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Survivorship for “cured” Hodgkin patients – How should we be following them? Carrie Thompson, MD Mayo Clinic Lymphoma & Myeloma 2014 ©2014 MFMER | slide-1 Disclosures • I have nothing to disclose ©2014 MFMER | slide-2 Outline • Surveillance for relapse • Screening for late effects • Cardiovascular disease • Secondary malignancies • Psychosocial issues • Care models ©2014 MFMER | slide-3 Background: Survivorship • 13.7 million cancer survivors in the US • ~200,000 survivors of HL • Decreased survival compared to general pop SEER Cancer Statistics Review, 1975-2008, NCI. JCO 2003; 21:3431-9 ©2014 MFMER | slide-4 Do surveillance scans improve outcomes in HL? Cancer 2014;120:2122-9 ©2014 MFMER | slide-5 Surveillance for relapse • Negatives of routine scans • Radiation exposure • False positives • Anxiety • Cost ©2014 MFMER | slide-6 Surveillance guidelines • Physical examination, history, and clinical judgement are the cornerstone of followup • Q 3 mos years 1-2, q 4 mos year 3, then q 6 mos years 4-5 • Imaging studies • NCCN • CXR or CT chest and CT A/P q 6-12 mos x 2 yrs • Lugano Classification • Routine scans are discouraged • Scans prompted by clinical indications NCCN.org Version 2.2014 JCO 2014; 32:3059-67 ©2014 MFMER | slide-7 Monitoring for Late Effects • Cardiovascular disease • Secondary malignancies • Psychosocial issues • Other ©2014 MFMER | slide-8 Congestive heart failure: chemotherapy agents • Cytotoxic agents • Doxorubicin, cyclophosphamide, ifosfamide, cisplatin, fluorouracil, paclitaxel • Targeted agents • mTOR inhibitors • PI3 kinase inhibitors • Trastuzumab • Bevacizumab ©2014 MFMER | slide-9 Congestive heart failure in HL • Subclinical (asymptomatic, echo abnormal) • 27.6% in lymphoma survivors1 • Do not know if this will lead to clinical CHF • Clinical CHF • 7.2% incidence with 6 year followup2 • May become evident during times of increased cardiac workload • Pregnancy, anesthesia, BMT, illness 1JCO 1998; 16:3502-8 2Ryberg 1998 ©2014 MFMER | slide-10 Coronary artery disease in HL • Caused by radiation therapy • Prospective study in 294 survivors of HL • ≥35 Gy to mediastinum • Excluded patients with known CVD • Nuclear study and stress test • 40 patients (14%) underwent coronary angiography • Coronary artery stenosis >50% in 22 patients • 7.4% of those screened JCO 2007; 25:43-9 Blood 2007; 109:1878-86 ©2014 MFMER | slide-11 CAD in HL • Coronary CT angiography in 31 adult survivors of childhood HL with hx radiation therapy • ECG, treadmill stress test, echo • 12 (39%) patients with coronary lesions • 3 (10%) with obstructing lesions on coronary angiogram • 2 of these 3 died from CVD • All had abnormal ECG, 1 abnormal treadmill, 0 abnormal echo Cancer 2014; Jul 16 Epub ©2014 MFMER | slide-12 Other cardiac diseases • Valvular disease • Predominantly mitral and aortic valves affected • Pericardial disease • Historically most commonly affected cardiac structure • Conduction system • Arrhythmias and QT prolongation ©2014 MFMER | slide-13 Cardiac Follow-Up Expert Guidelines JCO 2011; 29:1885-1892 ©2011 Annals Onc 2012; 23:Suppl 7 MFMER | JASE 2014;27:911-39 ©2014 MFMER | slide-14 slide-14 Screening Recommendations: CVD • Annual physical exam • BP check • Lipids every 3-5 years • Glucose annually • Particularly if hx paraaortic LN xrt • Treat cardiac risk factors • Lifestyle modifications JCO 2009; 27:5383-89 JCO 2014; 32 ©2014 Epub MFMER | slide-15 Benefits of exercise JCO 2014; 32 Epub ©2014 MFMER | slide-16 Screening Recommendations: CVD • Post-radiation therapy • If >30 Gy to mediastinum • Stress test (exercise stress echo) starting 5-10 years post therapy then q 5 years • Post anthracycline chemotherapy • If >240 mg/m2 doxorubicin • Echo starting 5 years after treatment then q 5 years ©2014 MFMER | slide-17 For female cancer survivors contemplating pregnancy • Refer to cardiology if… • >240 mg/m2 anthracycline dose • >30 Gy radiation to the heart or surrounding tissue • Any combination of the above with high-dose cyclophosphamide ©2014 MFMER | slide-18 Late Effects: Secondary Malignancies • Breast cancer • In those treated for childhood HL, estimated incidence of breast cancer 20% at age 45 • Thyroid cancer • Lung cancer • Risk significantly increases in those who smoke after radiation therapy • Gastric/colorectal cancers • Sarcoma JCO 2007; 25:1489-97 ©2014 MFMER | slide-19 Types of secondary cancers, continued • AML/MDS • Mostly due to chemotherapy (alkylators) • NHL • ~5% lifetime risk in those treated for Hodgkin lymphoma • Skin cancers ©2014 MFMER | slide-20 Recommendations for those at risk • Annual skin exam in irradiated field • Annual mammogram (+/- MRI) 8 years after radiation or at age 40, whichever is earlier • Colonoscopy 15 years after pelvic, abdominal, spinal irradiation or at age 35 • Tobacco cessation • ?low dose CT scan chest • ?EGD • Life-long surveillance Am J Med 2011; 12:1606-12 ©2014 MFMER | slide-21 Fertility Issues • Very important issue • ABVD does not affect fertility • Fertility preservation pre-treatment • Wait 2 years post-treatment to have children • No increase in birth defects, miscarriage, cancer in offspring compared to general population www.fertilehope.org ©2014 MFMER | slide-22 Fatigue • 26% of survivors of Hodgkin lymphoma have significant fatigue • Higher than general population, other cancer types • Fatigue associated with higher symptoms of anxiety and PTSD and lower QOL • Unclear etiology, literature suggests may be related to long term health complications JCO 1999; 17:253-61, JCO 2005; 23:6587-95, Thompson 2009 ©2014 MFMER | slide-23 Loss of Immunity: for all HL survivors • NO live vaccines • No shingles vaccine, influenza vaccine live • Influenza vaccine annually • Tdap/Td q 10 years • HPV vaccine if <age 26 • Pneumococcal vaccine • PCV-13 followed by PPV26 8 weeks later, second dose PPV26 5 years later • If <age 60, PPV26 at age 65 http://www.cdc.gov/vaccines/schedules/ hcp/imz/adult-conditions.html ©2014 MFMER | slide-24 Loss of Immunity • If splenectomy or splenic RT • Meningococcus, HIB, PCV13 at time of treatment • PPV23 8 weeks later then 5 years later • Meningococcus q 5 years • If hematopoietic stem cell recipient • More complicated revaccination schedule ©2014 MFMER | slide-25 Depression and Anxiety in Cancer Survivors • Depression higher than general population in 1st 2 years after diagnosis, then no different • Anxiety levels higher than general population and tend to persist Lancet Oncology 2013; 14:721-32 ©2014 MFMER | slide-26 Anxiety in Lymphoma Survivors and Spouses Lancet Oncology 2013; 14:721-32 ©2014 MFMER | slide-27 Survivorship Care Models • Primary care providers not trained in care of long-term cancer survivors • Communication and coordination of care is key • Survivorship care plan • Treatment summary • Follow-up care plan JOP 2014; Epub 10/14/14 www.asco.org ©2014 MFMER | slide-28 Does education and screening for late effects decrease QOL? Int J Rad Onc Biol Phy 2014; 90:164-71 ©2014 MFMER | slide-29 Summary • Surveillance for relapse • Physical examination, history, and clinical judgement are the cornerstone of followup • Late effects • Cardiovascular disease, secondary malignancies, fatigue, fertility, loss of immunity, psychosocial issues • Coordinated care ©2014 MFMER | slide-30 Thank you! [email protected] ©2014 MFMER | slide-31