Download here - Trent Occupational Medicine Annual Symposium

Working Beyond Cancer
Dr Eliot Chadwick
Consultant Clinical Oncologist
Nottingham University Hospitals NHS Trust &
The Nottingham Oncology Group
Trent Occupational Medicine
Annual Symposium 2014
Email: [email protected]
Macmillan – the scene
• In the UK, over 100,000 people of working age are
diagnosed with cancer each year.
• More than 700,000 people of working age are living
with a cancer diagnosis.
• The HR department of a large employer will see
more new cancer diagnoses in a year than a GP.
Cancer
Incidence
(CRUK)
Cancer
Incidence
(CRUK)
The Big 4
Cancer
survival
(CRUK)
Cancer
survival
(CRUK)
…and
then there
were 3
Why Toxicity?
• Normal tissue reaction
to chemotherapy and
radiotherapy.
• Relates to cell turnover.
• Early vs late broadly
correlates with α/β ratio
Timelines - toxicity
Long term
Short term
4/52
8/52
6/12
20yrs
The Return to Work
Fear of
relapse
Pragmatism
Denial
Time
DECISION
Guilt
Independence
Empowerment
Finance
Self
Employment
Identity
Self
worth
Breast Cancer
•
•
•
•
•
Surgery
Chemotherapy
Hormones
Radiotherapy
Biological agents (Herceptin®)
Fatigue
“...5 years after....I've been off sick from work since
then...and, being completely honest, I have no
desire of returning. I don't feel I can't work full time
and, I can't survive on a part time wages. I have
chronic fatigue, chemo brain and PSD. So far,
nobody seems to care about the devastating effects
of the aftermaths of cancer. The unrealistic
expectations of employers, colleague and friends
and, maybe my own, really puzzled me.”
Longitudinal patient
case rates for
persistent fatigue
over 12 months (n =
218).
Goldstein D et al. JCO 2012;30:1805-1812
©2012 by American Society of Clinical Oncology
Lymphœdema
Stiffness
Pain
BrCa Side effects
ACUTE
Peri-operative
complications,
seroma, infection
Poor wound healing,
infection, nausea,
mucositis, alopecia
Neuralgia, shoulder
stiffness, fatigue
Lymphœdema, cardiac, depression
6/52
3/12
2yr
10yrs
20yrs
Prostate Cancer
Risk of treating a
non-lethal disease
Success &
morbidity of
treatment
Hormones
LHRHa
EBRT
3/12
6/12
18/12
2yrs
3yrs
Hormones
• Insulin resistance*
/ cardiovascular morbidity
• ↓muscle mass
• Cognitive impairment
• Hot flushes
*LGI diet advised (but see
Pelvic RT)
Hormones - summary
• Effects as long as administered, and months to
years beyond.
• Probably underplayed.
• Impact on occupation not necessarily direct.
Pelvic
Radiotherapy
ACUTE
Fatigue, *proctitis,
cystitis, prostatitis
nausea, skin reaction
Pelvic RT effects
EBRT
CHRONIC / LATE
*Proctitis, cystitis, arthritis,
hip fracture
6/52
3/12
* ”Beige” diet advised
2yr
10yrs
20yrs
Case 1 – 38yrs female, anal Ca
Mitomycin C D1
EBRT 50.4Gy /28#
5-fluorouracil D1-4
Coronary artery spasm from 5-FU. D22-25 not given.
5.4Gy boost given in lieu.
}
At 18m, ongoing discomfort in perineum, frequency of
stool 5-10/day, with urgency and occ. incontinence.
Works at check-out in supermarket.
Case 2 – 56yrs male, peri-anal Ca,
vegetarian.
Mitomycin C D1
5-fluorouracil D1-4, D22-25
Electron boost of 20Gy/10#
}
EBRT 50.4Gy /28#
At 12m, ongoing discomfort in perineum, frequency of
stool 5/day, with urgency. Struggles to maintain wt.
Pre treatment, worked for council – refuse, gardens.
Now medically retired.
Radiotherapy - summary
• Can cause significant long term effects.
• Functional deficit.
• Not easily treated.
Chemotherapy
Chemotherapy effects
ACUTE
Multiple, disparate
effects. Not all
intuitive.
Fatigue, myalgia,
arthralgia
dysgeusia
Wt gain, Neuropathy, cardiac
6/52
3/12
2yr
10yrs
20yrs
Case 3 – 48yrs male, rectal Ca, node
positive on MRI.
Capecitabine 825mg/m2/bd + EBRT 50.4Gy / 28#
Works in abattoir. Develops palmar-plantar erythema
(PPE). Capecitabine stopped during RT.
Post-op (stoma). Pathologically node positive. For further
capecitabine + oxaliplatin adjuvantly.
Pt declines oxaliplatin. Starts capecitabine, but stops early
due to PPE.
Case 4 – 65yrs male, colon Ca,
Duke’s C
Referred for adjuvant chemotherapy
5-fluorouracil / oxaliplatin q2/52 for 12 cycles.
Loses sense of taste and smell. Develops PPE.
Continues to work as Michelin star chef but finds it
increasingly difficult.
Chemo - Summary
•
•
•
•
Most chemo effects acute.
Fatigue most common long term.
Subjective.
Pts occupational circumstance may dictate chemo
given.
Surgery
Surgery effects
ACUTE
Peri-operative
complications
Fatigue, poor wound
healing, TED
Anterior resection
syndrome
Hernia, stoma, incontinence
6/52
3/12
2yr
10yrs
20yrs
Case 5 – 28yrs female, sigmoid Ca,
emergency Hartmann’s.
pT4b tumour
Referred for adjuvant chemotherapy.
Receives 8 cycles of capecitabine / oxaliplatin within SCOT
study
Regular FU post-chemo for SCOT data collection. Regular
discussion regarding stoma.
Pt works in clothes shop. Gaining weight, as finds it difficult to
exercise. Stoma reversal on hold until 1 year CT performed. 1
year CT ?Ovarian mass
Surgery - summary
• Surgery usually irreversible.
• Implications for lifestyle should be explored,
particularly if options available.
• Can have significant body image as well as
functional effects.
Are we
doing
enough?
Challenges
• Patients not informed about impact of cancer on their
working lives.
• Many patients do not have access to vocational
rehabilitation services.
• Employers don’t know how to support staff with cancer.
• (Cancer specialists don’t know how to support
employers.)
Questions?