4 most common cancers people survive from?
Breast, prostate, colorectal and melanoma
4 models of cancer survivorship care
1) Academic/Oncology-Based: resource intense and organized by cancer or tx type 2) Shared: patient care is shared between 2+ specialties (PCP and oncologist) 3) Community-Based: care provided by PCP and PCP refers patient to specialists as needed 4) Nurse Practitioner managed care: NP follows survivors and acts as a bridge between primary care and oncology
2 types of academic and community models of cancer survivorship care
1) Multidisciplinary: lots of specialists evaluate patient at single visit 2) Disease/Tx specific: follow-up clinic is specific for the disease and treatment
What is the difference between family practitioners and cancer centers in cancer survivor follow up care?
Outcomes are fairly similar, however, family practitioners do not fell as confident identifying recurrence.
Tier 1 elements of cancer survivorship care (things that MUST be provided)
Care plan (including psychosocial care) w/treatment summary, screening for new cancers and surveillance of recurrence, PCP and oncology coordination strategy, health promotion education, symptom management/palliative care.
Components that go into an oncologist’s survivor care plan
1) Dx and Tx summary 2) Schedule for follow up visits 3) Schedule for follow up tests 4) Late and long term effects 5) Symptoms to look out for
What things are critical to managing survivorship issues?
Accurate medical information, dates of Tx, types of surgeries, location/doses of radiation and types/doses of chemotherapy.
Curative intent chemotherapy
Intense & given for a period of time and then stopped. This includes adjuvant chemotherapy after surgical resection. The exception to this rule is CML, where chemotherapy may be required indefinitely.
Cure is note expected, but therapy is given to control symptoms, stabilize disease, improve progression free survival and overall survival. This is commonly used when trying to get metastatic disease under control and you must find a balance between survival, quality of life and toxicity.
When does cancer survivorship begin
At time of diagnosis
Issues that come up after diagnosis of cancer
1) Toxicity of therapy 2) Genetics: is my kid susceptible? 3) Neurocognitive changes (chemo brain) 4) Fear of recurrence after chemo has completed and surveillance begins 5) Secondary malignancy and organ damage from treatment
A 40 year old childhood leukemia survivor presents because he is worried about recurrence, secondary malignancy and premature death. He was diagnosed at age 3, relapsed at age 5 and has been in remission since finishing maintenance therapy at age 8. He was given vincristine, dexamethasone, doxorubicin, L-asparaginase, MTX, 6-mercaptopurine, cyclophosphamide and AraC. What do you want to check? What do you tell him about his risk for recurrence?
If he had AML, it’s about 2% recurrence rate. Secondary tumors have developed from cyclophosphamide and etoposide use 15 years after Tx, but he is well beyond that. If he had ALL, it is nearly 0%. All patients who have been irradiated have 11% greater incidence of cancer 30 years after radiation, but he was not irradiated so that is good. I would check TSH, exposure to known carcinogens, get a detailed physical exam and encourage age-appropriate cancer screening.
Most common secondary CNS neoplasms seen in patients who received cranial spinal XRT?
Most common secondary carcinomas in patients who received XRT?
Basal cell carcinoma
Other common secondary neoplasms in patients who received XRT?
Thyroid, parotid, SCCa and sarcomas
A 40 year old childhood leukemia survivor presents because he is worried about recurrence, secondary malignancy and premature death. He was diagnosed at age 3, relapsed at age 5 and has been in remission since finishing maintenance therapy at age 8. He was given vincristine, dexamethasone, doxorubicin, L-asparaginase, MTX, 6-mercaptopurine, cyclophosphamide and AraC. After a preliminary evaluation you note that he has a BMI of 28 and ALT/alk phos are elevated. What concerns do you have?
Cardiovascular risk (cancer survivors have increased risk of death from CVD and CVA, CVA especially when exposed to CNS XRT), metabolic syndrome (more prevalent in patients that received CNS XRT at a young age) and infection from transfusions (should be screened for hepB and hepC because he received transfusions prior to 1990). He was also exposed to doxorubicin which (along with daunomycin) can cause cardiomyopathy and CHF 20-30 years down the road. This is especially prevalent when young kids are exposed.
A 55 year old woman has a history of nodular sclerosing stage IIIB Hodgkin lymphoma. She has had a splenectomy. At age 20 she received “MOPP” and “ABVD” chemotherapy. She received 40Gy mantle radiation to the mediastinum. What are some red flags in this patient?
Chemotherapy: Mechlorethamine and procarbazine are alkylating agents and can cause leukemia and/or myelodysplastic syndromes, bleomycin can cause pulmonary fibrosis and doxorubicin can cause cardiomyopathy. Radiation: mantle irradiation hit thyroid (if hypothyroidism is untreated, increased risk for cancer), heart (accelerated atherosclerosis) and breasts (increased risk for breast CA). Splenectomy: did she receive pre-op vaccinations?
A 55 year old woman has a history of nodular sclerosing stage IIIB Hodgkin lymphoma. She has had a splenectomy. At age 20 she received “MOPP” and “ABVD” chemotherapy. She received 40Gy mantle radiation to the mediastinum. How do you manage this patient?
CBC (r/o MDS), PFT (r/o pulmonary fibrosis), lipid panel, fasting blood glucose, BP, echo. Get TSH (r/o hypothyroidism), EKG and mammography (30% incidence of breast CA w/chest radiation as a young female). Educate about risks of splenectomy (sepsis, encapsulated bacteria, CMV and parasite infections)
A 52 year old woman has stage II ER/PR +, Her2 -, node - breast adenocarcinoma. She had a lumpectomy followed by doxorubicin, cyclophosphamide, paclitaxel, trastuzumab, radiation to the breast and anastrazole for 5 years following. She has a family history of breast cancer and has 2 daughters she is worried about. What things are you worried about in this patient?
Accelerated bone loss (anastrazole), cognitive function, cardiomyopathy (doxorubicin or trastuzumab), myelodysplasia/secondary leukemia (cyclophosphamide).
How do you perform a risk assessment for other family members of a cancer survivor?
Cancers that show an increased incidence with BRCA1/2 mutations
Female breast, ovarian, male breast and prostate.
Testing in patients who have Lynch Syndrome (HNPCC)
MLH1, MSH2, MSH6, PMS2 on all colon cancer tumors and endometrial cancers (age 60 and younger). Note that the majority of these mutations are sporadic and 10-30% are actually familial.
Gene mutated in patients that get colon cancer sure to FAP (Familial Adenomatous Polyposis)