Transcript Moving Forward after Cancer - The Manitoba College of Family

Moving Forward after Cancer
Caring for patients in primary care
after cancer treatments are done
Developed by:
Brent Kvern MD, CCFP, FCFP
Associate Professor,
Department of Family Medicine, University of Manitoba
Jeff Sisler MD, MClSc, CCFP, FCFP
Director - Primary Care Oncology, CCMB
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Conflict of Interest Disclosure

No consultant or speaker fees

Received a grant from the Canadian
Partnership Against Cancer to develop this
session
A question…
A 61 year old patient
of yours who
completed treatment
for breast cancer 3
months ago is your
next patient.
What is on your mental
“to-do” and “to-talkabout” list for this and
upcoming visits?
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Objectives
•
Define survivorship phase of cancer.
•
Apply a new framework to consider the
care needs of cancer patients in follow-up
•
Be familiar with important tasks in breast
and colorectal cancer follow-up care
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Cancer Survivorship
A distinct phase in the cancer trajectory
following primary treatment, lasting until
recurrent or end-of-life.1
Diagnosis
1Bell
Acute
Phase
K, Scalzo K, Stephen J, BC Cancer Agency, 2007
Survivorship
or Chronic
Phase
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The survivorship phase
Number of adult
cancer survivors
is > 1 million and
will double by
the year 2050
Age of cancer survivors2
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A new perspective

Think about patients who’ve finished cancer
treatment like your patients with a recent MI
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A new perspective





Survived something potentially lethal
Need close monitoring for recurrence.
Need an aggressive approach to risk reduction
Lifestyle issues very important
Your role as a FP/NP is critical to rehabilitation
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4 essential physician tasks
Our framework of survivorship
HEALTH PROMOTION / PREVENTION
FAMILY CANCER RISKS
CANCER RELATED MONITORING
MANAGEMENT
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2
P FRiM
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Health Promotion
Prevention

Promotion of healthy behaviours

Screening for new cancers

Age appropriate screening for other medical
conditions
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Family Cancer Risks
Assessing the risk of family members
• Modifying THEIR risk factors
• Recommending a screening plan
• Referring for genetic testing
Assessing family and marital health
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Monitoring
•
Watching for recurrence of the primary
cancer
•
Monitoring for worrisome “late effects”
– Cardiomyopathy
•
Monitoring rehabilitation and recovery
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Management

Side-effects of cancer treatments
• Physical
• Psychological
• Social

Ongoing care for any non-cancer conditions
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Colorectal Cancer
Sunga AY, et al. Am Fam Physician, 2005
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Colorectal cancer
Background information

Most recurrences in the first 3 years
• Liver – most common site metastases
o
•
•
•
20% of those with liver metastases are
candidates for resection
10%- local recurrence at original site
30% - no rise in CEA
No delayed / late effects of
chemotherapy
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Colorectal cancer
Health promotion & prevention

Exercise
 4 hours a week of activity associated with 53%
reduced recurrence and CRC mortality regardless of
stage, age, BMI or previous activity level.

Smoking Cessation

Medications for secondary prevention
•No

role yet for NSAIDs, ASA
BMD of hip if pelvic radiation therapy given
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Colorectal cancer
Family Cancer Risks
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If index patient is
diagnosed…
Recommendations
Before age 60 years
All asymptomatic 1st degree relatives, starting at
age 40 (or 10 years earlier than patients age at
diagnosis) need colonoscopy Q5 years
After age 60 years
All asymptomatic 1st degree relatives, starting at
age 40 yrs are at slightly above average risk.
FOBT Q2 years followed by colonoscopy if any one
sample if positive.
After age 60 years &
All asymptomatic 1st degree relatives, starting at
age 40 (or 10 years earlier than patients age at
diagnosis) need colonoscopy Q5 years
another 1st degree
relative also has a
diagnosis of CRC at any
age
Family history of
known hereditary
syndrome
Referral for specialist assessment
Colorectal cancer
Monitoring
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Monitoring
Visit frequency
• Q3 months for 3 years following
treatment
• Q6 months for next 2 years
• Annually thereafter
Test to DO
• CEA at each visit for first 3 years
• CT chest and abdomen – annually for
first 3 years
• Colonoscopy – 1 year after initial
diagnostic scope, then at 3 years, then
every 5 years afterward
Tests NOT TO DO
• routine CBC, LFTs
• routine CXR
• FOBT
Colorectal cancer
Management

Cancer related fatigue
•
•
Consider other etiologies
Physical activity works!
Peripheral neuropathy from oxaliplatin
 Radiation proctitis
 Diarrhea
 Sexual dysfunction

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Colorectal cancer
Management

Anxiety
•
Consider possibility PTSD like reaction
Employment difficulties
 Insurance difficulties
 Social well-being

•
“How are things going between you and your
partner?”
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Breast Cancer
Non
survivors
12%
5 year survival rates
Sunga AY, et al. Am Fam Physician, 2005
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All Oral Cancer Treatments
now fully covered!
Tamoxifen and AIs free for patients as of
April 19, 2012
 Existing patients should already be
identified by the DPIN system
 Pharmacare registration needed

 Call the Provincial Drug Program at 786-
7141 or 1-800-297-8099

Help! ? Call the CCMB Pharmacy at
787-4591
Breast Cancer
Background information

Recurrences usually occur within five years.
• Peaks at 2nd yr after surgery
o
•
Non-specific symptoms are common
indicators of relapse
o
•
Risk declines with time but continues for at least
20 years.
Weight loss / Persistent cough / Breast
changes / Chest wall changes / Adenopathy
75% recurrences found by the women
themselves
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Breast cancer
Health promotion & prevention

Exercise
Cohort studies suggest a 50% survival advantage for
breast cancer survivors over those not physically
active
Most beneficial in ER+ tumours

Diet

Medications for secondary prevention
•Tamoxifen,

aromatase inhibitors (AIs)
BMD and/or bisphosphonates if AIs used
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Breast cancer
Family Cancer Risks
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Inherited Risk for Breast
Cancer
Mutations of BRCA1 or BRCA2
cause about 5-10% of breast
cancers
• Usually cancer occurs early in life.
• Strong family history
Criteria for referral for genetic
counselling
• Breast cancer at age <35 yrs
• Bilateral breast cancer at age <50 yrs
• Ovarian cancer <60 yrs
• Breast and ovarian cancer <50 yrs
• Two or more ovarian cancers, any age
• Male breast cancer
• Ashkenazi Jewish or Icelandic descent
If patient BRCA +ve
• Family members need to know
• Initiate screening at age 25 with MRI
(or five years younger than earliest
reported cancer in the family)
Breast cancer
Monitoring
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Monitoring
Visit frequency
• Careful history and physical exam
• Q3 -6 months for 3 years
• Q6-12 months for next 2 years
• Annually thereafter
Test to DO
• Mammograms annually for life.
Tests NOT to do
• routine CBC, LFTs
• routine CXR
• routine bone or liver scans
• routine tumour markers
Breast cancer
Monitoring

Breast cancer survivors have an increased risk
of a second primary cancer
• Often involving
ipsilateral breast
contralateral breast
colon?
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Monitoring
Congestive
Cardiomyopathy
• From anthracyclines (doxorubicin,
epirubicin, trastuzumab)
• Can present 10-15 years after chemo
• Be alert for CHF symptoms
Myelodysplasia
or
Leukemia
• Associated with cyclophosphomide
• Rare
•No screening recommended.
Breast cancer
Management
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Cancer related fatigue
•
•
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Menopause
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•
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Rule out other etiologies (drugs, depression,
cardiac, thyroid, anemia)
Physical activity, yoga
Related to chemotherapy
Retrospective studies have not shown harm with
HRT
no RCT has been performed to allow confident
use
Osteoporosis
•
Check for AI use
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Tamoxifen
•Hot flashes and night sweats
•SSRIs can partially alleviate
•Avoid paroxetine, fluoxetine,
bupropion
• Venlafaxine drug of choice
Aromatase
inhibitors
• Post-menopausal women only
• Arthralgias and aches: NSAIDs, time
Anastrozole
Letrozole
Exemestane
• Switch to a different AI or Tam if not
tolerable
Breast cancer
Management

Peripheral neuropathy



Post treatment cognitive impairment or
“Brain fog”
•

If treated with taxanes (docetaxel)
Use gabapentin*, pregabalin, tricyclics*
Rule out or address other aetiologies (drugs, depression)
Chronic Pain
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Breast cancer
Management
Sexual dysfunction
 Anxiety

 Fear of recurrence: Consider CBT
Employment and insurance difficulties
 Social wellbeing

 “How are things going between you and
your partner?”
In closing:
Caring for Cancer Survivors

A distinct phase in the cancer continuum.

Increasingly a responsibility of primary care

Cancer survivors are at increased risk – think of
them like post-MI patients
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4 essential physician tasks
Our framework of survivorship
HEALTH PROMOTION / PREVENTION
FAMILY CANCER RISKS
CANCER RELATED MONITORING
MANAGEMENT
2
2
P FRiM
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Moving Forward after Cancer
Dr Jeff Sisler
[email protected]
Questions?
Call the UPCON Helpline at (204) 226-2262