doses of chemotherapy
 Types and cumulative doses of radiation therapy
 Survivorship care plan
 Describes follow-up scans, lab tests, office visits
 Identifies potential late effects + surveillance specifics
 Contains other, individualized information
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Transition to
Follow-up Care...
 Timing varies for transition from oncology care to primary care
 Shared care model is optimal
 Information needed for follow-up care
 Treatment summary
 Survivorship care plan
 Communication and collaboration among providers is critical
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What cardiac issues should the
clinician consider?
 Vascular disease
 Hypertension
 Myocardial dysfunction
 Consider the following actions
 Check lipids, thyroid function, BP, weight
 Ask about additional familial risk for CV disease
 Do a stress ECHO if symptoms are present
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What pulmonary conditions should
the clinician consider?
 Bleomycin-induced inflammation of lung (pneumonitis)
 Dose-dependent, reversible acute toxicity
 Increased risk of anesthetic complications
 Radiation-induced pneumonitis
 Reversible with corticosteroid therapy
 Manifests many years after treatment
 Ask about exercise endurance, respiratory symptoms
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What cognitive issues should the
clinician consider?
 Cognitive changes from chemo and endocrine therapy
 Breast cancer, ovarian cancer survivors
 Leukemia, lymphoma survivors
 Prostate cancer survivors (androgen-deprivation Rx)
 With whole-brain radiation, changes may be delayed
 Cause may be difficult to determine
 Aging, depression, or stress — or cancer Rx itself
 Combination of these factors
 Neuropsychological testing may help define symptoms
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What sexual and reproductive issues
should the clinician consider?
 Women
 Menopausal symptoms: chemotherapy or pelvic radiation
 Infertility: gynecologic surgery, radiation, chemotherapy
 Men
 Hypogonadism from some hormonal drugs, chemotherapy,
bilateral orchiectomy, or pelvic / cranial radiation
 Infertility from testicular cancer, systemic chemotherapy,
radiation; pelvic and retroperitoneal surgery
 Both Women and Men
 Psychological issues can cause sexual dysfunction
 Anatomical injury can directly cause dysfunction
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What bone health issues should the
clinician consider?
 Osteoporosis (Screen for bone loss with DEXA scans)
 Surgical oophorectomy / orchiectomy
 GnRH agonists / antagonists
 Chemo-induced ovarian failure
 Aromatase inhibitors
 Avascular necrosis of any joint
 Corticosteroids can affect blood supply
 If patient reports joint pain, consider MRI
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What other medical issues should the
clinician consider?
 Second malignant neoplasms
 Endocrinopathies
 Neurotoxicity, ototoxicity, nephrotoxicity
 Lymphedema
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Are there specific medical issues for
survivors of the most common cancers?
 Lung cancer
 Decreased pulmonary reserve
 Smoking cessation reduces risk for new cancers
 Colon cancer
 Second malignant neoplasms
 Life-altering issues with weight, continence, or bowels
 Breast cancer
 Second breast cancers
 Premature ovarian failure; lymphedema
 Cardiac toxicity (from chest radiation and some chemo)
 Prostate cancer
 Erectile dysfunction; symptoms from androgen ablation Rx
 Urinary incontinence; GI symptoms related to proctitis
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Are there common medical issues for
survivors of lymphoma, leukemia, and
hematopoietic cell transplantation?
 Late effects of chemotherapy or radiation
 Second malignant neoplasms
 Cardiac effects
 Lifelong immunodeficiency and increased infection risk
 Hypoglobulinemia
 Functional asplenia
 Chronic graft-vs-host disease
 From allogeneic hematopoietic cell transplantation
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Are there specific medical issues for
survivors who were treated with surgery,
radiation therapy, or chemotherapy?
 Depends on the dose and field of radiation therapy
 Depends on specific agents and doses of chemotherapy
 Chest radiation therapy: surveillance for breast cancer;
thyroid testing; cardiac evaluation
 Chest radiation or doxorubicin: ECHO; yearly lipid screen
 Anthracyclines + chest radiation: cardiac dysfunction risk
 Childhood cranial or craniospinal radiation: assess for
cognitive, fertility, other endocrine issues
 Major abdominal or pelvic surgery or radiation: risk for
wide array of issues many years after treatment
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Follow-up
Medical Care...
 Know the risks for treatment-related medical effects
 Collaborate with oncologists to optimize care
 Use the summary of cancer treatment to guide follow-up care
 Monitor for late medical effects of treatment
 Fertility
 Bone health
 Cardiac, pulmonary, cognitive, and sexual functioning
 Secondary malignancy
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Who provides surveillance for recurrent
cancer and secondary cancers?
 Follow-up care clinician if patient has transitioned
 Communicate with oncologists, seek guidance when needed
 Schedule appropriate surveillance and screening
 In the shared care model, assign responsibility to the
oncologist or the primary care physician
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What about pain and fatigue?
 Pain and fatigue are associated with…
 Sleep disturbance, menopausal symptoms, anxiety,
depression
 Distinguish survivors from those in active treatment
 Cancer survivors report few physical symptoms after
treatment
 Management can be difficult

If the cause is uncertain, involve the oncologist

If the problem is a chronic treatment effect, refer
patient to pain management team

Consider the possibility of psychosocial factors
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What about psychological and
emotional problems?
 Oncologists often prescribe medications for sleep
problems, anxiety, and depression during treatment
 Many patients remain on them after treatment
 Evaluate and manage as you would in any other patient
 Refer to appropriate mental health practitioners
 Concerns about cancer recurrence may be high
 Suicidal ideation may be increased
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is the role of exercise and
rehabilitation?
 Maintains healthy body composition and image
 Improves quality of life, and aids in managing fatigue,
mood disorders, and sleep problems
 The goal is a return to normal activities
 Low- to moderate-intensity activity doesn’t usually
require formal evaluation
 For more vigorous exercise, follow guidelines for
exercise testing before starting
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is the role of complementary and
alternative medicine?
 Can help survivors take active role in improving health
 The emphasis on QOL improves mental outlook
 Acupuncture, meditation, yoga, dance therapy, art therapy
 Improve menopausal symptoms
 Relieve fatigue, pain, and sleep problems
 Help manage fear of recurrence and reduced QOL from longterm treatment
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What about employment, insurance,
and disability?
 Personal and work lives are affected by cancer
 Survivors may hesitate to disclose their diagnosis because of
concerns about
Employment and work advancement
Insurance
Personal relationships
 Be prepared to discuss these issues
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Additional
Issues in Follow-up Care…
 Care for cancer survivors can be complicated and challenging
 Provide surveillance and screening for cancer recurrence
 Ensure social, psychological, and economic well-being
 Be familiar with available resources
 Provide referrals as indicated

PT and OT for neurocognitive evaluations

Acupuncture and other supportive services

Pain management teams

Social service agencies
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.