Working Beyond CancerDr Eliot ChadwickConsultant Clinical OncologistNottingham University Hospitals NHS Trust &The Nottingham Oncology Group

Trent Occupational Medicine Annual Symposium 2014

Email: eliot.chadwick@tnog.co.uk

Macmillan – the scene• In the UK, over 100,000 people of working

age are diagnosed with cancer each year.

• More than 700,000 people of working age are living with a cancer diagnosis.

• The HR department of a large employer will see more new cancer diagnoses in a year than a GP.

Cancer Incidence(CRUK)

Cancer Incidence(CRUK)

The Big 4

Cancer survival(CRUK)

Cancer survival(CRUK)

…and then there were 3

Why Toxicity?

• Normal tissue reaction to chemotherapy and radiotherapy.

• Relates to cell turnover.

• Early vs late broadly correlates with α/β ratio

Timelines - toxicity

Long term

Short term

4/52 8/52 6/12 20yrs

The Return to Work

Denial

Independence

Empowerment

Identity

Selfworth

Pragmatism

Time

Guilt

FinanceSelf

Employment

Fear of relapse

DECISION

Breast Cancer

• Surgery• Chemotherapy• Hormones• Radiotherapy• Biological agents (Herceptin®)

Fatigue“...5 years after....I've been off sick from work

since then...and, being completely honest, I have no desire of returning. I don't feel I can't work full time and, I can't survive on a part time wages. I have chronic fatigue, chemo brain and PSD. So far, nobody seems to care about the devastating effects of the aftermaths of cancer. The unrealistic expectations of employers, colleague and friends and, maybe my own, really puzzled me.”

Longitudinal patient case rates

for persistent fatigue over 12

months (n = 218).

Goldstein D et al. JCO 2012;30:1805-1812

©2012 by American Society of Clinical Oncology

LymphœdemaStiffnessPain

BrCa Side effects ACUTEPeri-operative complications,

seroma, infection

6/52 3/12 2yr 10yrs 20yrs

Poor wound healing, infection, nausea,

mucositis, alopecia

Lymphœdema, cardiac, depression

Neuralgia, shoulder stiffness,

fatigue

Prostate Cancer

Risk of treating anon-lethal disease

Success & morbidity of treatment

Hormones

LHRHa

EBRT

3/12 6/12 18/12 2yrs 3yrs

Hormones

• Insulin resistance* / cardiovascular morbidity• ↓muscle mass• Cognitive impairment• Hot flushes

*LGI diet advised (but seePelvic RT)

Hormones - summary

• Effects as long as administered, and months to years beyond.

• Probably underplayed.• Impact on occupation not necessarily direct.

Pelvic Radiotherapy

Pelvic RT effects ACUTEFatigue, *proctitis, cystitis, prostatitis

nausea, skin reactionEBRT

6/52 3/12 2yr 10yrs 20yrs

CHRONIC / LATE*Proctitis, cystitis,

arthritis, hip fracture

* ”Beige” diet advised

Case 1 – 38yrs female, anal Ca

Mitomycin C D15-fluorouracil D1-4Coronary artery spasm from 5-FU. D22-25 not given.5.4Gy boost given in lieu.

At 18m, ongoing discomfort in perineum, frequency of stool 5-10/day, with urgency and occ. incontinence.

Works at check-out in supermarket.

}EBRT 50.4Gy

/28#

Case 2 – 56yrs male, peri-anal Ca, vegetarian.Mitomycin C D15-fluorouracil D1-4, D22-25Electron boost of 20Gy/10#

At 12m, ongoing discomfort in perineum, frequency of stool 5/day, with urgency. Struggles to maintain wt.

Pre treatment, worked for council – refuse, gardens. Now medically retired.

}EBRT 50.4Gy

/28#

Radiotherapy - summary

• Can cause significant long term effects.• Functional deficit.• Not easily treated.

Chemotherapy

Chemotherapy effects ACUTEMultiple, disparate

effects. Not all intuitive.

6/52 3/12 2yr 10yrs 20yrs

Fatigue, myalgia, arthralgiadysgeusia

Wt gain, Neuropathy, cardiac

Case 3 – 48yrs male, rectal Ca, node positive on MRI.Capecitabine 825mg/m2/bd + EBRT 50.4Gy / 28#

Works in abattoir. Develops palmar-plantar erythema (PPE). Capecitabine stopped during RT.

Post-op (stoma). Pathologically node positive. For further capecitabine + oxaliplatin adjuvantly.

Pt declines oxaliplatin. Starts capecitabine, but stops early due to PPE.

Case 4 – 65yrs male, colon Ca, Duke’s C

Referred for adjuvant chemotherapy

5-fluorouracil / oxaliplatin q2/52 for 12 cycles.

Loses sense of taste and smell. Develops PPE.

Continues to work as Michelin star chef but finds it increasingly difficult.

Chemo - Summary

• Most chemo effects acute.• Fatigue most common long term.• Subjective.• Pts occupational circumstance may dictate

chemo given.

Surgery

Surgery effects ACUTEPeri-operative complications

6/52 3/12 2yr 10yrs 20yrs

Fatigue, poor wound healing, TED

Hernia, stoma, incontinence

Anterior resection syndrome

Case 5 – 28yrs female, sigmoid Ca, emergency Hartmann’s.pT4b tumour

Referred for adjuvant chemotherapy.

Receives 8 cycles of capecitabine / oxaliplatin within SCOT study

Regular FU post-chemo for SCOT data collection. Regular discussion regarding stoma.

Pt works in clothes shop. Gaining weight, as finds it difficult to exercise. Stoma reversal on hold until 1 year CT performed. 1 year CT ?Ovarian mass

Surgery - summary

• Surgery usually irreversible.• Implications for lifestyle should be

explored, particularly if options available.• Can have significant body image as well as

functional effects.

Are we doing enough?

Challenges• Patients not informed about impact of cancer on their

working lives.

• Many patients do not have access to vocational rehabilitation services.

• Employers don’t know how to support staff with cancer.

• (Cancer specialists don’t know how to support employers.)

Questions?