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Moving Forward after Cancer Caring for patients in primary care after cancer treatments are done Developed by: Brent Kvern MD, CCFP, FCFP Associate Professor, Department of Family Medicine, University of Manitoba Jeff Sisler MD, MClSc, CCFP, FCFP Director - Primary Care Oncology, CCMB 2 Conflict of Interest Disclosure No consultant or speaker fees Received a grant from the Canadian Partnership Against Cancer to develop this session A question… A 61 year old patient of yours who completed treatment for breast cancer 3 months ago is your next patient. What is on your mental “to-do” and “to-talkabout” list for this and upcoming visits? 4 Objectives • Define survivorship phase of cancer. • Apply a new framework to consider the care needs of cancer patients in follow-up • Be familiar with important tasks in breast and colorectal cancer follow-up care 5 Cancer Survivorship A distinct phase in the cancer trajectory following primary treatment, lasting until recurrent or end-of-life.1 Diagnosis 1Bell Acute Phase K, Scalzo K, Stephen J, BC Cancer Agency, 2007 Survivorship or Chronic Phase 6 The survivorship phase Number of adult cancer survivors is > 1 million and will double by the year 2050 Age of cancer survivors2 7 A new perspective Think about patients who’ve finished cancer treatment like your patients with a recent MI 8 A new perspective Survived something potentially lethal Need close monitoring for recurrence. Need an aggressive approach to risk reduction Lifestyle issues very important Your role as a FP/NP is critical to rehabilitation 9 4 essential physician tasks Our framework of survivorship HEALTH PROMOTION / PREVENTION FAMILY CANCER RISKS CANCER RELATED MONITORING MANAGEMENT 2 2 P FRiM 10 Health Promotion Prevention Promotion of healthy behaviours Screening for new cancers Age appropriate screening for other medical conditions 12 Family Cancer Risks Assessing the risk of family members • Modifying THEIR risk factors • Recommending a screening plan • Referring for genetic testing Assessing family and marital health 13 Monitoring • Watching for recurrence of the primary cancer • Monitoring for worrisome “late effects” – Cardiomyopathy • Monitoring rehabilitation and recovery 14 Management Side-effects of cancer treatments • Physical • Psychological • Social Ongoing care for any non-cancer conditions 15 Colorectal Cancer Sunga AY, et al. Am Fam Physician, 2005 16 Colorectal cancer Background information Most recurrences in the first 3 years • Liver – most common site metastases o • • • 20% of those with liver metastases are candidates for resection 10%- local recurrence at original site 30% - no rise in CEA No delayed / late effects of chemotherapy 17 Colorectal cancer Health promotion & prevention Exercise 4 hours a week of activity associated with 53% reduced recurrence and CRC mortality regardless of stage, age, BMI or previous activity level. Smoking Cessation Medications for secondary prevention •No role yet for NSAIDs, ASA BMD of hip if pelvic radiation therapy given 18 Colorectal cancer Family Cancer Risks 19 If index patient is diagnosed… Recommendations Before age 60 years All asymptomatic 1st degree relatives, starting at age 40 (or 10 years earlier than patients age at diagnosis) need colonoscopy Q5 years After age 60 years All asymptomatic 1st degree relatives, starting at age 40 yrs are at slightly above average risk. FOBT Q2 years followed by colonoscopy if any one sample if positive. After age 60 years & All asymptomatic 1st degree relatives, starting at age 40 (or 10 years earlier than patients age at diagnosis) need colonoscopy Q5 years another 1st degree relative also has a diagnosis of CRC at any age Family history of known hereditary syndrome Referral for specialist assessment Colorectal cancer Monitoring 21 Monitoring Visit frequency • Q3 months for 3 years following treatment • Q6 months for next 2 years • Annually thereafter Test to DO • CEA at each visit for first 3 years • CT chest and abdomen – annually for first 3 years • Colonoscopy – 1 year after initial diagnostic scope, then at 3 years, then every 5 years afterward Tests NOT TO DO • routine CBC, LFTs • routine CXR • FOBT Colorectal cancer Management Cancer related fatigue • • Consider other etiologies Physical activity works! Peripheral neuropathy from oxaliplatin Radiation proctitis Diarrhea Sexual dysfunction 23 Colorectal cancer Management Anxiety • Consider possibility PTSD like reaction Employment difficulties Insurance difficulties Social well-being • “How are things going between you and your partner?” 24 Breast Cancer Non survivors 12% 5 year survival rates Sunga AY, et al. Am Fam Physician, 2005 25 All Oral Cancer Treatments now fully covered! Tamoxifen and AIs free for patients as of April 19, 2012 Existing patients should already be identified by the DPIN system Pharmacare registration needed Call the Provincial Drug Program at 786- 7141 or 1-800-297-8099 Help! ? Call the CCMB Pharmacy at 787-4591 Breast Cancer Background information Recurrences usually occur within five years. • Peaks at 2nd yr after surgery o • Non-specific symptoms are common indicators of relapse o • Risk declines with time but continues for at least 20 years. Weight loss / Persistent cough / Breast changes / Chest wall changes / Adenopathy 75% recurrences found by the women themselves 27 Breast cancer Health promotion & prevention Exercise Cohort studies suggest a 50% survival advantage for breast cancer survivors over those not physically active Most beneficial in ER+ tumours Diet Medications for secondary prevention •Tamoxifen, aromatase inhibitors (AIs) BMD and/or bisphosphonates if AIs used 28 Breast cancer Family Cancer Risks 29 Inherited Risk for Breast Cancer Mutations of BRCA1 or BRCA2 cause about 5-10% of breast cancers • Usually cancer occurs early in life. • Strong family history Criteria for referral for genetic counselling • Breast cancer at age <35 yrs • Bilateral breast cancer at age <50 yrs • Ovarian cancer <60 yrs • Breast and ovarian cancer <50 yrs • Two or more ovarian cancers, any age • Male breast cancer • Ashkenazi Jewish or Icelandic descent If patient BRCA +ve • Family members need to know • Initiate screening at age 25 with MRI (or five years younger than earliest reported cancer in the family) Breast cancer Monitoring 31 Monitoring Visit frequency • Careful history and physical exam • Q3 -6 months for 3 years • Q6-12 months for next 2 years • Annually thereafter Test to DO • Mammograms annually for life. Tests NOT to do • routine CBC, LFTs • routine CXR • routine bone or liver scans • routine tumour markers Breast cancer Monitoring Breast cancer survivors have an increased risk of a second primary cancer • Often involving ipsilateral breast contralateral breast colon? 33 Monitoring Congestive Cardiomyopathy • From anthracyclines (doxorubicin, epirubicin, trastuzumab) • Can present 10-15 years after chemo • Be alert for CHF symptoms Myelodysplasia or Leukemia • Associated with cyclophosphomide • Rare •No screening recommended. Breast cancer Management Cancer related fatigue • • Menopause • • • Rule out other etiologies (drugs, depression, cardiac, thyroid, anemia) Physical activity, yoga Related to chemotherapy Retrospective studies have not shown harm with HRT no RCT has been performed to allow confident use Osteoporosis • Check for AI use 35 Tamoxifen •Hot flashes and night sweats •SSRIs can partially alleviate •Avoid paroxetine, fluoxetine, bupropion • Venlafaxine drug of choice Aromatase inhibitors • Post-menopausal women only • Arthralgias and aches: NSAIDs, time Anastrozole Letrozole Exemestane • Switch to a different AI or Tam if not tolerable Breast cancer Management Peripheral neuropathy Post treatment cognitive impairment or “Brain fog” • If treated with taxanes (docetaxel) Use gabapentin*, pregabalin, tricyclics* Rule out or address other aetiologies (drugs, depression) Chronic Pain 37 Breast cancer Management Sexual dysfunction Anxiety Fear of recurrence: Consider CBT Employment and insurance difficulties Social wellbeing “How are things going between you and your partner?” In closing: Caring for Cancer Survivors A distinct phase in the cancer continuum. Increasingly a responsibility of primary care Cancer survivors are at increased risk – think of them like post-MI patients 39 4 essential physician tasks Our framework of survivorship HEALTH PROMOTION / PREVENTION FAMILY CANCER RISKS CANCER RELATED MONITORING MANAGEMENT 2 2 P FRiM 40 Moving Forward after Cancer Dr Jeff Sisler [email protected] Questions? Call the UPCON Helpline at (204) 226-2262