The Young Adult Cured of The Young Adult Cured of Cancer in ChildhoodCancer in Childhood

Melissa M. Hudson, M.D.After Completion of Therapy

ClinicSt. Jude Children’s Research

Hospital

Transition of Care After Pediatric Transition of Care After Pediatric CancerCancer

Transition of Care After Pediatric Transition of Care After Pediatric CancerCancer

Cancer Diagnosis

Long-Term Survival

Health &Resilience

Primary PreventionRisk-adapted therapyFavorable: Reduce therapyUnfavorable: Intensify therapy

Secondary PreventionHealth educationCancer screeningTherapeutic interventions

PediatricHealth Care

AdultHealth Care

Optimal Care After CancerOptimal Care After Cancer Optimal Care After CancerOptimal Care After Cancer Longitudinal care from diagnosis to death. Comprehensive care including preventive

measures to reduce morbidity and mortality. Coordination of care by provider

knowledgeable about cancer-related risks working with multidisciplinary team.

Health care sensitive to cultural and spiritual values and issues of the cancer experience

Challenges to Providing Challenges to Providing CareCare

Challenges to Providing Challenges to Providing CareCare

Evolving therapies and late effects. Long latency to evaluate health

outcomes. Multiple factors contributing to cancer-

related health risks. Unknown effects of aging on many

treatment sequelae. Lack of consensus regarding screening

guidelines and risk reduction methods.

Challenges to Providing CareChallenges to Providing CareChallenges to Providing CareChallenges to Providing Care

Transitioning from oncology to primary care. Transitioning from pediatric to adult care. Lack of knowledge by primary care providers:

Cancer-related health risks Risk-reduction methods.

Lack of support from healthcare system for specialized survivor care, e.g., long-term follow-up programs.

Goals of After Therapy Goals of After Therapy CareCare

Goals of After Therapy Goals of After Therapy CareCare

To maintain cancer-free survival. To detect cancer-related complications

at early stages. To prevent, reduce, or correct cancer-

related complications. To optimize health and resilience.

Prevention of MorbidityPrevention of MorbidityPrevention of MorbidityPrevention of Morbidity

Identify factors predisposing to cancer-related morbidity.

Identify factors modifying cancer-related health risks.

Provide interventions to prevent, reduce, correct cancer-related morbidity.

Factors Contributing to Factors Contributing to MorbidityMorbidity

Factors Contributing to Factors Contributing to MorbidityMorbidity

Cancer-Related Morbidity

Host Factors

AgeGenderRace

Premorbid conditions

Treatment Factors

SurgeryRadiationChemotherapy

Health Behaviors

TobaccoDietAlcoholExerciseSun

Genetic

BRCA, ATM, p53polymorphisms

HistologySiteBiologyResponse

Tumor Factors

Aging

????? Treatment Events

RelapseVital Organ Toxicity

Risk-Based CareRisk-Based Care Screening/prevention plan that integrates

cancer experience with health care needs.

Considers risk for morbidity related to: Host: sex, race, age at diagnosis & follow-up Cancer: location, treatment modalities Genetic/familial predispositions Lifestyle habits Co-morbid health conditions

Case Study: Adult SurvivorCase Study: Adult Survivor 25 year-old female patient diagnosed with

Hodgkin’s disease at age 15 years Combined modality treatment with

COPP/ABV and mantle (21 Gy) radiation Family history: Mother - breast cancer at

42 years; Father - angioplasty at 44 years Social history: cigarette smoking, tanning

bed use; drinks alcohol socially; noncompliant with breast cancer surveillance

Review Risk FactorsReview Risk Factors Host: female, pubertal status during

treatment, 10 years after therapy Treatment: alkylating agents,

anthracycline, bleomycin, chest radiation Familial: pre-menopausal breast cancer,

early-onset coronary artery disease Lifestyle: tobacco, tanning, alcohol

Assess Late Effects RisksAssess Late Effects Risks Dental: xerostomia, accelerated dental decay Thyroid: hypothyroidism, thyroid nodules Cardiac: cardiomyopathy, atherosclerosis Pulmonary: restrictive lung disease Gonadal: infertility, early menopause Second malignancy, especially breast

cancer

Counsel to Promote HealthCounsel to Promote Health Inform of potential health risks. Address increased vulnerability Provide personalized risk information Establish priority health goals. Discuss benefits of protective behaviors. Discuss barriers to/personal costs Provide follow-up counseling.

Educate About Risks Educate About Risks

Cancer diagnosis and treatment Cancer-related health risks Behavioral factors affecting risk Risk reduction strategies

Address Increased Vulnerability

Address Increased Vulnerability

Sociodemographic factors Cancer treatment modalities Family history/genetic

predisposition Maladaptive behaviors Unknown impact of aging

Personalize Health Education

Personalize Health Education

Predisposing cancer treatments: Radiation, Adriamycin, bleomycin, alkylators

Predisposing family history First-degree relative with breast cancer

First-degree relative with early onset CAD Maladaptive lifestyles

Smoking, tanning, alcohol use

Address also: diet, weight control, exercise Need for early breast cancer surveillance.

Encourage Health GoalsEncourage Health Goals Stop smoking. Use sun protection measures. Eat a healthy diet. Limit alcohol intake. Adopt a physically active lifestyle. Maintain a healthful weight. Pursue early breast cancer screening.

Discuss BenefitsDiscuss BenefitsSmoking cessation Reduce risk of heart and lung disease. Reduce risk of tobacco-related cancers. Sun protection Reduce risk of premature skin aging. Reduce risk of skin cancer.

Discuss BenefitsDiscuss Benefits

Healthy diet and physical activity Reduce risk of cardiovascular disease. Reduce risk of breast, colon, uterine

and other cancers.Limit alcohol consumption Reduce risk of liver disease. Reduce risk of mouth, pharynx, larynx,

esophagus, liver, and breast cancer.

Discuss BenefitsDiscuss Benefits

Regular screening examinations Early detection of health problems Prevention of health problems Early intervention to reduce

morbidity

Address BarriersAddress Barriers Appreciate that barriers may be personal,

familial, social, economic in etiology. Fear/discomfort with breast screening Insurance denial of clinician/imaging

screening Provide information to facilitate

behavioral change. Patient education about breast screening Clinician communication with primary care

providers or insurance company

Health Behavior Counseling

Health Behavior Counseling

Discuss alternative behaviors and choices.

Anticipate reactions/responses by family and peers.

Challenge survivor (and family) to commit to healthier lifestyle.

Provide follow-up counseling.

Barriers to Risk-Based Care

Barriers to Risk-Based Care

Clinic environment: work flow impeded with time-consuming counseling

Clinical staff: time constraints with patient care and lack of knowledge about cancer-related health risks

Survivors/Family: lack of interest or resistance to counseling efforts

Requisites for SuccessRequisites for Success Dedicated time/day for survivor follow-up Dedicated staff with interest in late effects

Specialty or advance practice nurse most commonly utilized

Multidisciplinary participation Oncologists - Nurse Psychologist - Social worker Allied and subspecialty care providers

For Comprehensive Risk-Based

Screening Recommendations and Patient Education

Materials

For Comprehensive Risk-Based

Screening Recommendations and Patient Education

Materials

For complete recommendations:

Children’s Oncology Group

Long-Term Follow-Up Screening Guidelines

http://www.survivorshipguidelines.org

Know about cancer/cancer-related health risks. Keep a record of medical events. Share record with all providers. Pursue routine medical evaluations. Review lifestyle for methods of risk reduction. Keep informed about late effects research.

Advice to SurvivorsAdvice to Survivors

Serious late effects occur in a minority. Late effects are possible only when cancer

therapy is successful. Research can reduce and prevent late

effects. Knowledge of factors predisposing to late

effects can reduce their incidence.

Taming Anxiety About Late Effects

Taming Anxiety About Late Effects