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Flashcards in Primary Care for Cancer Survivors Deck (39):
1

Describe a cancer survivor?

A cancer survivor is anyone who has been diagnosed with cancer from the time of initial diagnosis until the end of their life.

2

Estimated number of persons alive by site:
Top 4?

Female breast – 23%
Prostate – 19%
Colorectal – 10%
Gynecological – 9%

Other GU (Bladder & Testis) – 6%
Hematologic – (HD, NHL, Leukemia) – 7%
Melanoma – 6%
Lung – 3%
Other – 17%

3

What are the types of Sequelae of cancer treatment and describe them?
4

1. Physical/Medical – Second cancers, cardiac dysfunction, pain, lymphedema, sexual impairment, infertility

2. Psychological – Depression, anxiety, uncertainty, isolation, altered body image

3. Social – Changes in interpersonal relationships, concerns regarding health or life insurance, career issues, return to school, financial burden

4. Existential and Spiritual Issues – Sense of purpose or meaning, appreciation of life

4

Optimal healthcare delivery to this unique population, cancer survivors, requires the establishment of necessary infrastructure, including several key components?
3

(1) A longitudinal care plan utilizing a comprehensive multidisciplinary team approach

(2) Continuity, with a single healthcare provider coordinating needed services

(3) An emphasis on the whole person, with sensitivity to the cancer experience and its impact on the entire family

5

Survivors at highest risk for late term effects include (also state the most common long term problem):
3

1. Bone tumors – These patients commonly experience disfigurement and functional limitations caused by amputations and other surgeries.

2. CNS tumors – Often the most severely affected, particularly if they received radiation, chemo and surgery. Potential difficulties include:

3. Hodgkins lymphoma – Patients may
-experience lung damage,
-abnormal skeletal growth and maturation,
-infertility,
-hypothyroidism

6

Additional late term effects for the following cancers:
1. Bone tumors? 3
2. CNS tumors? 8
3. Hodgkins? 1

1.
-problems with fertility,
-heart and kidney damage and
-second cancers related to treatment

2.
-Cognitive impairment,
-short stature,
-hearing loss,
-problems with balance and coordination,
-hypothyroidism,
-thyroid nodules,
-kidney damage and
-second cancers

3. Females who received chest radiation are at increased risk for breast cancer up to 26% greater than that of national average

7

In some studies 60% of survivors of pediatric cancer will have some disability secondary to treatment.
Such as?
6

1. Secondary malignancies
2. Growth complications
3. Endocrine complications
4. Cardiopulmonary complications
5. Renal complications
6. Neuropsychological/Psychosocial complications

8

1. Secondary malignancies
Up to 12% of pediatric patients will develop a new cancer within 20 years. ___x increase over the general pediatric population

2. What are the most common causes of this? 2

3. Genetic and familial conditions increase the risk of certain malignancies such as?
3

1. 10

2. Exposure to
-alkylating agents and
-radiation therapy

3.
-Retinoblastoma,
-neurofibromatosis,
-nevoid basal cell carcinoma

9

Growth complications are a result of what?

A result of direct damage to endocrine tissue

10

1. Children with what are at highest risk? 4

2. 90% of patients that receive less than 30 Gy of radiation to the CNS will show growth hormone deficiency within __ years and 50% receiving 24 Gy

3. Children under the age of __ at the time of radiation are the most vulnerable

4. These patients may benefit from receiving what therapy?

1.
-ALL,
-brain tumors,
-orbital tumors and
-nasopharyngeal cancers who have received radiation

2. 2

3. 5

4. growth hormone

11

Primary Care for Cancer Survivors.
Growth complications:
3

1. Spinal radiation inhibits vertebral body growth.
2. Asymmetric exposure of the spine may result in scoliosis.
3. Chemotherapy alone may result in an attenuation of linear growth.
-This, however, is usually temporary, as a period of catch-up occurs when the drugs are discontinued.

12

Primary Care for Cancer Survivors.
Endocrine complications:
1. In addition to growth hormone deficiency, prepubertal children given cranial radiation may experience early puberty secondary to what?

2. Results in?

3. more common in who?

1. premature activation of the hyptholamic-pituitary-gonadal axis.

2.
-premature closure of the epiphyses, which translates to decreased growth and height.

3. More common in girls.

13

Endocrine complications:
1. What is common in those receiving brain/neck radiation?

2. This can manifest as early as what and as late as what?

3. They will usually have normal what with an abnormal what?

4. They should be considered for what kind of therapy?

5. because persistent stimulation of the thyroid from an elevated TSH may predispose them to what?

1. Thyroid dysfunction

2. 6 months, 7 years

3. thyroxine levels, TSH

4. thyroid replacement

5. thyroid nodules and carcinomas.

14

Endocrine complications:
1. Gonadal dysfunction from radiation can result in what? 3

2. Patients who receive what?
3. as part of therapy for what are at highest risk? 3

4. Ovarian dysfunction from radiation can result in what? 3

1.
-azospermia,
-low testosterone levels and
-delayed sexual development

2. testicular radiation

3.
-ALL,
-abdominal radiation for Hodgkin’s or
-total body radiation

4.
-failure to undergo menarche,
-increased FSH and LH levels
-and low estrogen

15

1. Endocrine complications:
Girls receiving what may also develop delayed menses and are at risk for early menopause?

2. Women who have received abdominal radiation and develop uterine vascular insufficiency or fibrosis of the abdominal and pelvic musculature or uterus may have an increased risk of what?

3. So what should be considered high risk?

1. craniospinal radiation for ALL

2.
-perinatal death or
-low-birth-weight,

3. premature infants and their
pregnancies should be considered high-risk

16

1. Cardiopulmonary complications:
Several chemotherapeutic agents are known to cause cardiopulmonary dysfunction, such as?
4

2. May also cause what kind of pulmonary manifestations? 2

3. Anthracyclines cause what kind of Cardio complications?
2

1.
-Bleomycin,
-the nitrosoureas,
-cyclophosphamide,
-methotrexate

2.
-May also cause pulmonary fibrosis
-Restrictive lung disease (decreased carbon monoxide diffusion and small lung volumes)

3.
-Congestive heart failure (myocytes are destroyed and lead to inadequate myocardial growth as the child ages)
-Arrhythmias are also common due to changes in the electrical cell structure

17

Radiation therapy to the mediastinal region has been linked to what? 2

Children treated under the age of ___ with mediastinal radiation or anthracycline are at greatest risk

1. increased risk of CAD and
2. chronic restrictive pericarditis


4

18

Renal Complications: Most long-term renal complications stem from what?

chemotherapy

19

Renal Complications:
1. Cisplatin may cause what? 2

2. Cyclophosphamide can cause what? Which leads to what?

3. Ifosfamide can cause what which may result in what if adequate phosphate replacement is not provided?

1.
-an abnormal glomerular filtration rate and
-persistent tubular dysfunction

2. hemorrhagic cystitis which can lead to increased chance of bladder CA

3. Fanconi syndrome, clinical rickets

20

What is Fanconi syndrome? 4

What is clinical rickets? 1

1.
-proteinuria,
-glycosuria,
-phosphaturia with
-hypophosphatemia

2.
-hypophosphatemic rickets as opposed to nutritional rickets

21

Neuropsychological complications:
1. Which pts are at highest risk? 2

2. Severity depends on what? 4

3. Why are girls more suseptible to CNS toxicity?

4. The main effects of CNS radiation appear to be related to what? 4

1. Patients who
-received cranial radiation for
ALL or
-brain tumors

2. Severity depends on
-dose,
-size and location of radiation field,
-child’s age when radiation was administered and
-gender

3. Girls appear to be more susceptible to CNS toxicity because they have more rapid growth development during childhood

4. The main effects of CNS radiation appear to be related to
-visual processing speed,
-visual motor integration,
-sequencing ability and
-short-term memory

22

1. What may cause Psychosocial Complications in cancer survivors?

2. Adolescent survivors may demonstrate an increased sense of physical fragility and vulnerability manifested by what? 2

1. Absence from school, frequent medical appointments and hospitalizations may lead to social isolation

2.
-hypochondria or
-phobic behaviors

23

Primary Care for Cancer Survivors
Surveillance:
Medical Goals? 3
Psycho-social goals? 3

1.
-Early recognition and treatment of late effects
-Improve quality of life
-Decrease healthcare costs

2. Psycho-social Goals:
-Establish “new normal”
-Social life
-School and work

24

Surveillance caveats:
1. Over screening can cause? 3

2. Underscreening can cause? 4

1. Over Screening
-Undue fear
-Unnecessary screening
-High costs

2. Under Screening
-Missed late effects (potentially life threatening)
-Missed early intervention
-Missed chance to minimize morbidity
-Long run – higher healthcare costs

25

Surveillance:
What every survivor should know? 5

1. What kind of cancer they had
2. What kind of chemotherapy they received
3. What kind and how much radiation they received
4. Any adjunct therapy
5. Name of their oncologist/radiation oncologist

26

Surveillance: Routine monitoring
1. What do we need to monitor with CNS radiation?

2. What do we need to monitor with Chest radiation? 4

1.
-Growth needs to be closely monitored, and
-neuro-psych screening yearly

2.
-Thyroid monitoring,
-pulmonary function testing,
-cardiac workup for cardiac toxicity,
-breast CA monitoring in females

27

What kind of growth problems need to be monitored for?
5

1. height,
2. weight,
3. growth velocity,
4. scoliosis screening,
5. possible growth hormone testing)

28

Surveillance: Routine monitoring:
Abdominal/pelvic radation

1. Renal? 6

2. Males? 4

3. Females? 3

1. Renal –
-UA,
-CMP,
-eGFR,
-blood pressure,
-renal US,
-possible cystoscopy

2. Males –
-monitor testicular size,
-semen analysis,
-testosterone levels,
-FSH & LH levels

3. Females –
-Detailed menstrual history,
-FSH & estrogen levels,
-uterine US

29

Example of monitoring for cardiac toxicity:

1. Which factors would put you in a low risk cateogory for cardiac toxicity? 3

2. Moderate? 3

3. High? 3

1. Low risk:
-Anthracyclines 5 y.o at treatment

2. Moderate risk:
-Radiation to chest or neck
-Anthracyclines >250mg, less than 400mg
-Age less than 5 with any Anthracyclines

3. High risk:
-Anthracyclines plus radiation to chest
-Anthracyclines > 400mg
-Pre existing cardiac disease plus anthracyclines

30

Primary Care for Cancer Survivors: Goals of followup care?
4

1. Prevent premature mortality
2. Prevent or detect early physiologic or psychosocial sources of morbidity
3. Manage (or refer for management) of co-morbidities
4. Screen for 2nd cancers

31

Surveillance after breast cancer. 1. Surveillance for recurrence?
3

2. Surveillance for secondary cancers? 3

1. Surveillance for recurrence:
-Monthly self-breast examination,
-clinical breast exam every 6 months for 5 years and then annually,
-mammography annually

2. Surveillance for secondary cancers:
-Increased risk for ipsilateral and contralateral breast CA,
-ovarian and
-colorectal CA

32

Primary Care for Cancer Survivors
Surveillance after breast cancer:
1. Physical exam? 4

2. Psychosocial? 4


1.
-Lymphedema,
-premature menopause,
-osteoporosis,
-uterine CA

2.
-Distress about risk of recurrence,
-sexuality,
-body image,
-depression, anxiety

33

Surveillance after breast cancer:
Other considerations:
6

1. Assess age at diagnosis and family cancer history

2. Consider referral for genetic counseling for BRCA1 or BRCA2 mutations

3. Annual pelvic exam

4. Screening for colorectal and cervical cancer

5. Pneumococcal and influenza vaccinations

6. Assess psychosocial function

34

Surveillance after prostate cancer:
1. Surveillance for recurrence? 3

2. Surveillance for secondary cancers: Increased risk for?

1.
-Clinical evaluation,
-PSA every six months for five years, and then annually,
-digital rectal exam annually


2. bladder cancer

35

Surveillance after prostate cancer:
1. Physical exam? 4
2. Psychosocial? 2

1. Physical exam:
-Sexual dysfunction,
-bowel or urinary incontinence;
-radiation proctitis or
-diarrhea

2. Psychosocial
-Depression,
-sexuality

36

Surveillance after prostate cancer:
Other considerations?
5

1. Assess age at diagnosis and family history of CA
2. Consider referral for genetic counseling and assessment if strong family history
3. Colorectal cancer screening
4. Pneumococcal and influenza vaccinations
5. Assess psychosocial function

37

Surveillance after colorectal cancer:

Surveillance for recurrence? 4

Surveillance for secondary cancers? 1

Surveillance for recurrence
1. CEA,
2. clinical exam every three months for 2 years, and then every six months for 3-5 years,
3. CT scanning every 3-6 months for 2 years and then every 6-12 months for a total of 5 years.
4. Colonoscopy after one year, and then at three years, and then every five years

Surveillance for secondary cancers:
1. Colorectal cancer at a different site

38

Primary Care for Cancer Survivors
Surveillance after colorectal cancer:
1. Physical exam? 4

2. Psychosocial? 3

1. Physical exam:
-Ostomy care,
-rectal incontinence,
-radiation proctitis or diarrhea,
-adhesions

2. Psychosocial:
-Sexuality,
-body image,
-depression

39

Surveillance after colorectal cancer: Other considerations?
5

1. Assess family cancer history for familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer

2. Refer for genetic counseling and assessment

3. Breast and cervical cancer screening

4. Pneumococcal and influenza vaccinations

5. Assess psychosocial function