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Cancer Survivorship:
How To Manage Treatment-Related
Risks and Problems Outside of the
Oncology Setting
Tracy A. Johnson, DNP, FNP-BC
Disclosures
 No
financial relationships to disclose
 This CME presentation was developed
independent of any commercial
influences
Objectives

Articulate the purpose and key concepts of cancer survivorship
care

Identify cancer treatment regimens that present potential health
risks.

Perform accurate, targeted questioning of patient's medical history
to screen for potential issues and risks related to cancer treatment.

Incorporate appropriate diagnostic testing and screenings based on
health risks and problems related to cancer treatment.

Identify potential "red flags" in clinical presentation and symptoms
of cancer survivors.

Identify online cancer survivorship resources for health care
providers and survivors.
What Does It Mean To Be A Cancer Survivor?

Currently 12 million cancer survivors in the
United States

NCI SEER data:
◦ 70% all survivors alive 2 years after diagnosis
◦ 60% alive 10 years after diagnosis
What Does It Mean To Be A Cancer Survivor?

“Cancer survivor”: at diagnosis or after
treatment? (NCCS, NCI)

Enduring and overcoming all aspects of
diagnosis and treatment

Includes emotional, social, financial, medical
sequelae of treatment
So, What’s The Problem?
Advances in detection
+ Advances in treatment
+
Aging population
Growing number of cancer survivors
(Why is that a problem?)
So, What’s The Problem?

Growing number of cancer survivors potentially with
multiple comorbidities
◦ Typical aging, lifestyle, late effects from treatment

Increased burden on health care system (cost and
volume)

Focus shift from oncology to PCP

PCPs and other health care providers not familiar
with consequences of cancer and cancer treatment
Cancer Care Continuum
from Canadian Strategy for Cancer Control, 2005
Prevention
 Screening
 Diagnosis
 Treatment
 Survivorship Follow-Up Care
 Palliative Care

IOM 2005 report: “From Cancer Patient to
Cancer Survivor: Lost in Transition” (www.iom.edu)

Identified the need to provide survivorship care as a
distinct phase of oncology care

Recommendations for addressing late effects from
treatment (holistic)

Recommendations for transition from oncology to
primary care
What is Cancer Survivorship?

Assists with transition from cancer treatment to
living “a new normal”

Addresses the emotional, practical, and physical
effects of cancer treatment

Provides assessment, education, referrals, and
resources to meet the individual needs of cancer
survivors at any point after completing treatment
What Is A Survivorship Care Plan?
 Communication
between oncology &
PCP
 Roadmap
for long-term care
 Education
for survivor, family, and other
providers
How To Assess Risks Associated With
Cancer Treatment:
 Type
of cancer (s)
 Treatment
modalities
 Specific
treatment agents/fields
 Clinical
and Psychosocial findings
Types Of Cancer Treatment
Presenting Health Risks

Breast

Lung

Colon

Thyroid

Prostate

Head & Neck

GYN

Skin

Leukemia

Melanoma

Lymphoma
Types Of Cancer Treatment Presenting
Health Risks

Surgery?

Radiation?

Chemotherapy?

Hormonal therapy?

Transplant?
Types Of Cancer Treatment Presenting
Health Risks

Anthracyclines: Adriamycin, Daunomycin, Epirubicin, Idarubicin

Taxanes, Platinums,Vinca Alkaloids: Taxol/Taxotere,
Cisplatin/Carboplatin,Vincristine/Vinblastine

Radiation: left chest, mantle, prostate, TBI (total body
irradiation)

Monoclonal Antibody: Herceptin, Avastin, Erbitux, Rituxan

Hormonal: Tamoxifen, aromatase inhibitors (Arimidex, Femara,
Aromasin)

Transplant: Steroids, Immunosuppression, GVH (graft vs host)
Long Term Impact Of Cancer Treatment

Heart/cardiovascular
disease

Peripheral neuropathy

Dental problems

GI problems

Osteopenia

Pain

Menopause

Uterine problems
(Tamoxifen)
Long Term Impact Of Cancer Treatment

Skin cancer

Fatigue

Breast cancer


Lymphedema
Emotional: Depression,
Anxiety, PTSD, family,
social, body image

Functional limitations

Financial: work,
insurance
What Are The Long-Term Risks From Treatment ?

Chronic pain: surgery, chemotherapy, radiation,
hormonal therapy
◦ Bone, joints, back, abdominal/GI, surgical site
◦ What helps: exercise, PT, nutrition, yoga,
acupuncture, massage, medications,
education/counseling
What Are The Long-Term Risks From Treatment ?

Dental problems: chemotherapy, head/neck
radiation
◦ Frequent brushing/flossing, regular dental
visits, drink/rinse with water often
What Are The Long-Term Risks From Treatment ?

Decreased Bone Density: menopause (by any
cause), Arimidex, Aromasin, Femara, high dose
steroids, radiation
◦ Daily calcium 1200-1500mg and vitamin D 8001000 IU
◦ Weight bearing exercise, stop smoking
◦ Monitor bone density testing and vitamin D
levels
What Are The Long-Term Risks From Treatment ?

GI Problems:Vincristine, Vinblastine, abdominal or
pelvic surgery/radiation
◦ Motility problems, scarring, adhesions
◦ Dietary optimization, hydration, physical activity
◦ Referrals
What Are The Long-Term Risks From Treatment ?

Heart Risks: Adriamycin (“Red Devil”), other
anthracyclines, Left chest radiation
◦ Make sure cholesterol levels and blood pressure are
normal, exercise, healthy diet, no smoking
◦ EKG, echocardiogram (or MUGA, RVG) posttreatment baseline and every 2-5 years
What Are The Long-Term Risks From Treatment?

Cardiomyopathy

CAD/MI

Conduction defects,
dysrhythmias

Other cardiovascular
disease

Radiation associated
valvular disease

Cancer associated
thrombosis
What Are The Long-Term Risks From Treatment ?

Lymphedema, Functional limitations: surgery, radiation
◦ Helpful to have evaluation, treatment, and education by
physical therapist
◦ Lymphedema IS possible if you only had 1-2 lymph
nodes removed. Less risk, but not zero risk.
◦ Late onset lymphedema IS possible several years after
treatment. Less likely, but not zero risk.
What Are The Long-Term Risks From Treatment ?

Lymphedema, Functional limitations: surgery,
radiation
◦ Will always need to stretch & exercise affected
area to maintain function & prevent limitations
◦ Refer/evaluate early!
◦ Areas to consider: neck; breast/axilla; pelvic/genital;
lower extremity
What Are The Long-Term Risks From Treatment ?

Fatigue: surgery, chemotherapy, radiation, hormonal therapy,
stress, other medical conditions, LIFE
◦ Healthy lifestyle is very important!
◦ Exercise, weight loss, sleep, good nutrition
◦ Massage, acupuncture
◦ Talk to primary care, oncologist, other medical providers
about checking for abnormalities in thyroid, vitamins B & D,
iron, anemia, hormonal imbalances
◦ Counseling or wellness coaching for emotional problems,
stress, guidance for healthy living
What Are The Long-Term Risks From Treatment ?

Menopausal symptoms: natural or chemotherapy induced
menopause, surgical removal of both ovaries, hormonal
therapy
◦ Healthy lifestyle is very important!
◦ Exercise, weight loss, sleep, good nutrition
◦ Massage, acupuncture – great for pain and hot flashes
◦ Medications for hot flashes and mood swings
◦ Vaginal dryness – use over the counter daily moisturizers
(Replens, olive oil)
What Are The Long-Term Risks From Treatment ?

Peripheral neuropathy: Taxol, Taxotere,Vincristine,Vinblastine,
Cisplatin, Carboplatin, Oxaliplatin
◦ May or may not resolve after treatment
◦ Pharmacologic therapy
◦ Nutritional therapy
◦ Acupuncture
◦ Safety
What Are The Long-Term Risks From Treatment ?

Uterine problems: Tamoxifen
◦ Risk only if you still have uterus
◦ Yearly pelvic exam and PAP
◦ Report abnormal vaginal bleeding, pelvic pain
◦ Exams can be done by primary care, GYN, health
department
What Are The Long-Term Risks From Treatment ?

Skin cancers: Radiation
◦ Monthly self exams, be sure to look at skin in radiated areas
◦ Report new or changing areas on skin: pigmented, raised,
non-pigmented, red, itchy, crusty, ulcerated, etc.
◦ Primary care or dermatology can do simple biopsy if
needed
What Are The Long-Term Risks From Treatment ?




Elevated cholesterol
Fertility Problems
Hearing loss
Thyroid problems




Secondary cancers
Depression, anxiety
Memory problems
Sexual dysfunction
What About Genetics?

Encourage patients to keep a record of family history of
cancers, non-cancerous colon polyps, other health
problems

Consider genetics evaluation if diagnosed before age 50,
family history of breast cancers, or lots of cancers in
family
• Other hereditary syndromes besides BRCA
• Recommendations for screening for other cancers
• Recommendations for cancer screenings in family members,
children
Red Flags

Fatigue

Palpitations

Dyspnea/SOB/Orthopnea - one of most
under-reported by providers

Pelvic pain/vaginal bleeding/prior GYN history

Past medical history – also consider existing
health issues with new cancer diagnosis
Red Flags

Edema/functional limitations – arm, lower
extremities, abdominal/pelvic

Globus sensation/dysphagia

Past cancer history

Age/Gender

Lifestyle – smoking, alcohol, activity, diet

Family history
Screening Recommendations

Echocardiogram ,
Cardiac MRI, MUGA,
RVG (post-treatment
baseline, then every 2-5
years)

EKG

Cholesterol

BNP, Troponin

Coronary screening:
ischemic studies,
calcium scoring CT,
cardiac catheterization

Early detection + early
treatment = improved
cardiac status &
outcomes
Screening Recommendations

Bone Density: high dose
steroids, aromatase
inhibitors, early menopause

Reproductive hormones:
cranial or pelvic radiation,
alkylating agents (Cytoxan)

Dental exams: any
chemotherapy, head/neck
radiation

Pituitary labs: cranial
radiation

Thyroid labs/ultrasound:
neck radiation

Doppler ultrasound
(carotid, other
arterior/venous): radiation

Eye exams/cataracts: high
dose steroids, cranial
radiation
Prevention/Wellness

Encourage self care/wellness efforts!

Baby steps
• Don’t set goals too high
• Start small – easier to achieve, easier to see progress

Be consistent

Encourage survivors to be own advocate
• Ask questions
• Take advantage of local and online resources
• Write things down
Resources
Hewitt, M., Greenfield, S., Stovall, E. (2006). From Cancer Patient to
Cancer Survivor: Lost in Transition. National Academies Press:
Washington, DC.
 Adler, N. E., Page, A. E. K. (2007). Cancer Care for the Whole Patient:
Meeting Psychosocial Health Needs. Institute of Medicine, National
Academies Press, Washington, DC.
 Feuerstein, M. (2007). Handbook of Cancer Survivorship. Springer:
New York, NY.
 Lenihan, D., Cardinale, D., Cipolla, C. (2010). The Compelling Need for
a Cardiology and Oncology Partnership and the Birth of the International
CardioOncology Society. Progress in Cardiovascular Diseases, 53(2),
88-93. doi 10.1016/j.pcad.2010.06.002

Resources






NCI Office of Cancer Survivorship:
http://survivorship.cancer.gov
American Society of Clinical Oncology: http://www.asco.org/
Children’s Oncology Group:
http://www.childrensoncologygroup.org/
National Comprehensive Cancer Network:
http://www.nccn.org/
Journal of Cancer Survivorship: http://springerlink.com
REACH for Survivorship Program:
http://www.vanderbiltreach.org
Resources

www.nccn.com – Clinical guidelines for cancer
treatments
◦ Written for patients
◦ Diagnosis, work up, treatment, follow up
◦ Updated yearly, most current evidence from
research and clinical practice
Resources

http://www.cancer.net/patient/Survivorship website for cancer survivors
◦ Information from American Society of Clinical
Oncology (ASCO)
Resources

www.vanderbiltREACH.org- website for
cancer survivors
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Learn more about Cancer Survivorship care
Resources
Education
Community events