Tracy A. Johnson, DNP, FNP-BC

Cancer Survivorship: How To Manage Treatment-Related Risks and Problems

Outside of the Oncology Setting

Tracy A. Johnson, DNP, FNP-BC

DisclosuresNo financial relationships to disclose

This CME presentation was developed independent of any commercial influences

Objectives Articulate the purpose and key concepts of cancer survivorship

care Identify cancer treatment regimens that present potential health

risks. Perform accurate, targeted questioning of patient's medical

history to screen for potential issues and risks related to cancer treatment.

Incorporate appropriate diagnostic testing and screenings based on health risks and problems related to cancer treatment.

Identify potential "red flags" in clinical presentation and symptoms of cancer survivors.

Identify online cancer survivorship resources for health care providers and survivors.

What Does It Mean To Be A Cancer Survivor?

Currently 12 million cancer survivors in the United States

NCI SEER data: ◦70% all survivors alive 2 years after

diagnosis◦60% alive 10 years after diagnosis

What Does It Mean To Be A Cancer Survivor?

“Cancer survivor”: at diagnosis or after treatment? (NCCS, NCI)

Enduring and overcoming all aspects of diagnosis and treatment

Includes emotional, social, financial, medical sequelae of treatment

So, What’s The Problem? Advances in detection + Advances in treatment+ Aging population

Growing number of cancer survivors

(Why is that a problem?)

So, What’s The Problem?Growing number of cancer survivors potentially

with multiple comorbidities◦ Typical aging, lifestyle, late effects from treatment

Increased burden on health care system (cost and volume)

Focus shift from oncology to PCPPCPs and other health care providers not familiar

with consequences of cancer and cancer treatment

Cancer Care Continuumfrom Canadian Strategy for Cancer Control, 2005

PreventionScreeningDiagnosisTreatmentSurvivorship Follow-Up CarePalliative Care

IOM 2005 report: “From Cancer Patient to Cancer Survivor: Lost in Transition” (www.iom.edu)

Identified the need to provide survivorship care as a distinct phase of oncology care

Recommendations for addressing late effects from treatment (holistic)

Recommendations for transition from oncology to primary care

What is Cancer Survivorship?Assists with transition from cancer

treatment to living “a new normal”Addresses the emotional, practical, and

physical effects of cancer treatmentProvides assessment, education, referrals,

and resources to meet the individual needs of cancer survivors at any point after completing treatment

What Is A Survivorship Care Plan?

Communication between oncology & PCP

Roadmap for long-term careEducation for survivor, family, and other providers

How To Assess Risks Associated With Cancer Treatment:

Type of cancer (s)Treatment modalitiesSpecific treatment agents/fieldsClinical and Psychosocial findings

Types Of Cancer Treatment Presenting Health Risks

BreastColonProstateGYNLeukemiaLymphoma

LungThyroidHead & NeckSkinMelanoma

Types Of Cancer Treatment Presenting Health Risks

Surgery?Radiation?Chemotherapy?Hormonal therapy?Transplant?

Types Of Cancer Treatment Presenting Health RisksAnthracyclines: Adriamycin, Daunomycin, Epirubicin,

IdarubicinTaxanes, Platinums, Vinca Alkaloids: Taxol/Taxotere,

Cisplatin/Carboplatin, Vincristine/VinblastineRadiation: left chest, mantle, prostate, TBI (total body

irradiation)Monoclonal Antibody: Herceptin, Avastin, Erbitux, RituxanHormonal: Tamoxifen, aromatase inhibitors (Arimidex,

Femara, Aromasin)Transplant: Steroids, Immunosuppression, GVH (graft vs

host)

Long Term Impact Of Cancer Treatment

Heart/cardiovascular disease

Peripheral neuropathy

Dental problemsGI problems

OsteopeniaPainMenopauseUterine problems

(Tamoxifen)

Long Term Impact Of Cancer Treatment

Skin cancerBreast cancerLymphedemaFunctional limitations

FatigueEmotional: Depression,

Anxiety, PTSD, family, social, body image

Financial: work, insurance

What Are The Long-Term Risks From Treatment ?

Chronic pain: surgery, chemotherapy, radiation, hormonal therapy◦Bone, joints, back, abdominal/GI, surgical site

◦What helps: exercise, PT, nutrition, yoga, acupuncture, massage, medications, education/counseling


Dental problems: chemotherapy, head/neck radiation◦Frequent brushing/flossing, regular dental visits, drink/rinse with water often


Decreased Bone Density: menopause (by any cause), Arimidex, Aromasin, Femara, high dose steroids, radiation◦Daily calcium 1200-1500mg and vitamin D 800-1000 IU

◦Weight bearing exercise, stop smoking◦Monitor bone density testing and vitamin D levels


GI Problems: Vincristine, Vinblastine, abdominal or pelvic surgery/radiation◦Motility problems, scarring, adhesions◦Dietary optimization, hydration, physical

activity◦Referrals


Heart Risks: Adriamycin (“Red Devil”), other anthracyclines, Left chest radiation◦Make sure cholesterol levels and blood

pressure are normal, exercise, healthy diet, no smoking

◦EKG, echocardiogram (or MUGA, RVG) post-treatment baseline and every 2-5 years

What Are The Long-Term Risks From Treatment?

Cardiomyopathy Conduction

defects, dysrhythmias

Radiation associated valvular disease

CAD/MIOther

cardiovascular disease

Cancer associated thrombosis


Lymphedema, Functional limitations: surgery, radiation◦Helpful to have evaluation, treatment, and

education by physical therapist

◦Lymphedema IS possible if you only had 1-2 lymph nodes removed. Less risk, but not zero risk.

◦Late onset lymphedema IS possible several years after treatment. Less likely, but not zero risk.


Lymphedema, Functional limitations: surgery, radiation◦Will always need to stretch & exercise affected

area to maintain function & prevent limitations

◦Refer/evaluate early!

◦Areas to consider: neck; breast/axilla; pelvic/genital; lower extremity


Fatigue: surgery, chemotherapy, radiation, hormonal therapy, stress, other medical conditions, LIFE ◦ Healthy lifestyle is very important!

◦ Exercise, weight loss, sleep, good nutrition

◦ Massage, acupuncture

◦ Talk to primary care, oncologist, other medical providers about checking for abnormalities in thyroid, vitamins B & D, iron, anemia, hormonal imbalances

◦ Counseling or wellness coaching for emotional problems, stress, guidance for healthy living

What Are The Long-Term Risks From Treatment ?Menopausal symptoms: natural or chemotherapy

induced menopause, surgical removal of both ovaries, hormonal therapy◦ Healthy lifestyle is very important!

◦ Exercise, weight loss, sleep, good nutrition

◦ Massage, acupuncture – great for pain and hot flashes

◦ Medications for hot flashes and mood swings

◦ Vaginal dryness – use over the counter daily moisturizers (Replens, olive oil)


Peripheral neuropathy: Taxol, Taxotere, Vincristine, Vinblastine, Cisplatin, Carboplatin, Oxaliplatin◦ May or may not resolve after treatment

◦ Pharmacologic therapy

◦ Nutritional therapy

◦ Acupuncture

◦ Safety


Uterine problems: Tamoxifen◦ Risk only if you still have uterus

◦ Yearly pelvic exam and PAP

◦ Report abnormal vaginal bleeding, pelvic pain

◦ Exams can be done by primary care, GYN, health department


Skin cancers: Radiation◦ Monthly self exams, be sure to look at skin in

radiated areas

◦ Report new or changing areas on skin: pigmented, raised, non-pigmented, red, itchy, crusty, ulcerated, etc.

◦ Primary care or dermatology can do simple biopsy if needed


Elevated cholesterol

Fertility ProblemsHearing lossThyroid problems

Secondary cancers

Depression, anxiety

Memory problemsSexual

dysfunction

What About Genetics?Encourage patients to keep a record of family

history of cancers, non-cancerous colon polyps, other health problems

Consider genetics evaluation if diagnosed before age 50, family history of breast cancers, or lots of cancers in family• Other hereditary syndromes besides BRCA

• Recommendations for screening for other cancers

• Recommendations for cancer screenings in family members, children

Red FlagsFatiguePalpitationsDyspnea/SOB/Orthopnea - one of most

under-reported by providers Pelvic pain/vaginal bleeding/prior GYN

historyPast medical history – also consider

existing health issues with new cancer diagnosis

Red FlagsEdema/functional limitations – arm,

lower extremities, abdominal/pelvicGlobus sensation/dysphagiaPast cancer historyAge/GenderLifestyle – smoking, alcohol, activity, dietFamily history

Screening RecommendationsEchocardiogram ,

Cardiac MRI, MUGA, RVG (post-treatment baseline, then every 2-5 years)

EKGCholesterolBNP, Troponin

Coronary screening: ischemic studies, calcium scoring CT, cardiac catheterization

Early detection + early treatment = improved cardiac status & outcomes

Screening RecommendationsBone Density: high

dose steroids, aromatase inhibitors, early menopause

Dental exams: any chemotherapy, head/neck radiation

Eye exams/cataracts: high dose steroids, cranial radiation

Reproductive hormones: cranial or pelvic radiation, alkylating agents (Cytoxan)

Pituitary labs: cranial radiation

Thyroid labs/ultrasound: neck radiation

Doppler ultrasound (carotid, other arterior/venous): radiation

Prevention/WellnessEncourage self care/wellness efforts!Baby steps • Don’t set goals too high• Start small – easier to achieve, easier to see

progress

Be consistentEncourage survivors to be own advocate • Ask questions• Take advantage of local and online resources• Write things down

Resources Hewitt, M., Greenfield, S., Stovall, E. (2006). From

Cancer Patient to Cancer Survivor: Lost in Transition. National Academies Press: Washington, DC.

Adler, N. E., Page, A. E. K. (2007). Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Institute of Medicine, National Academies Press, Washington, DC.

Feuerstein, M. (2007). Handbook of Cancer Survivorship. Springer: New York, NY.

Lenihan, D., Cardinale, D., Cipolla, C. (2010). The Compelling Need for a Cardiology and Oncology Partnership and the Birth of the International CardioOncology Society. Progress in Cardiovascular Diseases, 53(2), 88-93. doi 10.1016/j.pcad.2010.06.002

ResourcesNCI Office of Cancer Survivorship:

http://survivorship.cancer.govAmerican Society of Clinical Oncology:

http://www.asco.org/Children’s Oncology Group:

http://www.childrensoncologygroup.org/National Comprehensive Cancer Network:

http://www.nccn.org/ Journal of Cancer Survivorship:

http://springerlink.comREACH for Survivorship Program:

http://www.vanderbiltreach.org

http://survivorship.cancer.gov/

http://www.asco.org/

http://www.childrensoncologygroup.org/

http://www.nccn.org/

http://springerlink.com/

http://www.vanderbiltreach.org/

Resourceswww.nccn.com – Clinical guidelines

for cancer treatments◦Written for patients◦Diagnosis, work up, treatment, follow up

◦Updated yearly, most current evidence from research and clinical practice

http://www.nccn.com/

Resources

http://www.cancer.net/patient/Survivorship - website for cancer survivors◦Information from American Society of

Clinical Oncology (ASCO)

http://www.cancer.net/patient/Survivorship

http://www.cancer.net/patient/Survivorship

Resources

www.vanderbiltREACH.org- website for cancer survivors◦Learn more about Cancer Survivorship

care◦Resources◦Education◦Community events

Documents

Tracy A. Johnson, DNP, FNP-BC