Download Care of the Cancer Survivor Management of Late Effects

Care of the Cancer Survivor
Management of Late Effects
12th Annual Mid-South Cancer Symposium
Baptist Cancer Center
November 14, 2014
Linda A. Jacobs, PhD, RN
Director
Survivorship Center of Excellence, Abramson Cancer Center
University of Pennsylvania
Clinical Associate Professor of Nursing
Who is at Risk?
• Risk depends upon a number of things:
• Age
– Now & when treated
– Older vs. younger
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General health & lifestyle
Family history
Chance
Treatment
– More courses of treatment may increase risk
– Type of drug/dose
– Radiation
• Dose & body location
Immediate & Late Effects of Treatment
Chemotherapy
Radiation
Surgery
Possible Complications of Cancer Treatment
• Long Term Effects of Treatment
– Develop during active treatment
– Persist for years
• Neuropathies
• Fatigue
• Cognitive & sexual difficulties
• Late Effects of Treatment
– Not present or identified until after treatment
• Develop as a result of treatment
– Organ systems
» Endocrine, cardiovascular (CV), pulmonary, CNS, etc.
– Psychological process
Hewitt M, Greenfield S, Stovall E. (2006). From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, D.C.:
The National Academies Press.
Survivorship care:
What is the state of the science?
• Prevention & detection of new cancers & recurrent cancer
• Intervention for consequences of cancer & its treatment
• Coordination between specialty & primary care
– Fragmented care, poor communication
– Confusion about role & responsibility
– PCPs lack information to support optimal care
• Disease & treatments received
• Secondary consequences (surveillance, intervention)
– Workforce trends will likely exacerbate problems
Institute of Medicine & National Research Council, 2006; Grunfeld & Earle, 2010.
Cancer Screening in Cancer Survivors
• Background
– Second cancers - 6th leading cause of cancer deaths
– 10% of all new cancers are diagnosed in survivors
• Adherence to cancer screening
– Cancer survivors adhere to recommendations as well
as or better than individuals without cancer
– Factors influencing adherence
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Sociodemographic factors
Perceived vulnerability to cancer
Perceived utility of screening
Access to health care
Provider recommendation of screening
Mayer et al. (2007). Screening practices in cancer survivors. Journal of Cancer Survivorship 1: 17-26.
Disease surveillance & follow up care
Goals:
1. Ensure recovery from treatment
2. Detect late complications
3. Monitor ongoing therapy
- i.e., endocrine therapy for breast cancer
4. Detect local & distant recurrence
5. Detect other cancers
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Contralateral (if applicable)
Secondary
Other cancer screening
Kramer, R. & Osborne, C.K. (2004). Evaluation of patients after primary therapy.
Overview
• NCCN Guideline Version 2:2014 Survivorship
– Focused on survivors after completion of cancer
treatment & in clinical remission
– May also be appropriate for survivors living with
metastatic disease as clinically appropriate
– Screening, evaluation, & treatment recommendations
for common consequences of cancer treatment and
cancer
– Provide a framework
• General survivorship care/management of potential
long-term &/or late effects of cancer & its treatment
• coordination of care between health care providers
NCCN Practice Guidelines Version 2. 2014: Survivorship http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
Long Term Survivors & Symptoms
1. Fatigue
2. Pain
• Peripheral neuropathy
3. Cognitive function
4. Sleep disturbances
5. Appetite loss
6. Dyspnea
7. Nausea/Vomiting
8. Constipation/Diarrhea
Journal of Pain & Symptom
Management 2012
• N=863 long-term
survivors of multiple
cancer types
• Principal component
–factor analysis N=591
–All 8 symptoms significantly
correlated with one another
Karabulu, Erci, Ozer, et al. Journal of Advanced Nurs. 2010; Brearley., Stamataki, Addington-Hall, et al.
European Journal of Oncology Nursing. 2011; Schmidt, Chang-Claude, Vrieling, et al. J Cancer Surviv. 2012;
Yang, Cheville, Wampfler, et al. Journal of Thoracic Oncology. 2012; Zucca, Boyes, Linden, et al: Journal of
Pain & Symptom Management, 2012.
Long Term Survivors & Their Symptoms
N=591 (5-6 years post diagnosis)
• 71.2% no symptoms
• 17.6% multiple
symptoms
• Reported 2 or more
symptoms
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breast
prostate
colorectal
melanoma
21.1%
20.2%
19.0%
4%
• No cancer specific
symptom clusters
• Individual symptoms
moderately
discriminated specific
cancer sites
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diarrhea
pain
constipation
insomnia
Zucca, Boyes, Linden, et al: Journal of Pain & Symptom Management, 2012.
Survivorship care is many things
• Patients completing treatment for different cancers
have very different needs & concerns
• Patients of different ages have very different needs &
concerns
A 70 yo man completing surgery, chemotherapy & radiation for head
& neck cancer
A 37 yo woman completing adjuvant chemotherapy & initiating
hormone therapy for breast cancer
A 17 yo woman completing combined modality therapy (ABVD &
mediastinal radiation) for Hodgkin’s lymphoma
Survivorship care is many things
A 70 yo man completing surgery, chemotherapy & radiation for
head & neck cancer
• Speech & swallowing issues, nutrition, aspiration
pneumonia
A 37 yo woman completing adjuvant chemotherapy &
initiating hormone therapy for breast cancer
• Fertility, bone health, long-term cardiac issues
A 17 yo woman completing combined modality therapy (ABVD
& mediastinal radiation) for Hodgkin’s lymphoma
• Breast cancer, cardiac & pulmonary disease, other
second cancers
Female Hodgkin’s Lymphoma Survivor
Late Effects of Treatment occurring over 30 years
•
1983, age 21 – Hodgkin Lymphoma, Stage IIA, splenectomy MOPP x 6,
mantle & para-aortic radiation
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1987, age 25 – thyroid failure, & oral replacement
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1994, age 32 – breast cancer – T1c, N0, bilateral mastectomies, CMF
chemotherapy
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2006, age 44 – fibroblastic proliferation left posterior back (in radiation field),
most consistent with extra-abdominal desmoid tumor – resected with poorly
healing wound
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2009, age 47 – > 40 colon sessile serrated polyps
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2010, age 48 – Barrett’s esophagus
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2013, age 51 – coronary artery disease, tachy-arrhythmias, intermittent
complete heart block, permanent pacemaker placement, continued
exertional dyspnea
Medical Late Effects
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Cardiovascular
Pulmonary
Endocrine
Central Nervous
System (CNS)
• Neurological
• Renal
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Genitourinary
Gastrointestional
Musculoskeletal
Integumentary
Lymphatic
Other
• Systems approach can guide
clinical practice
Hewitt M, Greenfield S, Stovall E. (2006). From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, D.C.: The National Academies Press.
Ganz, P. (2006)
… Medical Issues Resulting from
Cancer Treatment
• Examples
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Poor dental health
Eye problems
Lung fibrosis
Reduced thyroid function
Heart disease & stroke
• Risk factors
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Smoking
High blood pressure
Diabetes
Family history
Obesity
High cholesterol
Screening for All Patients
• Careful History & Physical exam
– Exercise-induced symptoms
– Other symptoms (dyspnea, chest pain, etc).
– CV exam, BP, carotid bruits
• Monitor risk factors
– FH, HTN, tobacco, diabetes, obesity
– Lipid profiles
• Consider cardiac referral
– Cardiac risk factors
– Abnormal exam findings
Carver et al. (2008). Cardiovascular late effects and the ongoing care of adult cancer survivors. Disease
Management 11(1), 1 – 6.
Chemotherapy Related
Cardiac Issues
• Anthracyclines & trastuzumab
– Asymptomatic ventricular dysfunction
– Cardiomyopathy & CHF
• Alkylating agents, esp. cisplatin
– Direct, chronic endothelial damage
– Increased risk of cardiovascular disease in germ
cell tumor survivors vs. controls
• Atherosclerosis - Raynaud’s symptoms
• Lipid abnormalities
- Hypertension
Yeh E et al. (2004). Cardiovascular complications of cancer therapy. Circulation 109:3122-3131.
Carver et al. (2008). Cardiovascular late effects and the ongoing care of adult cancer survivors. Disease Management 11(1), 1 – 6.
Radiation Therapy Related
Cardiac Issues
• Incidence of cardiac disease
– Peaks at 4 -6 years post-exposure
– 10 to 30% by 5 to 10 years post-treatment
– Up to 88% with asymptomatic abnormality
• Best studied in survivors of Hodgkin’s postmediastinal radiation
– Increased risk (2.2 to 7.2 RR) for fatal cardiovascular
disease
– Manifests 5 – 10 years post radiation
– 25% of non-Hodgkin’s related deaths
Carver J, Shapiro C, Ng A, Jacobs L, Schwartz C, Virgo K, Hagerty K, Somerfield M, Vaughn D. (2007). Journal of Clinical Oncology, ASCO Special Article, 25,
25:3391-4008
Radiation Therapy Related
Cardiac Issues
• Specific radiation-related effects
– Pericardial damage & fibrosis
• pericardial effusion (early), pericardial constriction (late)
– Vascular injury
• premature coronary artery disease (CAD)
• MI and sudden death
• carotid disease (incl. stenosis), stroke
– Valvular heart disease, fibrosis
• Aortic regurgitation most common (60%)
– Cardiomyopathy
• restrictive, diastolic dysfunction
– Conduction abnormalities/arrhythmias
Carver J, Shapiro C, Ng A, Jacobs L, Schwartz C, Virgo K, Hagerty K, Somerfield M, Vaughn D. (2007). American Society of Clinical Oncology Clinical
Evidence Review on the Ongoing Care of Adult Cancer Survivors: Cardiac and Pulmonary Late Effects. Journal of Clinical Oncology, ASCO Special Article,
25, 25:3391-4008
Yeh E et al. (2004). Cardiovascular complications of cancer therapy.Circulation 109:3122-3131.
Combination Anthracycline & Mediastinal
Radiation (High Risk Population)
• Patient characteristics
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Age <18 or > 65 years at treatment initiation
Pregnant or contemplating pregnancy
Extreme athletics
> 10 years from treatment
Pre-existing cardiac risk (CAD, HTN, LVD)
• Treatment factors
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>300 mg/m2 doxorubicin, >600 mg/m2 epirubicin
Mediastinal XRT + anthracycline
Radiation prior to 1970
> 35Gy to heart +/- >2 Gy/day
Absence of subcarinal blocking
Carver et al. (2008). Cardiovascular late effects and the ongoing care of adult cancer survivors. Disease Management 11(1), 1 – 6.
Cardiac Screening after Chest Radiation
• Cardiac screening 5 years post-treatment if any cardiac
abnormality or high risk
– 10 years post-treatment if not high risk
• Cardiovascular screening repeated every 5-10 years
– Presence of cardiac abnormalities & the level of risk
• All patients who had chest radiation
– Cardiac examination starting with ECHO
– Stress imaging, CT or cardiac MRI
– No established role in asymptomatic survivors
• Routine Holter, stress tests, or ECHOs
Lancellotti P. Eur Heart J Cardiovasc Imaging. 2013;14:721-740.
Breast Screening following Chest Radiation
Under age 40
• Mantle radiation
• Chest/chest region radiation
• Cranio-spinal/spinal radiation
• Annual breast MRI in women beginning at age 25 or
at least 8 years after radiation treatment
– Treated with any dose of radiation prior to age 40
NOTE: in addition to annual mammography
Oeffinger KC, Ford JS, Moskowitz CS. (2009). Breast Cancer Surveillance Practices Among Women Previously Treated With Chest Radiation for
a Childhood Cancer. JAMA, 301:4; 404-414.
Mulder RL, Kremer LC, Hudson MM. (2013) Recommendations for breast cancer surveillance for female survivors of childhood, adolescent, and
young adult cancer given chest radiation: a report from the International Late Effects of Childhood Cancer Guideline Harmonization
Group.www.thlancet.com/oncology Vol 14, 621-629.
ACS 2014 Guidelines for Breast MRI
• 20% to 25% or greater lifetime risk of breast cancer
based mainly on family history
• Known BRCA1 or BRCA2 gene mutation
• First-degree relative with a BRCA1 or BRCA2 gene
mutation
– have not had genetic testing themselves
• Radiation therapy to chest between the ages of 10-30 years
• Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndrome
– have first-degree relatives with one of these syndromes
http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs 2014
Screening for Bone Health
• NCCN Guidelines, 2011
– Screen all women at high risk
• All postmenopausal women receiving AI’s
• Therapy-associated premature menopause
– Monitor BMD with DEXA scan every 2 years
– Calcium (1200mg/day) & Vitamin D (400-600 IU/day
supplementation for all women
– Pharmacologic treatment when T-score < -2.5
• Lack of consensus between organizations on appropriate threshold
for initiation of treatment
Gralow J, Biermann JS, Farooki A, et al. (2011). NCCN Task Force Report: Bone Health in Cancer Care J Natl Compr Canc Netw.
Author manuscript; available in PMC Mar 2, 2011. edited form J Natl Compr Canc Netw. Jun 2009; 7(Suppl 3): S1–S35.
Pulmonary Late Effects
• Reduced pulmonary function
• Pneumonitis
– Bleomycin-induced (BIP)
– Radiation-induced (acute, chronic)
• Fibrosis
• Bronchiolitis obliterans
• Idiopathic pneumonia
• Interstitial pneumonitis
Kattlove & Winn (2003). CA: Ca Jnl Clinicians 53(3), 172-196.
Carver J, Shapiro C, Ng A, Jacobs L, Schwartz C, Virgo K, Hagerty K, Somerfield M, Vaughn D. (2007). ASCO Clinical Evidence Review on the Ongoing
Care of Adult Cancer Survivors: Cardiac and Pulmonary Late Effects. JCO, ASCO Special Article, 25, 25:3391-4008
Gospodarowicz M. (2008). Hematol Oncol Clin North Am.(2):245-55.
Pulmonary Late Effects
• Screening & Management
– Exercise endurance
– PFTs as indicated
– Radiation
• Risk of lung cancer
– Bleomycin
• Scuba diving warning
• Refer to Pulmonary
– Management as needed
Endocrine Late Effects
• Radiation
– Cranio-spinal radiation
• Pituitary/testicular/thyroid gland dysfunction
– Pelvic
• Ovaries/testicles/adrenals/GU/bowel dysfunction
• Chemotherapy
– Cyclophosphamide, Procarbazine, BCNU/CCNU, Ifosfamide
– Risk of premature ovarian/testicular failure
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bone density
libido
fertility
Symptoms
– hot flashes
– fatigue
Stricker and Jacobs (2008); Stein, Syrjala, & Andrykowski, 2008.
Endocrine Late Effects
• Screening & Management
– TFTs
– Exam
– Assess symptoms
– Fatigue
– Sexual function
– Mood
– Males-testosterone/LH
• Hormone replacement as needed
– Females
• Assess for ovarian failure
• LH, FSH, Estradiol
– Assess for psychosocial effects, refer as needed
– Bone Mineral Density-DEXA
Fertility & Sexual Function Issues
• Males
• Erectile dysfunction
• Low/no sperm count
• Psychological effects
• Females
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Hot flashes
Vaginal dryness
Pain
Premature ovarian failure
Psychological effects
• Management
– Refer to gynecology/urology/psychology/sex therapist as needed
– Acupuncture/pain management
Dorey G. (2007). A clinical overview of the treatment of post-prostatectomy incontinence. Br J Nurs. Oct 25-Nov 7;16(19):1194-9.
Robinson et al. (2002). (meta-analysis of rates of erectile dysfunction)
Central Nervous System (CNS)
Late Effects
• Causes/risk factors
– Chemotherapy induced
• Age < 3 years at treatment
• Cytarabine, Methotrexate
• Intrathecal chemotherapy
– Radiation induced
• dose related; combination w/chemo
• age related
CNS Late Effects
Radiation & Chemotherapy
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Meningiomas
Cavernomas
Neurocognitive deficit
Leukencephalopathy
– Seizures
– Radiation therapy, cytarabine, methotrexate,
fludarabine
Cognitive Dysfunction
“Chemobrain”
• Deficits in memory, concentration, & executive
functioning
• Examples of populations at risk
– Breast CA: some impairment at “baseline”
• 35% of women with breast cancer in one study
– Prostate CA: androgen deprivation therapy
• Psychological distress may be related
• Genetic predisposition is under investigation
Green et al., 2002; Koupparis et al., 2004, Wefel et al., 2004
Hede K, J Natl Cancer Inst. 2008 Feb 6;100(3):162-3, 169. Epub 2008 Jan 29.
Renal Late Effects
• Screening
– blood pressure (yearly)
– Urinalysis (yearly)
• U/S if micro heme +
– Baseline labs (repeat as
clinically indicated)
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BUN, creatinine
creatinine clearance
mag, phosphorus
protein, albumin
CBC, retic count
Stricker and Jacobs (2008)
• Treatment
– Renal referral
• hematuria
• HTN, proteinuria
• progressive renal insuff
– Treatments as indicated
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renal diet
diuretics
Mg/Phos supplements
AVOID nephrotoxins
Dermatologic Late Effects
• Radiation therapy
– Benign dermatologic changes
• Telangiectasias
• Fibrosis
• Hair loss, altered skin pigmentation
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Dysplastic nevi
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
• Screening
• annual skin exam
• Refer to derm as indicated
Stricker and Jacobs (2008); Ganz, 2006.
Factors Predisposing to Second Malignancies
• Genetic Conditions
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Genetic retinoblastoma (bilateral, familial)
Neurofibromatosis
Li-Fraumeni Syndrome
BRCA-1, BRCA-2
• Treatment
– Radiation
• Sarcomas
• Site-specific cancers
– e.g., rectal CA with prostate radiation
– Breast cancer with chest radiation age <30yo (15 year latency)
– Chemotherapy
• continued…..
Grady & Russell (2005). Gastroenterology 128(4):1114-1117.
Hancock et al. (1993). JNCI 85(1), 25-31.
Chemotherapy & Second Malignancies
• Alkylators
– Myeloid leukemia & MDS
• chromosomes 5 & 7 abnormalities
• latent period 3 to 7 years
• dose relationship
• Epipodophyllotoxin
– Monocytic leukemia
• chromosome 11q23 abnormality
• dose & schedule dependent
• short latent period
…Examples of Secondary Malignancies
• Malignancies related to a number of factors
– Breast
– Lung
– Skin
– Chest & neck
– Abdomen
– Leukemia & other blood disorders
Summary
• Cancer treatments increase the risk for myriad
late effects in survivors
– Age & dose are key risk factors
– Combination therapies are often synergistic
• Clinical evaluation should be guided by
– Treatments received
– Body systems approach
• Referral to specialists a critical component of
care
Other Late Effects of Treatment
Common Symptoms
& Management
Von Ah DM, Kang DH, Carpenter JS. (2008). Predictors of Cancer-Related Fatigue in Women With Breast Cancer
Before, During, and After Adjuvant Therapy. Cancer Nurs. (2):134-144.
Patridge, Burstein, & Winer (2001). J Natl Cancer Inst Monogr 30:305-313
Halbert CH, Weathers B, Esteve R, Audrain-McGovern J, Kumanyika S, DeMichele A, Barg F. (2008). Experiences
with weight change in African-American breast cancer survivors. Breast J. (2):182-7.
Fatigue, Pain, & Sleep Issues
• Among the most troublesome symptoms
experienced by cancer survivors
– Definition/description/associated factors
– Management
Pachman, Barton, Swetz, Loprinzi, JCO, October 20, 2012; Given, Given. Seminars in Oncology 2013.
Treatment of Fatigue
• Energy conservation
• Physical activity
• Psychosocial
interventions
• Treat contributing factors
– Cognitive behavioral
therapy
– Psychoeducational
therapies
– Emotional distress
NCCN Practice Guidelines Version 2. 2014: Survivorship; Brearley, Stamataki,
Addington-Hall et al. European Journal of Oncology Nursing. 2011. Karabulu,
Erci, Ozer, et al. Journal of Advanced Nursing. 2010. Bower, Bak, Berger, et
al. JCO, 2014; NCCN Clinical Practice Guidelines in Oncology: Cancer related
Fatigue Version 1.2013.
– Medication effects
– Pain *
– Anemia
• Iron, B12, folate deficiency,
referral
– Sleep issues *
– Nutritional deficits
– Co-morbidities
• Hepatic, renal, cardiac,
pulmonary, neuro,
endocrine
Medication Management for Fatigue
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Remains investigational
More evidence for methylphenidate (ritalin)
Less for modafinil (provigil)
Psycho stimulants
– Dosing & schedule have not been established
• Small pilots
– Ginseng, vitamin D, other supplements
• No consistent evidence to date
Chronic Pain
• Reported by 33% post treatment cancer
survivors
• Often leads to psychological distress & poor
quality of life
• Categories of cancer pain syndromes
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Neuropathic
Post-operative
Myalgias/arthralgias
Skeletal
Myofacial
GI/urinary/pelvic
Pachman, Barton, Swetz, Loprinzi, JCO, October 20, 2012.
Pain Management…
• Multidisciplinary approach
– Pharmacologic treatments (examples)
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Opiates (narcotics)
NSAIDS (Motrin, Aleve)
Vitamin D
Muscle relaxants (Baclifen)
Topical treatments
Adjuvant analgesics
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Antidepressants (elavil)
Anticonvulsants (gabapentin)
Corticosteroids (prednisone)
Topical agents
Paice JA, Ferrell B. CA CancerJ Clin, 2011; NCCN Practice Guidelines Version 2. Survivorship: 2014.
…Pain Management…
• Multidisciplinary approach
– Non-pharmacologic
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Exercise
Heat
Cold
Physical therapy
Aquatic therapy
Ultrasound stimulation
Syrjala, Jensen, Mendoza, et al. JCO, 2014.
…Pain Management
• Multidisciplinary approach
– Psychosocial/behavioral interventions
• Relaxation training
• Cognitive-behavioral therapy
– Proper hydration, bowel regimen, pelvic floor exercises
– Exercise therapy
– Interventional procedures
• Trans electrical nerve stimulation (TENS)
• Intercostal nerve blocks
• Dorsal column stimulation
• Referral to pain management
Sleep Disorders
• Affect 30-50% of patients with cancer & survivors
– Often in combination with fatigue, anxiety, &/or depression
– Successful treatment can improve fatigue, mood, QOL
• Insomnia
• Excessive sleepiness
• Sleep related movement/breathing disorders
– Parasomnias
• Talking/walking/grinding teeth/eating/etc.
• Restless leg syndrome
– Ferritin level <45-50 ng per ml
NCCN Practice Guidelines Version 2. 2014: Survivorship; Berger AM, Mitchell S. J Natl Compre Canc Netw , 2008.
National Heart, Lung, and Blood Institute Working Group on Insomnia.NIH Publication, 1998; NCCN Practice Guidelines Version 2. 2014:
.
Survivorship;
Nakamura, Lipschitz, Kuhn, et al. J Ca Survivorship, 2013
Treatment for Sleep Disorders…
• General sleep hygiene
• Physical activity
• Pharmacologic treatments
– Hypnotics
• Zolpidem (ambien)
• Ramalteon (rozerem ambien-like)
– Psycho-stimulants including those for narcolepsy
• Modafinil (provigil)
• Methylphenidate (ritalin)
Savard J, Simard S, Ivers H, et al. Journal of Clinical Oncology, 2005; NCCN Practice Guidelines Version 1. 2013: Survivorship.
…Treatment for Sleep Disorders…
• Pharmacologic treatments (cont.)
– Dopomine agonists (examples)
• Adderall & Adderall XR
• Dexadrine
• Ritalin
– Benzodiazepines
• Ativan
• Xanax
• Valium
– Garapentin enacarbil (for restless leg syndrome)
– Opiods (for restless leg syndrome)
• Examples:
– Hydrocodone, Vicodin, Oxycodone, Oxycontin, Percodan, Tramadol
Ryzolt, Ultram
• Refer to a sleep specialist
…Treatment for Sleep Disorders
• Psychosocial interventions
– Cognitive-behavioral therapy
– Psycho-educational therapy
– Supportive expressive therapy (group or individual)
– Exercise
– Weight loss if indicated
• Sleep apnea
– CPAP Oral appliance
NCCN Practice Guidelines Version 1. 2014: Survivorship; Bennett MI, Rayment C, Hjermstad M, et al. PAIN, 2011; Nakamura, Lipschitz, Kuhn, et al. J
Ca Survivorship, 2013.
Who should provide survivorship care?
• Multiple disciplines
• A designated individual should be responsible
for coordinating survivorship care
• Care is a shared responsibility
Hewitt, Greenfield, & Stovall (2005). From Cancer Patient to Cancer Survivor: Lost in Transition.
Care of the Cancer Survivor
• Improve quality of life through early
detection & intervention
• Offer support, guidance, & education