© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View

© Copyright Annals of Internal Medicine, 2011Ann Int Med. 155 (3): ITC2-1.

* For Best Viewing:

Open in Slide Show Mode Click on icon or

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* To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide


in the clinic

Care of the Adult Cancer Suvivor


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


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)


Which types of clinicians shouldprovide 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


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


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


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


What pulmonary conditions shouldthe 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


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


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


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


What other medical issues should the clinician consider?

Second malignant neoplasms

Endocrinopathies

Neurotoxicity, ototoxicity, nephrotoxicity

Lymphedema


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


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


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


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


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


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


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


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


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 long-term treatment


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


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

Documents

© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View