©2014 MFMER | slide-1 Survivorship for “cured” Hodgkin patients – How should we be following them? Carrie Thompson, MD Mayo Clinic Lymphoma & Myeloma 2014

©2014 MFMER | slide-1

Survivorship for “cured” Hodgkin patients – How should we be following them?Carrie Thompson, MDMayo ClinicLymphoma & Myeloma 2014


Disclosures

• I have nothing to disclose


Outline

• Surveillance for relapse

• Screening for late effects• Cardiovascular disease• Secondary malignancies• Psychosocial issues

• Care models


Background: Survivorship

• 13.7 million cancer survivors in the US• ~200,000 survivors of HL• Decreased survival compared to general pop

SEER Cancer Statistics Review, 1975-2008, NCI. JCO 2003; 21:3431-9


Do surveillance scans improve outcomes in HL?

Cancer 2014;120:2122-9


Surveillance for relapse

• Negatives of routine scans• Radiation exposure• False positives• Anxiety• Cost


Surveillance guidelines

• Physical examination, history, and clinical judgement are the cornerstone of followup

• Q 3 mos years 1-2, q 4 mos year 3, then q 6 mos years 4-5

• Imaging studies• NCCN

• CXR or CT chest and CT A/P q 6-12 mos x 2 yrs• Lugano Classification

• Routine scans are discouraged• Scans prompted by clinical indications

NCCN.org Version 2.2014JCO 2014; 32:3059-67


Monitoring for Late Effects

• Cardiovascular disease

• Secondary malignancies

• Psychosocial issues

• Other


Congestive heart failure: chemotherapy agents

• Cytotoxic agents• Doxorubicin, cyclophosphamide,

ifosfamide, cisplatin, fluorouracil, paclitaxel

• Targeted agents• mTOR inhibitors• PI3 kinase inhibitors• Trastuzumab• Bevacizumab


Congestive heart failure in HL

• Subclinical (asymptomatic, echo abnormal)• 27.6% in lymphoma survivors1

• Do not know if this will lead to clinical CHF

• Clinical CHF• 7.2% incidence with 6 year followup2

• May become evident during times of increased cardiac workload

• Pregnancy, anesthesia, BMT, illness

1JCO 1998; 16:3502-8 2Ryberg 1998


Coronary artery disease in HL

• Caused by radiation therapy

• Prospective study in 294 survivors of HL• ≥35 Gy to mediastinum• Excluded patients with known CVD• Nuclear study and stress test

• 40 patients (14%) underwent coronary angiography

• Coronary artery stenosis >50% in 22 patients• 7.4% of those screened

JCO 2007; 25:43-9 Blood 2007; 109:1878-86


CAD in HL

• Coronary CT angiography in 31 adult survivors of childhood HL with hx radiation therapy

• ECG, treadmill stress test, echo

• 12 (39%) patients with coronary lesions• 3 (10%) with obstructing lesions on coronary

angiogram• 2 of these 3 died from CVD

• All had abnormal ECG, 1 abnormal treadmill, 0 abnormal echo

Cancer 2014; Jul 16 Epub


Other cardiac diseases

• Valvular disease• Predominantly mitral and aortic valves

affected

• Pericardial disease• Historically most commonly affected cardiac

structure

• Conduction system• Arrhythmias and QT prolongation


Cardiac Follow-Up Expert Guidelines

©2011 MFMER |

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JCO 2011; 29:1885-1892Annals Onc 2012; 23:Suppl 7

JASE 2014;27:911-39


Screening Recommendations: CVD

• Annual physical exam• BP check• Lipids every 3-5 years• Glucose annually

• Particularly if hx paraaortic LN xrt

• Treat cardiac risk factors

• Lifestyle modifications

JCO 2009; 27:5383-89

JCO 2014; 32 Epub


Benefits of exercise

JCO 2014; 32 Epub


Screening Recommendations: CVD

• Post-radiation therapy• If >30 Gy to mediastinum

• Stress test (exercise stress echo) starting 5-10 years post therapy then q 5 years

• Post anthracycline chemotherapy• If >240 mg/m2 doxorubicin

• Echo starting 5 years after treatment then q 5 years


For female cancer survivors contemplating pregnancy

• Refer to cardiology if…• >240 mg/m2 anthracycline dose• >30 Gy radiation to the heart or surrounding

tissue• Any combination of the above with high-dose

cyclophosphamide


Late Effects: Secondary Malignancies

• Breast cancer• In those treated for childhood HL, estimated

incidence of breast cancer 20% at age 45

• Thyroid cancer

• Lung cancer • Risk significantly increases in those who

smoke after radiation therapy

• Gastric/colorectal cancers

• Sarcoma

JCO 2007; 25:1489-97


Types of secondary cancers, continued

• AML/MDS• Mostly due to chemotherapy (alkylators)

• NHL• ~5% lifetime risk in those treated for Hodgkin

lymphoma

• Skin cancers


Recommendations for those at risk

• Annual skin exam in irradiated field

• Annual mammogram (+/- MRI) 8 years after radiation or at age 40, whichever is earlier

• Colonoscopy 15 years after pelvic, abdominal, spinal irradiation or at age 35

• Tobacco cessation

• ?low dose CT scan chest

• ?EGD

• Life-long surveillanceAm J Med 2011; 12:1606-12


Fertility Issues

• Very important issue

• ABVD does not affect fertility

• Fertility preservation pre-treatment

• Wait 2 years post-treatment to have children• No increase in birth defects, miscarriage,

cancer in offspring compared to general population

www.fertilehope.org


Fatigue

• 26% of survivors of Hodgkin lymphoma have significant fatigue

• Higher than general population, other cancer types

• Fatigue associated with higher symptoms of anxiety and PTSD and lower QOL

• Unclear etiology, literature suggests may be related to long term health complications

JCO 1999; 17:253-61, JCO 2005; 23:6587-95, Thompson 2009


Loss of Immunity: for all HL survivors

• NO live vaccines• No shingles vaccine, influenza vaccine live

• Influenza vaccine annually

• Tdap/Td q 10 years

• HPV vaccine if <age 26

• Pneumococcal vaccine• PCV-13 followed by PPV26 8 weeks later,

second dose PPV26 5 years later• If <age 60, PPV26 at age 65

http://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html


Loss of Immunity

• If splenectomy or splenic RT• Meningococcus, HIB, PCV13 at time of

treatment• PPV23 8 weeks later then 5 years later• Meningococcus q 5 years

• If hematopoietic stem cell recipient• More complicated revaccination schedule


Depression and Anxiety in Cancer Survivors

• Depression higher than general population in 1st 2 years after diagnosis, then no different

• Anxiety levels higher than general population and tend to persist

Lancet Oncology 2013; 14:721-32


Anxiety in Lymphoma Survivors and Spouses

Lancet Oncology 2013; 14:721-32


Survivorship Care Models

• Primary care providers not trained in care of long-term cancer survivors

• Communication and coordination of care is key• Survivorship care plan

• Treatment summary• Follow-up care plan

JOP 2014; Epub 10/14/14www.asco.org


Does education and screening for late effects decrease QOL?

Int J Rad Onc Biol Phy 2014; 90:164-71


Summary

• Surveillance for relapse• Physical examination, history, and clinical

judgement are the cornerstone of followup

• Late effects• Cardiovascular disease, secondary

malignancies, fatigue, fertility, loss of immunity, psychosocial issues

• Coordinated care


Thank you!

[email protected]

Documents

©2014 MFMER | slide-1 Survivorship for “cured” Hodgkin patients – How should we be following them? Carrie Thompson, MD Mayo Clinic Lymphoma & Myeloma 2014