Download Methods Variables Measured

Curing Patients with Cancer,
But At What Cost: The Doubleedged Sword of Cancer Therapy
---
May the best of what we have done in the
past, be the worst of what we will do in the
future
Louis S. Constine, MD, FASTRO
Professor of Radiation Oncology and Pediatrics
Cancer Incidence – Distribution by Site
SEER Program, 2006
Multiple primary cancers
Prostate
Breast
Lung and bronchus
Colon /rectum
Urinary bladder
Melanomas of the skin
Non-Hodgkin lymphoma
Uterine corpus
Kidney
Pancreas
Ovary
Thyroid
Stomach
Brain & CNS
Multiple myeloma
Cervix
Esophagus
Liver
Larynx
Hodgkin lymphoma
Testis
Soft tissue including heart
Bone and joint
17.70%
14.60%
12.20%
9.80%
7.90%
3.30%
3.70%
3.50%
2.50%
2.30%
2.10%
1.30%
2.20%
1.30%
1.20%
1.00%
0.70%
0.80%
1.20%
0.60%
0.60%
0.60%
0.50%
0.20%
0
2
Total invasive cancers: 129,552
4
6
8
10
Percent
12
14
16
18
5-Year Survival of Patients with Cancer
by Era, SEER, 1975-1998
80
Year of
Diagnosis
2004
Projected
Survival (%)
70
1993-98
60
1987-92
Peak to Valley
Transformation
50
1981-86
1975-80
40
0
10
20
30
40
50
60
Age at Diagnosis (Years)
70
In patients diagnosed with cancer before age 15,
the 5-year survival rate improved from
58% in 1975 to 80% in 1997
--- an average annual change of 1.68%
Less well known is the remarkable
improvement in prolonging survival
in adult patients, especially those
between 50 and 80 years of age
Estimated Number of Cancer Survivors in
the United States Over Time
12.1 Million Cancer Survivors
United States: 2007
Female Breast
23%
Other
17%
Prostate
19%
Colorectal
10%
Gynecologic
9%
Lung
3%
Melanoma
6%
Hematologic
7%
Genitourinary
6%
Source: http://dccps.nci.nih.gov/ocs/prevalence/prevalence.html. Last accessed Oct. 2009
Cancer Survivorship

U.S.: 12 million cancer survivors
• 3.5% population
• Impact on public health

Increases in cancer survival
• Earlier diagnosis (screening)
• More effective treatment
• Prevention of secondary disease
• Decreases in mortality from other causes
Caring for Cancer Survivors
Do you care for survivors in your practice?
Always
264 (31.4%)
Sometimes
408 (48.6%)
Rarely
126 (15.0%)
Not at all
Do not care for survivors
36 (4.3%)
6 (0.7%)
Are you comfortable providing this care?
Yes
512 (61.2%)
No
213 (25.5%)
Do not provide
111 (13.3%)
ASCO Prevention Survey, 2004
Essential Elements Of Survivorship Care
• Education of the cancer survivor, family, health care providers
– Care plan based on future health risks
– Promotion of healthy lifestyles
– Possible genetic predispositions for counseling
• Surveillance for cancer spread, recurrence, or second cancers and
for long-term adverse physical, psychosocial, socioeconomic effects
• Intervention to prevent or treat consequences of cancer or therapy
• Communication between specialists and primary care providers to
ensure that the survivor’s health needs are met
• Research focused on understanding, preventing, treating adverse
consequences of cancer or its therapy
• Patient advocacy to address problems related to employment,
insurance, and disability
Components of Treatment Summary
•
•
•
•
•
Contact information for key individual providers
Dates of treatment initiation and completion
Diagnostic tests and results
Tumor characteristics
Therapies provided, including specific agents, title of
clinical trials (if any), treatment response, and
toxicities experienced
• Psychosocial and nutritional services provided
• Identification of a coordinator of continuing care
Components of Care Plan
•
•
•
•
•
Likely course of recovery from treatment
Recommended surveillance
Possible long-term effects of treatment and symptoms
Possible signs of recurrence and second tumors
Possible effects of cancer on daily life (personal
relationships, work, mental health) and available
resources for support
• Potential insurance, employment, and financial
consequences of cancer and referrals to counseling,
legal aid, and financial assistance if needed
Treatment Summary Concordance with IOM
Concordance with IOM recommendations
N=65 TSs/13 sites
(for each domain)
No. of sites achieving
adequate (≥75%) concordance
Descriptive statistics
Mean
SD
Range
N (%)
Diagnosis
0.46
0.31
0.00–1.00
2 (15.4)
Staging and tumor characteristics
0.65
0.35
0.00–1.00
9 (69.2)
Surgery
0.73
0.22
0.38–0.98
7 (53.8)
Treating physician contact information
0.33
0.30
0.00–0.75
1 (7.7)
Clinical trials
0.18
0.25
0.00–0.60
0 (0.0)
Chemotherapy
0.52
0.24
0.10–0.83
3 (23.1)
Radiotherapy
0.55
0.19
0.26–0.80
2 (15.4)
Hormonal therapy
0.79
0.20
0.40–1.00
7 (53.8)
Targeted therapy
0.34
0.38
0.00–1.00
3 (23.1)
Toxicity
0.52
0.48
0.00–1.00
7 (53.8)
Genetic testing
0.26
0.24
0.00–0.60
0 (0.0)
Supportive therapy
0.03
0.08
0.00–0.27
0 (0.0)
Follow-up care contacts
0.08
0.18
0.00–0.50
0 (0.0)
TS Total
0.46
0.19
0.14–0.70
0 (0.0)
Survivorship Care Plan concordance with IOM
Concordance with IOM recommendations
N=65 TSs/13 sites
(for each domain)
No. of sites achieving adequate
(≥75%) concordance
Descriptive statistics
Mean
SD
Range
N (%)
Toxicities and late effects
0.98
0.07
0.75–1.00
13 (100)
Breast cancer surveillance
0.82
0.11
0.67–1.00
8 (61.5)
Cancer surveillance
0.43
0.35
0.00–1.00
3 (23.1)
Non-cancer surveillance
0.77
0.21
0.33–1.00
6 (46.2)
Signs of cancer (recurrent and second)
0.32
0.27
0.00–1.00
1 (7.7)
Psychosocial effects
0.52
0.35
0.00–0.86
6 (46.2)
Referrals and resources
0.62
0.35
0.00–1.00
8 (61.5)
Prevention/health promotion
0.46
0.14
0.00–0.50
0 (0.0)
Genetic testing recommendations
0.62
0.51
0.00–1.00
8 (61.5)
Relatives’ cancer risk
0.01
0.03
0.00–0.10
0 (0.0)
SCP total
0.59
0.16
0.37–0.83
2 (15.4)
Survivorship Program Components Across Four
Health Care Organizations
Organization
Type
Survivorship Program
Providers
Academic
In-person clinical evaluation with Medical oncologist,
medical
multidisciplinary team
nurse practitioner,
center
psychologist,
social worker
Community
hospital
County
hospital
Primary-care
medical
group
Nurse-led, telephone-based
Oncology-certified
program; survivors also
registered nurse
receive mailings and follow- up
calls
Nurse-practitioner–led clinical
Nurse practitioner
program; survivors assessed,
followed and primary care
needs addressed
Social worker–led, telephoneLicensed clinical
based program; survivors also
social worker
receive mailings and follow-up
calls
Partnerships
Faculty practice
medical group
Local physicianowned oncology
network
In-house Navigation
Program
Oncology medical
groups contracted
to provide services
to plan members
SCP Components Across Four Health Care Organizations
Organization Type
SCP Completed By
Treatment History
Components
Received By
Detailed summary of
radiation, chemotherapy,
surgeries, hormonal
treatment
Patient copy, provider
copy (PCP, oncologist,
ob/gyn, etc), paper
chart, and EMR
General summary of
radiation, chemotherapy,
surgeries, hormonal
treatment
Patient keeps own copy
and distributes to
oncology care team
and primary care
Academic medical
center
Multidisciplinary
survivorship team:
oncologist, nurse
practitioner, psychologist
Community hospital
Patient, with telephone
assistance from
survivorship oncology
nurse
County hospital
Survivorship nurse
practitioner
Detailed summary of
radiation, chemotherapy,
surgeries, hormonal
treatment
Patient copy, copy in
paper chart, and copy
scanned into EMR
(electronic template in
progress)
Primary-care medical
group
Contracted oncology group
physicians and staff, with
assistance from
survivorship social worker
Detailed summary of
radiation, chemotherapy,
surgeries, hormonal
treatment
Scanned into EMR
(electronic template in
progress) and in
oncology group paper
chart
Abbreviations: SCP, survivorship care plan, EMR, electronic medical record; PCP, primary care provider; ob/gyn, obstetrician/gynecologist
Survivorship begins at diagnosis!
Cancer
Diagnosis &
Treatment
Health &
Quality of
Life
Long-Term
Survival
What are the physical
costs of survivorship?
General Considerations
• Risk of late effects depends on the tissue and
age of patient at time of treatment
• Late effects are dose and modality specific
(e.g., surgery, radiation, chemotherapy)
• Combined modality therapy can have additive
risks
Tissues at Risk for Late Toxicity
• Bone/soft tissues
• Immune system
• Cardiovascular
• Nervous system
• Dental
• Neuropsychologic
• Endocrine
• Ophthalmologic
• Gastrointestinal
• Pulmonary
• Hepatic
• Renal
• Hematological
• Reproductive
Factors Contributing to Morbidity
Host Factors
Genetic
BRCA, ATM, p53
polymorphisms
Age
Gender
Race
Tumor
Factors
Cancer-Related
Morbidity
Health
Behaviors
Tobacco
Diet
Alcohol
Exercise
Sun
Premorbid
Conditions
Treatment
Factors
Aging
Histology
Site
Biology
Response
Surgery
Chemotherapy
Radiation therapy
Treatment
Events
Why, a four-year old child could
understand this.
Someone get me a four-year old
child!
-- Groucho Marx
Radiation therapy is getting complicated
Tables and data and lines, oh my...
Know Your Cancer-Related Health Risks
Surgery for Solid Tumors
• After removal of one of paired organs, the
remaining organ usually maintains function:
–
–
–
–
Enucleation (removal of eye)
Nephrectomy (removal of kidney)
Oophorectomy (removal of ovary)
Orchiectomy (removal of testes)
• It’s important to take precautions to preserve
the health of the remaining organ
Know Your Cancer-Related Health Risks
Surgery for Solid Tumors
• Surgery to remove tumors of bones or soft
tissue may affect strength, function, mobility
• These surgeries may also
cause chronic pain that
limits activity
• Examples include:
– Amputation
– Limb-sparing surgery
Know Your Cancer-Related Health Risks
Chemotherapy for Cancer
Prednisone and
Methotrexate affect
bone strength
Anthracyclines (drugs
like doxorubicin and
daunorubicin) affect
heart muscle function
Bleomycin,
BCNU, CCNU,
and busulfan
can cause lung
scarring
Know Your Cancer-Related Health Risks
Chemotherapy for Cancer
Cisplatin, carboplatin
and ifosfamide can
affect kidney function
Cyclophosphamide can cause
injury to the bladder lining
Know Your Cancer-Related Health Risks
Chemotherapy for Cancer
Cisplatin and carboplatin
can cause hearing loss
Vincristine and cisplatin can
affect nerve function
Know Your Cancer-Related Health Risks
Chemotherapy for Cancer
Methotrexate
and Cytarabine
(Ara C) given by
vein or into the
spinal fluid can
affect learning,
concentration
and memory
Know Your Cancer-Related Health Risks
Chemotherapy for Cancer
Alkylating agents chemotherapy affects testicular and ovarian function
• Risk of injury is related to total dose of medication received
• Alkylating agents most often used for childhood cancer:
cyclophosphamide, procarbazine, nitrogen mustard, ifosfamide
Know Your Cancer-Related Health Risks
Radiation for Cancer
Brain radiation can affect
learning & memory, motor
function and sensation
Endocrine gland radiation can affect
growth, metabolism, and reproduction
Know Your Cancer-Related Health Risks
Radiation for Cancer
Lung scarring from radiation leads to
stiff lungs that restrict air flow during
breathing
Scarring from radiation can
affect heart rhythms, heart
muscle and valve function and
blood vessel flow
Know Your Cancer-Related Health Risks
Radiation for Cancer
Radiation cause kidney
damage and bladder scarring
Some of the signs of radiation
injury of the urinary tract are:
• High blood pressure
• Blood in urine
• Incontinence
• Problems voiding
Know Your Cancer-Related Health Risks
Radiation for Cancer
• Decreased testosterone
• Decreased, damaged or
absent sperm
• Damage to duct system to
transport sperm
• Sexual dysfunction from
damage to pelvic nerves
Know Your Cancer-Related Health Risks
Radiation for Cancer
• Decreased estrogen
• Damage or depletion of
eggs in ovaries
• Scarring of lining of the
uterus (womb)
• Scarring of blood supply
to uterus
Multiple Primary Cancers
Etiologic Factors
Cancer
#1
Treatment
Lifestyle
Environment
Host factors
•
•
•
•
•
•
•
•
•
•
•
•
Tobacco
Alcohol
Diet
Other
Contaminants
Occupation
Viruses
Other
Cancer
#2
Age and gender
Genetics
Immune function
Hormonal, other
Modified from Travis LB. Acta Oncologica 2002; 323-333.
Interactions and
other influences
• Gene-environment
• Gene-gene
Subsequent Malignant Neoplasms
DCCPS and DCEG
Who is at risk? When to worry?
• Age at treatment
• Sex/race of survivor
• Type/strength of
therapy
– Chemotherapy
– Radiation therapy
– Transplant
•
•
•
•
•
Time from treatment
Type of cancer
History of relapse
Family history
Health habits
Age at Treatment Matters…
• Learning problems after brain radiation
– Younger patients at higher risk compared
to older patients
• Infertility after alkylating chemotherapy
– Older females at highest risk compared to
younger females
Chemotherapy Dose Matters…
Heart muscle problems after anthracyclines
Risk
Anthracycline dose
Low
Less than 100 mg/m2
Medium
Between 100 and 300 mg/m2
High
More than 300 mg/m2
Combination of Treatments Matters…
• Chest radiation:
scarring of heart
lining, heart valves, or
blood vessels
• Anthracycline
chemotherapy:
weakening of the
heart muscle
Risk of heart problems is greater if
cancer treatments have similar risks
for health problems.
Health habits matter…
• Lung scarring can occur
after chest radiation and
bleomycin
• Stiff lungs restrict air flow
during breathing
• Thick scarred air sacs do
not release oxygen to the
tissues as well
• Smoking increases the
risk of lung injury
Genes & Family History Matter…
Cancer treatment may result in an earlier onset
of diseases that “run” in families, especially
those that usually present in adulthood
•
•
•
•
Heart disease
High cholesterol
High blood pressure
Diabetes
•
•
•
•
Arthritis
Osteoporosis
Kidney problems
Cancer
Important Facts About Late Effects
• The chances of having late effects after cancer is high
• The chance of having serious or life-threatening late
effects after modern cancer therapy is low
• Knowing your cancer history and possible health risks can
help you and your doctor
work together to prevent
late
effects or diagnose
health
problems early
• Regular check-ups are
needed to diagnose and
prevent late effects
What Doctors Can Do…
• Design cancer treatments to
reduce the risk of late effects
• Develop therapies to protect
normal tissues
• Monitor childhood cancer
patients for late effects
• Prescribe corrective therapy
What Survivors Can Do…
• Have regular check-ups so late
effects can be prevented or
detected in earlier stages
• Follow doctor’s advice about
medications and other interventions
that can reduce the risk of late
effects
• Practice health behaviors that
reduce the risk of late effects
Habits that affect risk
• Smoking
• Sun
exposure
• Diet
• Physical
activity
• Alcohol
intake
Tobacco Use
•
•
•
•
•
Don’t smoke. If you do smoke, QUIT!
Don’t use any tobacco products
Avoid smoke-filled rooms
Exercise regularly to keep your lungs fit
Check out:
1.877.4SJ.QUIT
Preventing Skin Cancer
• Do not tan.
• When outdoors, stay
in the shade.
• Limit sun exposure
from 10-4.
• Practice sun
protection measures.
– Sunscreen
Apply frequently!
– Wide brim hat
– Long-sleeve shirt
– Sun glasses with UV
absorption
A Healthy Diet
• Eat a variety of healthful foods, with an
emphasis on plant sources
 Eat > 5 vegetables and fruits servings each day.
 Choose whole, rather than processed, grains
 Limit consumption of red meats
 Choose foods to maintain a healthful weight
• Check out:
Physical Activity and Weight
• Adopt a physically active lifestyle
 Moderate activity for > 30 minutes on > 5 days
 Moderate-to-vigorous activity for > 45 minutes on
> 5 days may further reduce breast and colon
cancer risks
 Balance caloric intake with physical activity
• Check out:
 http://www.cdc.gov/healthyweight/
 http://www.mypyramidtracker.gov/
Maintain a Healthy Weight
• Body mass index
Weight (kg) divided by
height (cm)2
• Normal weight = BMI 18.5-25
• Overweight = BMI 25-30
• Obese = BMI > 30
Check out: http://www.cdc.gov/healthyweight
Alcohol and Health
• Alcohol increases risk of cancer of the mouth,
throat, voice box, esophagus, liver, and
breast
• Alcohol may also increase the risk of colon
cancer
• Alcohol increases risk of liver injury in people
with chronic hepatitis and other liver disease
• Alcohol may have some benefit in preventing
cardiovascular disease
Guidelines for Alcohol Intake
• If you drink, limit
alcohol drinks to less
than two drinks a day
for men and one for
women
• A drink is defined as
12 ounces of beer, 5
ounces of wine, or
1.5 ounces of 80
proof distilled spirits
Just
remember,
only one
or two!
Good Health Habits…
•
•
•
•
•
•
Lower cancer risk
Lower cardiovascular disease risk
Lower bone and muscle problems
Improve energy level and mood
Improve productivity
Lower late effects risks
in cancer survivors
Specific f/u recommendations for
Hodgkin Lymphoma, part 1
• Annual visit to health care provider for
prevention and age appropriates screening
• Annual physical exam including thyroid and
breast exam for women
• Consider low dose CT in patients at high risk
for lung cancer
• Thyroid function tests annually in pts after
neck/chest RT
Specific f/u recommendations for
Hodgkin Lymphoma part 2
• Vaccinations q 6 years in patients after
splenectomy
• Lipid screening q 1-3 years (LDL <100)
• CAD risk factor modification
• Women after chest RT treated at age <35 y:
– Yearly mammogram 8 years after RT or
age 40
– Consider breast MR
Specific f/u recommendations for
Hodgkin Lymphoma - part 3
• Cardiac work up with EKG, echo, stress test;
consider visit with a cardiologist at 10 years
• Skin check annually
• Baseline vitamin D level
• Consider a screening colonoscopy prior to
age 50 if prior abdominal radiation
We Are Working Hard:
»To cure patients with cancer
»To minimize late effects
And we are making
progress!