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Native Cancer 101:
Module 9: Chronic Conditions
and Cancer
Linda Burhansstipanov, MSPH, DrPH
(Cherokee Nation of Oklahoma)
Native American Cancer Initiatives, Incorporated
Linda U. Krebs, PhD, RN, AOCN, FAAN, Oncology Consultation,
Education and Advocacy Network (OCEAN)
Kerri Lopez, BS, Tolowa Nation,
Northwest Portland Area Indian Health Board
Paulette Baukol, BS, Mayo Clinic, Rochester, MN
Dana Kontras,RN, Mayo Clinic, Jacksonville, FL
Please turn off your cell
phones or switch them
to “vibrate” mode
Audience Response
System (the Keypads)
(TP)
Turning Point Keypads
Lanyard
that
goes
around
your
neck
These are
NOT
calculators
and need to
be returned
to the faculty
at the end of
the session
please
Audience Response System (ARS) – keypads
This is how we vote on different items and issues
Although the keypads are “anonymous” (we don’t
know who uses which keypad); but we would like
you to use the same one throughout the workshop
You do not need to “point” the keypad (like a TV
remote control)
You will see a counter on the screen that shows
how many people have “voted” on any item
You press the number on the keypad that best
describes your answer (use “0” for “10” on the
keypad)
Audience Response System (ARS) – keypads
You can change your vote up until the final vote
has been collected and the slide advances
A top bar appears and the upper right-hand box
needs to be “green” before you vote.
A summary of bar graphs appears on the screen
after the votes are completed for most items so
that everyone can see the total tallies
The summary bar graph will not appear for preworkshop knowledge items or workshop
satisfaction
5 Demographic items
(TP)
What is your gender?
1. Male
2. Female
3. Don’t want to answer
67%
33%
0%
1
2
3
About How Old are You?
1.
2.
3.
4.
5.
6.
7.
8.
9.
81 and older
65-80
50-64
41-49
31-40
21-30
13-20
Under 12
Don’t want to answer
67%
33%
0%
0%
0%
1
2
3
4
5
0%
0%
0%
0%
6
7
8
9
brthyr5
What is Your Primary Race?
67%
1. American Indian / Alaska Native
(AIAN)
2. Pacific Islander
33%
3. Asian
4. African-American
5. Non-Hispanic white (Caucasian)
6. Other
7. Don’t know / Don’t want to answer
1
0%
2
3
Are you Hispanic, Latino or Chicano?
1.
2.
3.
4.
Yes
25%
No
Don’t Know / Not sure
Don’t want to answer
1
25%
25%
2
3
25%
4
How Much Schooling have You Completed?
1. Elementary (kindergarten through grade 6 /
grade school)
2. 7th , 8th , or 9th grade (middle school)
3. 10, 11, or 12th grade (no degree)
4. High school graduate / GED
5. Technical school /apprentice training
6. Some college (no degree)
7. College AA degree
8. College BA, BS degree
9. Masters’ degree
10. Doctorate or more
67%
33%
0%
0%
0%
0%
0%
1
2
3
4
5
6
7
0%
0%
8
9
0%
10
Personal
Experience
Questions (TP)
1 item
Have You ever been Told by a Healthcare
Provider that you have Cancer?
100%
1.
2.
3.
4.
No
Yes
Don’t know
Don’t want to answer
0%
1
2
0%
3
0%
4
4 Pre-Session
Knowledge Items
WIRB Approved –
Which is True?
1. Cancer cells do not die as
normal cells do
2. About half of all cancers are
inherited from your parents
3. A tumor the size of a pea
usually takes about 3 years
to develop
4. Most “benign” tumors
spread to other parts of the
body
5. Don’t know / not sure
WIRB Approved –
Which is true?
1. Cancers are diagnosed by a
process called, “metastasis”
2. Cancer is becoming a “chronic”
disease (like diabetes)
3. Only 30% of lung cancers
could be prevented by not
using tobacco habitually
4. Accurate screening tests are
available for gallbladder cancer
5. Don’t know / Not sure
WIRB Approved –
What is the cause of most (~90%) of all
cancers?
1.Family history
2.Smoking for 5 years
3.Being exposed to radiation
4.Lifestyle and physical
environment
5.Don’t know / Not sure
WIRB Approved –
If a “breast” cancer cell spreads to the
kidney, what is the new cancer called?
1.New primary cancer
2.Recurrent breast cancer
3.Breast cancer
4.Kidney cancer
5.Don’t know / Not sure
Module 9 Objectives for Chronic Conditions and
Cancer. By the end of this session the participant
will be able to:
1. Distinguish between a health condition
that is acute versus one that is chronic.
2. Identify at least 3 common chronic
conditions in AIAN communities.
3. Describe at least 5 risk factors for chronic
conditions.
Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest
Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated (NACI)
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Module 9 Objectives for Chronic Conditions and
Cancer. By the end of this session the participant
will be able to:
4. Describe how co-morbidities impact
cancer and quality of life.
5. Explain the differences between acute,
chronic and late effects of cancer and
cancer treatment (optional)
6. Identify at least 5 strategies for
addressing chronic side effects of
cancer/cancer treatment (optional)
Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest
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Introduction
Historical Footprint
Chronic diseases were rare
among our ancestors
Where we are now with
chronic diseases evolved
from living on Reservations
for 7 generations
Curtis photograph of Kerri
Lopez’s grandmother, Ada
Richards (Tolowa Nation)
Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest
Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated (NACI)
23
QUESTION: Why is Understanding Chronic
Conditions Important to AIANs?
Leading causes of death among adult
AIANs
Leading causes of conditions that interfere
with our daily quality of life
I want my grandchildren to live long, healthy lives like
our ancestors. Today we forget how to act in ways
that honor those who came before us. Our ancestors
didn’t have these diseases.
Anonymous AI, 2011
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24
Would you like to review some cancer
basics / background?
1. Yes
2. No
3. Don’t know / Not sure
33%
33%
33%
If Yes, click on
the turtle
hyperlink
1
2
Burhansstipanov, Native American Cancer Initiatives, Inc. (NACI) subcontract
to Mayo Clinic’s
“Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605]; Northwest
Portland Area Indian Health Board
3
25
Which is an example of an “acute” condition?
1.Cancer
2.Arthritis
3.Trauma (car accident)
4.Diabetes
5.Don’t know / Not sure
Objective 1:
Distinguish between a health
condition that is acute versus
one that is chronic.
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27
Definitions
Acute (uh-KYOOT) condition:
A condition or disease that begins and
worsens quickly.
Usually lasts less than a year.
If managed well will resolve (or improve
and become chronic).
What would be an example of an
acute illness?
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28
Examples of Common Acute
Conditions
Cold or flu
Infection
Trauma (car accident, broken leg)
Allergic reactions
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29
Definitions
Chronic (KRAH-nik) condition:
A condition or disease that persists or
progresses over a long period of time.
May have previously been acute
Can be managed, but usually does not
go away completely
What would be an example of a
chronic condition?
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Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated (NACI)
30
Examples of Common Chronic
Conditions
Heart Disease
Cancer
Diabetes
High blood pressure (hypertension)
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31
Characteristics of Chronic
Conditions
Lasts one year or longer
Requires ongoing medical
care
Limits daily activities
Often interferes with one’s
quality of life
My doctor
wouldn’t listen to
me or to my
husband. Finally
they learned that
I had a heart
condition,
probably from my
chemo.
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32
Objective 2
Identify at least 3 common
chronic conditions in AIAN
communities.
33
Common Chronic Conditions
The most common, costly, and
preventable chronic conditions in the
U.S. are:
Heart disease
Cancer
Diabetes
Arthritis
Obesity
This is true for AIANs too
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34
Examples of Other Chronic
Conditions
Stroke
Substance abuse and addiction disorders
Mental illness
Dementia
Cognitive impairment disorders
Developmental disabilities
NOTE: Heart disease, cancer and stroke
account for ½ of all deaths each year.
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Northwest Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated
(NACI)
35
Cancer
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36
Cost of Chronic Conditions or all
Americans
Annual healthcare costs = $2.5 trillion
Heart Disease = $108.9 Billion
Stroke = $53.9 Billion
Hypertensive = $93.5 Billion (CDC 2010)
Cancer = $263.8 Billion in medical cost
and lost productivity (CDC 2010)
Diabetes = $132 Billion (IHS 2002)
Obesity: $450 Billion
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37
Heart (Cardiovascular) Disease (CVD)
AIANs have the highest percentage (36%) of
deaths from premature heart disease.
This is nearly 2½ times that of whites.
AIANs have more risk factors for CVD than
do Non-Hispanic Whites
Obese
High blood pressure (21% to 41% AIs)
Commercial tobacco use (15 to 70% AIs)
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38
Diabetes
Type 2 diabetes is caused by the body’s
resistance to the action of insulin and by
impaired insulin secretion.
Higher blood levels of HbA1c suggests an
increased risk for the development of
diabetes.
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39
Diabetes (cont)
Most AIANs with diabetes have type 2,
which usually develops in adults but within
AIAN communities it is no longer
uncommon for diabetes to develop in
children and adolescents.
A small number (2-4%) of AIANs have
type 1 diabetes.
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40
Diabetes (cont)
The “TRIPLE TRIPLE” of diabetes in
Native America
~3x risk of heart disease and stroke
3.5x risk of kidney failure
3x rate of death
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41
Diabetes (cont)
Diabetes can be PREVENTED
Disease and early death is not inevitable.
It is never too late to change and improve
health.
Family & community efforts are the key
7% weight loss from 150 min of activity per
week and healthy meals can reduce the risk of
diabetes by > 50%
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42
Arthritis
Arthritis is the most common cause of
disability.
25.2% of AIs have arthritis; ~ 40% have
activity limitations and ~38% have work
limitations
The prevalence high in Alaska (26.1%)
and low in the Southwest (16.5%) as
compared with the US pop. (21.5%).
http://www.cdc.gov/arthritis/data_statistics/race.htm
Arthritis Rheum. 2008 Aug 15;59(8):1128-36.
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43
Arthritis
Having arthritis increases risk of dying
from cancer, but not being diagnosed with
cancer
John Wiley & Sons, Inc. (2007, February 27). Link Between Rheumatoid Arthritis And Cancer.
ScienceDaily. Retrieved January 10, 2012, from http://www.sciencedaily.com
/releases/2007/02/070227105344.htm
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44
Obesity
Over the past 3 decades, being
overweight or obese has become a major
health concern.
Obesity is a risk factor for many other
chronic conditions
The number of adults and children who
meet the definition for obesity has more
than doubled.
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45
Cancer
Now considered a chronic disease
Most common types among AIANs are:
Breast
Lymphoma
Ovarian
Lung & Bronchus
Pancreas
Colon & Rectum
Cervix
Corpus & Uterus
Thyroid
Kidney & Renal
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46
Objective 3
Describe at least 5
risk factors for chronic
conditions.
47
Examples of “Risk Factors”
Foods and drinks we consume
Lack of physical activity
Exposure to environmental contaminants
Spiritual distress
Social distress (dysfunctional families,
neighbors or work settings)
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48
Shield of Health
The shield represents your
protection (shield of health)
against things that may make
you more susceptible to cancer
(cancer risks)
The larger the holes and the
more number of holes in the
shield, the less likely it is to
protect you from cancer or
other health problems
http://www.NatAmCancer.org
49
Cancer risks that “damage” the shield of protection
include factors such as:
1. Age: AIANs over 50 (risk
increases as you get older)
2. Family history (“1st degree
relative” diagnosed with
cancer)
3. Race, such as Alaska
Nations, Northern or
Southern Plains higher
cancer incidence for most
cancers than other tribal
Nations
http://www.NatAmCancer.org
50
Cancer risks that “damage” the shield of protection
include factors such as:
4. Regular use of
manufactured tobacco
5. High fat diet (especially
animal fats)
6. Alcohol (>7 [women] to14
[men]drinks a week)
7. Lack of daily physical
activity
8. Previous personal
diagnosis of cancer
http://www.NatAmCancer.org
51
Cancer risks that “damage” the shield of protection
include factors such as:
For example, the “shield” of health
against prostate cancer may include
daily physical activity; healthy, low fat
diet; limited or no alcohol; and so on
What does this shield tell you
about this man’s cancer risks?
http://www.NatAmCancer.org
52
Additional Risk Factors
Not actually risk factors, but increase the
likelihood that a problem or condition is not
managed well and may become acute or
chronic:
Healthcare access and screening
services
Affordable quality health care (hopefully
will be addressed via Affordable Care
Act)
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53
What “makes” something a bigger
“risk” for chronic conditions?
Frequency
how often does the “risk” or behavior
happen? (e.g., smoke >2 packs of
cigarettes a day)
Duration
how long does the “risk” or behavior last?
(e.g., smoked since 14 years old)
Intensity
how strong is the dosage of the “risk” or
behavior? (e.g., smoke Marlboro -- high
nicotine cigarettes)
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54
Behavioral Risk Factors
Alcohol (~ >7 for women or >14 for men
drinks a week) is a risk factor for:
Diabetes
Obesity
Liver and kidney disease
Cancers, such as
Breast
Lung
Colon
Prostate
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55
Behavioral Risk Factors
Habitual tobacco use (or
“secondhand smoke”) is a
risk factor for:
Heart
Diabetes
Arthritis
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56
Smoking Disparities by State
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Behavioral Risk Factors
Habitual tobacco use (continued)
Cancers, such as:
NOTE: “Ceremonial
Cervix
tobacco use” typically is not
a risk because there is short
Colorectal
(1) frequency
Esophageal
(2) duration
Lung
(3) intensity (dosage)
Stomach
Pancreas
Prostate
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Behavioral Risk Factors
Non-Traditional use
tobacco smokers are 3040% more likely to die
from colon cancer
Smoking rates in most
IHS regions > 40%
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Behavioral Risk Factors
Obesity is a risk factor for:
Heart disease (and other CVD, like stroke)
Diabetes
Arthritis
Cancers, such as
Breast
Colorectal
Gallbladder
Prostate
“Obesity” = “Body Mass
Index” (BMI) more than
30
Usually at least 25
pounds over
recommended weight
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Behavioral Risk Factors
Unhealthy (high fat, high sugar, white
starches, low fiber, low intake of fruits and
vegetables) diet is a risk factor for:
Heart disease (and other CVD, like stroke)
Diabetes
Obesity
Cancers, such as:
Breast
Colorectal
Gallbladder
Prostate
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Behavioral Risk Factors
Sedentary (not physically active)
behaviors are a risk factor for:
Heart disease (and other CVDs)
Diabetes
Obesity
Arthritis
Depression / Suicide
Substance abuse
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Behavioral Risk Factors
Sedentary lifestyle (continued)
Cancers, such as
Breast
Colorectal
Gallbladder
Prostate
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Behavioral Risk Factors
More than three sexual partners
throughout your lifetime (not all at the
same time …. ahem!)
Increased risk of HPV
Increased risk of cervical cancer
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Environmental Risk Factors
Exposure to contaminants through home,
work, fishing, hunting or hobbies such as:
Tobacco
Alcohol
Ultraviolet radiation
(sunlight)
Viruses, Bacteria
Dioxins
Ionizing radiation
Pesticides
Medical drugs
Solvents
Fibers, Fine
Particles, Dust
*Cancer and the Environment
(2003). NIH Publication No. 03-2039.
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65
Environmental Risk Factors
Exposure to:
Polycyclic aromatic hydrocarbons (PAH)
Metals (mercury)
Diesel exhaust particles
Toxins from fungi
Vinyl Chloride
Benzene
PCBs
*Cancer and the Environment
(2003). NIH Publication No. 03-2039.
Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest
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66
Environmental Risk Factors
Exposure to environmental contaminants
is a risk factor for:
Heart
Diabetes
Arthritis
Lung diseases (emphysema; COPD)
*Cancer and the Environment
(2003). NIH Publication No. 03-2039.
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67
Environmental Risk Factors
Exposure to environmental contaminants
is a risk factor for:
Cancers such as:
Lung
Thyroid
Cervix
Head and neck
Lymphoma
Skin
Breast
*Cancer and the Environment
(2003). NIH Publication No. 03-2039.
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68
Social Risk Factors
Healthcare access and screening
services, such as:
Lack of Transportation (distance)
Insufficient / Non-existent local
screening services
Lack of child / elder care
Lack of 1st language (Native tongues
spoken)
Time off work to attend to health needs
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69
Social Risk Factors
Affordable quality health care, such as:
Timely access or CHS referral to care /
treatment
(average 6 months from biopsy to
initiation of breast cancer treatment of
AIAN women who must rely on IHS
referrals for care)
Lack of appointments in tribal / urban
health clinics for several months
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Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest
Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated (NACI)
71
Social Risk Factors
Affordable quality health care (cont.)
34% of AIANs have private health
insurance
Surveys erroneously collapse AIAN’s
responses of “yes, I have IHS” as
health insurance
Beginning in 1998, the US Census
Bureau ceased counting IHS eligibility
as “health insurance coverage.
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72
Social Risk Factors
Affordable quality health care (cont.)
Medicaid, Medicare (CMS) coding errors
result in elimination of payment for
medical services
Local IHS / tribal clinics sometimes have
medical providers who have lost their
medical privileges yet practice in tribal
and IHS settings
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73
Psychosocial/Spiritual Risk Factors
Spiritual Distress
Inability to practice faith; take part in
ceremonies
Social Distress
Dysfunctional families, neighbors work
settings
Poor social support
Depression/Anxiety
Difficulty coping
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Objective 4:
Describe how comorbidities impact
cancer and quality of
life.
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Chronic Conditions AND Cancer
As we grow older, our risks for developing
chronic conditions increases.
Like those with diabetes, persons living
with cancer require care and management
over their lifespan
Whether or not a person has other existing
chronic conditions may impact the type
and outcome of cancer treatment.
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Co-Morbidities AND Cancer
Many older adults with cancer often have
one or more other chronic conditions, such
as:
Diabetes, heart disease, depression,
arthritis, obesity, menopausal symptoms
All contribute to quality of life (ability of the
individual to do everything they want to do
body, mind, emotions and spirits)
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Co-Morbidities AND Cancer
Diabetes and cancer have similar risk
factors (unhealthy diet, lack of physical
activity, obesity)
Organs / systems damaged by diabetes
include eyes / vision, nerves (peripheral),
kidneys, immune system
Organs / systems damaged by cancer /
cancer treatment include nerves
(peripheral), liver, immune system
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Co-Morbidities AND Cancer
Survivors who have both diabetes and
cancer have significantly more problems
that can affect quality of life
Chemo medications may interfere with
insulin management
Insulin management may interfere with
absorption of chemo medications
Resulting in increased problems / side
effects of both diseases
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Concerns for people with chronic
conditions AND cancer
AIAN Cancer Survivors, Denver, CO 2009
Lack of information
Potential impact on:
Quality of life
Ability for self-care
Cancer treatment
decisions
Cancer treatment
outcomes
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QUESTION: What is the relationship between
Diabetes and Cancer among AIANs?
30+% of AI/AN over age 55 have
diabetes
38% of AIANs (n-822) in “Native
American Cancer Education for
Survivors” survivorship program
have both diabetes and cancer
Diabetes is associated with a 30%
increased risk of colon cancer
Larsson SC et al JNCI 2005;97:22: 1679-87
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Interactive Activity:
Bear and Coyote
10 items
82
Bear of Truth vs.
Baby Coyote Trickster (10)
1.
About 15% of AIANs have diabetes.
Coyote / False
2.
About 25% (1/4) of all cancers are
inherited from your parents.
Coyote / False
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
83
Bear of Truth vs.
Baby Coyote Trickster (10)
3.
If a “breast” cancer cell spreads to
the kidney, the new kidney cancer is
still referred to as “breast cancer”
Bear of Truth
4.
“Chronic” conditions mean they last
at least 5 years
Coyote / False
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
84
Bear of Truth vs.
Baby Coyote Trickster (10)
5. The most common chronic conditions
experienced by AIANs are cancer,
diabetes and HIV infection
Coyote / False
6. AIANs have the nearly 2½ times deaths from
cardiovascular disease (CVD) that of whites.
Bear of Truth
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
85
Bear of Truth vs.
Baby Coyote Trickster (10)
7. To save tobacco for ceremonial use
only (no habitual use) would reduce
MOST lung cancer in Indian Country.
Bear of Truth
8. Higher blood levels of HbA1c suggests the
patient has cancer.
Coyote / False
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
86
Bear of Truth vs.
Baby Coyote Trickster (10)
9. The “triple triple” threat for diabetes among
AIANs is >3 times the risk of heart disease
and stroke, kidney failure and death.
,
Bear of Truth
10. The greatest risk factor for cancer is
environmental contamination
Coyote / False
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
87
Optional Objective 5:
Identify differences in
acute, chronic and late
side effects
Slides used with permission from Linda U.
Krebs, RN, PhD, AOCN, FAAN, University of
Colorado, Denver, College of Nursing
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Side Effects –Types
Acute – occur during or shortly after
treatment
Usually resolve with time
Chronic / long term – continue months to
years after treatment
Can be managed but do not completely
resolve
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89
Side Effects –Types
Late – not present or identified during or
right after treatment
Develop based on effects of treatment
on organ systems (heart, bones, etc.)
May be a result or of psychological
process related to having cancer or
being treated for cancer (depression /
anxiety)
Often confused with chronic (long term)
side effects
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90
Side Effects – Factors Influencing
Development
Type of treatment (RT, Chemo, Surgery,
etc.)
Exact tissue and amount of tissue
treated/removed
Dose of chemo /RT given
Method of delivery
Individual factors
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91
General Side Effects
Fatigue
Most common side affect – can be both
acute and chronic
Extreme tiredness; does not improve
with sleep or rest
Worsens throughout treatment
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General Side Effects
Cognitive dysfunction
Also known as chemo brain or brain fog
Signs/symptoms
Memory loss
Trouble paying attention; making
decisions
Difficulty with activities of daily living
Make silly mistakes; difficulty writing
Trouble making decisions
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General Side Effects
Pain
Pain can be caused by cancer, cancer
treatment or other conditions
Pain often not well managed because of
poor communication and coping between
provider and patient
20% of survivors have cancer-related
chronic pain
Of these, 43% had pain since diagnosis
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General Side Effects
Pain more common in women than in
men
Women almost twice as likely as men
to have pain since diagnosis (56% vs.
30%)
Women twice as likely to have pain
with activity (50% vs. 24%)
Women more likely to have cognitive
dysfunction
women had more pain, more flare-ups
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General Side Effects
Women had more:
Pain
Flare-ups of pain
Higher disability related to pain
Depression
http://www.medscape.com/viewarticle/736176
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96
Site Specific Side Effects – RT/Chemo
Brain – erythema (redness), cerebral
edema (brain swelling), sleepiness,
Head/Neck – mucositis/xerostomia
(mouth sores), dental caries (cavities),
esophagitis (sore throat), taste changes,
decreased hearing
Breast – skin reactions from RT
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97
Site Specific Side Effects – RT/Chemo
Lung – pneumonitis (lung irritation or
inflammation); lung damage
Heart – pericarditis (inflammation);
decreased function
Abdomen/pelvis/renal – Nausea and
vomiting, diarrhea, proctitis, cystitis,
kidney damage, vaginal
dryness/shortening
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Site Specific Side Effects-RT/Chemo
Skin – alopecia (hair loss), erythema
(redness), rash, itching, poor wound
healing
Reproduction – infertility, early
menopause, sterility
Bone marrow – decreased white cell, red
cell and platelet counts
Nervous system – neuropathy (pain and/
or numbness in fingers and toes)
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99
Side Effects-Surgery
Pain, nausea
Impaired wound healing
Changes in bowel/bladder function
Difficulties with nutrition
Amputation, ostomy
Anxiety, depression, body image changes
Gemmill, R. ( 2004) in C. Varricchio, 2004
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100
Optional Objective 6:
Identify at least 5 strategies
for addressing chronic side
effects of cancer/cancer
treatment
Slides used with permission from Linda U.
Krebs, RN, PhD, AOCN, FAAN, University of
Colorado, Denver, College of Nursing
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101
Managing Chronic Side Effects
Fatigue
Most common side effect
Practice energy conservation
Conserve energy for important tasks
each day
Provide/accept support
Make lists of what you need; ask
Optimize nutritional intake
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Cognitive Dysfunction
Cognitive dysfunction
Also known as chemo brain or brain fog
Signs/symptoms
Memory loss
Trouble paying attention; making
decisions
Difficulty with activities of daily living
Make silly mistakes; difficulty writing
Trouble making decisions
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Managing Chronic Side Effects
Cognitive dysfunction
Conserve attention
Supportive environment
Restore attention
Keep an active brain (games)
Medications
Manage menopause, depression
Stimulants
Herbs
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Managing Chronic Side Effects
Cognitive dysfunction
Exercise
Write it down
Remind friends and family
Get enough sleep
Manage stress
Read/Crosswords (Brain work)
Eat right (good nutrition)
AND … Don’t be hard on yourself
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Managing Chronic Side Effects
Pain
“Pain is whatever the experiencing
person says it is, existing whenever the
experiencing person says it does.”
Needs to be assessed frequently – use
of pain journal, phone app or other
monitoring
Set goals for pain relief (pain may be
noticeable but not bothersome)
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Managing Chronic Side Effects
Pain (continued)
Take pain medications as prescribed
Around the clock
Before pain becomes severe
Use other methods to manage pain
Music
Cold/heat
Relaxation, distraction
Massage
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Managing Chronic Side Effects
Skin Reactions
May be acute or chronic (hair will grow
back after chemo; not after RT)
Keep scalp clean; avoid damaging hair
(perms, dyes)
Provide moisture to skin
Avoid irritants, perfumes, coarse
clothing, sun exposure
Haas, M. (2004) in C. Varricchio, 2004
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108
Managing Chronic Side Effects
Nutritional alterations
Changes in taste, smell; difficulty eating
May need to try new foods, different
spices; use nutritional “food plate” as
guide
Best not to cook or limit times with hot
foods/cooking smells
Use small plates and small amounts of
food
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109
Managing Chronic Side Effects
Reproduction/sexuality/ intimacy
Treatment may affect ability to become
pregnant or father a child
Having cancer can affect intimacy and
sexual function
Early menopause is common with
chemo, especially as women near their
late 30s into 40s
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Managing Chronic Side Effects
Peripheral Neuropathy
Pain and numbness in fingers and toes
Pain: sharp, stabbing, burning
Numbness: tingling, loss of feeling
Usually damage to nerve endings from
chemotherapy
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Managing Chronic Side Effects
Peripheral neuropathy (continued)
Increased problems in those with:
Diabetes
Alcohol
Poor nutrition;
B12 deficiency
Shingles
Safety is important
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Managing Chronic Side Effects
Peripheral neuropathy (continued)
Pain relievers (non-aspirin; pain
patches; narcotics)
Drugs for epilepsy
Drugs for depression
Massage
Exercise
Acupuncture
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Managing Chronic Side Effects
Peripheral neuropathy (continued)
Self Management
Avoid repetitive activities
Avoid alcohol
Use braces, splints
Occupational therapy
Take medications as
ordered; do not skip
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114
Managing Chronic Side Effects
Constipation
Prevention
Dietary fiber
Increased fluids
Exercise
Management
Bulk or other laxatives
Lubricants
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Managing Chronic Side Effects
Diarrhea
Management is essential for well-being
and quality of life
Drink fluids – electrolyte rich
Watch diet – eat bananas, rice,
applesauce, toast, other bland foods
Use antidiarrheal agents
Keep perianal area clean and dry
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Managing Chronic Side Effects
Secondary malignancies
Occur as a result of having prior cancer
treatment and surviving a long time
May be difficult to treat
Need to be diligent about follow-up and
routine screenings; report concerns to
healthcare provider
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Post Session
Knowledge Items (TP)
4 items
118
Which is True?
1. Cancer cells do not die as
normal cells do
2. About half of all cancers are
inherited from your parents
3. A tumor the size of a pea
usually takes about 3 years
to develop
4. Most “benign” tumors
spread to other parts of the
body
5. Don’t know / not sure
56%
24%
12%
4%
1
2
3
4
4%
5
Which is true?
1. Cancers are diagnosed by a
process called, “metastasis”
2. Cancer is becoming a “chronic”
disease (like diabetes)
3. Only 30% of lung cancers
could be prevented by not
using tobacco habitually
15%
4. Accurate screening tests are
available for gallbladder cancer
5. Don’t know / Not sure
1
56%
15%
15%
0%
2
3
4
5
What is the cause of most (~90%) of all
cancers?
1.Family history
2.Smoking for 5 years
3.Being exposed to radiation
4.Lifestyle and physical
environment
5.Don’t know / Not sure
75%
11%
11%
4%
1
2
3
0%
4
5
If a “breast” cancer cell spreads to the
kidney, what is the new cancer called?
1.New primary cancer
2.Recurrent breast cancer
3.Breast cancer
4.Kidney cancer
5.Don’t know / Not sure
56%
26%
15%
4%
0%
1
2
3
4
5
Workshop
Evaluation (TP)
4 items
(you won’t see the
answers)
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
123
Overall, how understandable was the presentation?
1. Very understandable
2. Fairly understandable
3. Not understandable
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
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E_undrst
Overall this session provided useful information to me.
1.
2.
3.
4.
I strongly agree
I agree
I don’t agree
I strongly disagree
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
125
E-useful
Overall, what was the quality of the information content
of the presentation?
1. High
2. Average
3. Low
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
126
E_quality
Would you recommend this workshop to your friends or
colleagues?
1. Yes
2. Maybe
3. No
4. Not Sure
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
127
E_rec
Excerpts from Native American
Cancer Research
Corporation (NACR)
Cancer 100
Cancer Terms
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128
Different types of cancer affect different
types of body tissue
Carcinoma. Originates from tissues that cover a
surface or line a cavity of the body. This is the most
common type of cancer.
Sarcoma. Originates from tissues which connect,
support or surround other tissues and organs. Can be
either soft tissue or bone sarcomas.
Myeloma. Originates in the bone marrow in the blood
cells that manufacture antibodies.
Lymphoma. Originates in lymph system--the circulatory
network of vessels, spaces, and nodes carrying lymph,
the almost colorless fluid that bathes the body’s cells.
Leukemia. Involves the blood-forming tissues and blood
cells.
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
129
What is cancer? (continued)
Cancers are identified by the place they
originate within the body. For example:
Breast
Cervix
Colon
Prostate
Pancreas
Stomach
Brain
Bladder
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
130
Normal Cells
Excerpt from the Kansas State University “coloring book”
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
131
Cancer Cells
Excerpt from the Kansas State University “coloring book”
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
132
Activity: Cancer Definition Cards
A stack of index cards is on the table.
Please take at least one card.
A definition is written out on each card.
During the session, when you feel you
know the word of phrase that the definition
explains, please go to the cards on the wall
and place the definition on the Velcro strap
immediately below the word(s) your card is
defining.
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
133
Cancer (CAN-sir)
Cancer cells have the ability to spread from
one part of the body to another part of the
body
When cancer cells go to another body part,
they can begin to grow without control in the
new location
But a breast cancer cell in the liver is still
“breast cancer” (primary site)
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
134
Metastasis (ma-TAS-sta-sis)
This means that cancer cells have
spread from one body part to another
The cancer cells spread from the
"primary site" to other
organs by traveling
through the blood
vessels or lymph vessels
QUESTION: What is the
lymphatic system?
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
135
Diagnosis (die-egg-NOH-sis)
The process and result of
determining if the symptoms
or evidence of cancer is
really cancer
QUESTION: What type of
information does the provider
need to make a diagnosis?
Ruby Wells
I had a mammogram 6 months prior to finding a lump
and thought I was in the clear. … I give myself a self- Cherokee Nation of OK
Dx. breast 2001
breast exam and I located a knot. I went to the doctor
and they proceeded with tests. …. they thought it was a
cyst, but I still never thought it could be cancer…when
the surgery was over the doctor told me it had grown to
9 cm.
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
136
Diagnosis (die-egg-NOH-sis)
The Provider…
suspicious
Asks about symptoms
Asks about medical history
Performs a physical exam
Orders tests and imaging
procedures
Performs biopsy--to
determine whether cancer
cells are present
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
137
Biopsy (bye-OP-see)
The physician takes a piece of tissue (a
group of cells) from the growth or cyst
Sometimes these cells are cut, and other
times they are "sucked" out with a needle
(fine needle aspiration)
These cells are examined by a "pathologist”
A biopsy is a sure way to make a diagnosis
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
138
QUESTION: What is a Tumor (TOO-mer)
Normally, cells grow and divide to produce
more cells only when the body needs them
This keeps the body healthy
Sometimes cells keep dividing when new
cells are not needed
Or the cells do not know how to die
(apoptosis)
These extra cells form a mass of tissue,
called a growth or tumor
Cancer 100 “Overview of Cancer” (Burhansstipanov)
Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]
139
Tumor (TOO-mer)
This is a growth or mass formed by excess
cells
A "benign" tumor is not cancer and it does
not “become” cancer. It just stays “benign”
8 out of 10 tumors are not cancer (they are
"benign")
A "malignant" tumor is cancer and can
spread to other parts of the body
Cancer 100 “Overview of Cancer” (Burhansstipanov)
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Two types of tumors:
Benign tumors:
not cancer
can often be removed
in most cases do not
come back
do not spread to other
parts of the body
rarely a threat to life
Malignant Tumors
are cancer
cells abnormal
cells divide
without control or
order
enlarge “mass”
metastasize
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Treatments (like chemo) may be given
before surgery to help the tumor shrink
Locally
advanced
breast
cancer
(left)
After 3
months of
Tamoxifen
treatment
(right). The
tumor is
now
operable.
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%
Type of pre-cancer or cancer
6.0
0.2
68.0
10.0
3.0
3.0
3.0
2.0
Non-invasive (not cancer yet)
Ductal carcinoma, in situ
Lobular carcinoma, in situ
Invasive (cancer)
Ductal carcinoma
Lobular
Tubular
Cribriform
Medullary
Mucinous
2.0 Microinvasive
1.0 Papillary
1.8 Other rare types (apocrine, metaplastic, adenodcystic cancers)
Cancer Develops Over Time
It is a result of a complex mix of factors
related to:
Lifestyle (daily behaviors)
Environment
Heredity
These are called risk factors
See Breast Risk / Health Protection Shield
on NACR web site http://www.NatAmCancer.org
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“Risk Factors”
Usually refers to a behavior or exposure to
something that increases your chances of
getting cancer
They may also be something that you
have little to no control over
Hereditary genes from your parents
Your gender (male or female)
Pollution of the water or land where you
fish or hunt
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