Download Treatment

The Young Adult Cured
of Cancer in Childhood
Melissa M. Hudson, M.D.
After Completion of Therapy Clinic
St. Jude Children’s Research Hospital
Transition of Care After Pediatric Cancer
Cancer
Diagnosis
Pediatric
Health Care
Primary Prevention
Risk-adapted therapy
Favorable: Reduce therapy
Unfavorable: Intensify therapy
Long-Term
Survival
Adult
Health Care
Secondary Prevention
Health education
Cancer screening
Therapeutic interventions
Health &
Resilience
Optimal 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 Care





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 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 Care




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 Morbidity



Identify factors predisposing to cancerrelated morbidity.
Identify factors modifying cancer-related
health risks.
Provide interventions to prevent, reduce,
correct cancer-related morbidity.
Factors Contributing to Morbidity
Premorbid
conditions
Host Factors
BRCA, ATM, p53
polymorphisms
Age
Gender
Race
Tumor
Factors
Cancer-Related
Morbidity
Health
Behaviors
Tobacco
Diet
Alcohol
Exercise
Sun
Genetic
Treatment
Factors
Aging
?????
Treatment
Events
Relapse
Vital Organ Toxicity
Surgery
Radiation
Chemotherapy
Histology
Site
Biology
Response
Risk-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 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 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 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 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




Cancer diagnosis and treatment
Cancer-related health risks
Behavioral factors affecting risk
Risk reduction strategies
Address Increased Vulnerability





Sociodemographic factors
Cancer treatment modalities
Family history/genetic predisposition
Maladaptive behaviors
Unknown impact of aging
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 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 Benefits
Smoking 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 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 Benefits



Regular screening examinations
Early detection of health problems
Prevention of health problems
Early intervention to reduce morbidity
Address 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




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



Clinic environment: work flow impeded with
time-consuming counseling
Clinical staff: time constraints with patient
care and lack of knowledge about cancerrelated health risks
Survivors/Family: lack of interest or
resistance to counseling efforts
Requisites 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 complete recommendations:
Children’s Oncology Group
Long-Term Follow-Up Screening Guidelines
http://www.survivorshipguidelines.org
Advice to Survivors






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.
Taming Anxiety About Late Effects




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.