SURVIVORSHIP - Family Medicine · 04-07-2017 · • Overview of cancer survivorship • Risk-based health care of survivors • Future directions. 7/12/17 2 DEFINITION OF SURVIVOR

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SURVIVORSHIP John W. Ragsdale III, MD

Associate Professor

Duke Family Medicine

July 2017

GOALS & OBJECTIVES

• Definesurvivorship• Overviewofcancersurvivorship• Risk-basedhealthcareofsurvivors• Futuredirections

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DEFINITION OF SURVIVOR

•A patient is considered a survivor at the time of diagnosis, through the balance of his or her life.• Family members, friends and caregivers are also impacted

•

CANCER SURVIVORS IN U.S.

• There were more than 13 million cancer survivors in the United States today. This number is expected to exceed 20 million by 2026.1

There are 14.5 million survivors in the U.S. today

By 2020 there will be 18 million

DeMoorJS,etal.CancerEpidemiol BiomarkersPrev,2013

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TRENDS IN CANCER DEATH RATES AMERICAN CANCER SOCIETY 1930-2014

Women Men

LATEMORTALITYAMONG5+YEARSURVIVORSCHILDHOODCANCERSURVIVORSTUDY(N=20,483)

Causes SMRSecondcancers 15.2Cardiac 7.0Pulmonary 8.8

MertensAC,etal.JNatl CancerInst,2009

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CUMULATIVEINCIDENCEBYCAUSESOFDEATHFORPATIENTSWITHSTAGEITESTICULARSEMINOMA

BeardCJ,etal.Cancer2013

SEERRegistry:N=9193men;Diagnosed1973-2001

PROBABILITYOFDEATHFROMBREASTCANCEROROTHERCAUSESAMONGWOMENAGE50

ANDOLDERWITHER+EARLYSTAGEBREASTCANCER

SEER:1988-2001

Hanrahan EO,etal.JClinOncol,2007

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ACHIEVING HIGH QUALITY CANCER CARE: CHALLENGES &

OPPORTUNITIES

• Population is heterogeneous

• Increased risks for long term morbidity and mortality • Cancer itself

• Pre-existing co-morbidities

• Exposure to therapy

• Atypical presentations

• Premature development of common health conditions

• Poor response to treatments that are usually effective

• HLatage13(1979)• StageIA• MantleRT

• October2005• Esophagealstrictures• ModeratelysevereAI• Severerestrictivedisease

• Severe3vesselCAD• Asplenic

• Kyphosis

• Died,August22,2006

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System

Exposures

Potential Late Effects

Cardiac

Radiation therapy Anthracyclines

Valvular disease Pericarditis Myocardial infarction Congestive heart failure

Pulmonary

Radiation therapy BCNU/CCNU Bleomycin

Restrictive lung disease Exercise intolerance

Renal/Urological

Radiation therapy Platinums Ifosfamide/Cyclophos

Atrophy or hypertrophy Renal insufficiency or failure

Endocrine

Radiation therapy Alkylating agents

Growth failure Pituitary, thyroid, adrenal disease Ovarian or testicular failure Delayed 2o sex characteristics Infertility

CNS

Radiation therapy Intrathecal chemotherapy

Learning disabilities Cognitive dysfunction

Psychological

Cancer

Post-traumatic stress Employment & educational problems Insurance discrimination Adaptation/problem solving

Second malignancies

Radiation therapy Alkylating agents Epipodophyllotoxins

Solid tumors Leukemia Lymphoma

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Late Effect Risk

AgingPremorbid conditions

Treatment Factors

SurgeryChemotherapyRadiation therapy

Treatment Events

AgeGenderRace

Host Factors

Health Behaviors

TobaccoDietAlcoholExerciseSun

Genetic

BRCA, ATM, p53polymorphisms

HistologySiteBiologyResponse

Tumor Factors

Hudson MM. Cancer, 2005

FACTORS CONTRIBUTING TO LATE EFFECTS

ACHIEVING HIGH QUALITY CANCER CARE: ACTIVE

TREATMENT

• A challenging time : • lots of information about treatment, inadequate understanding • Apprehension about the future • “primary provider” is transitioning to oncologist

•Often primary care provider withdraws except for ACV• PCP and patient may uncertainly around PCP’s role during this

critical time

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PCP ROLE INACTIVE TREATMENT &

SURVEILLANCE

•How we can and do help • Decision making : solicit questions on what to expect

• Increased variety of options: Risks and benefits

• Symptom management

• Nausea/vomiting (most common related to therapy)

• Symptom “cluster” : pain, fatigue, sleep• Depression, anxiety, panic


SURVEILLANCE• Pain management:

• 30-50% of all patients

• More prevalent in pancreatic, lung and individuals with bone metastasis

• 1-10 scale and qualify : neuropathic, bone pain, compression

• Sever uncontrolled pain is an emergency

• Early referral to palliative care or pain clinic as indicated is critical

• Treat pain and anxiety/depression together and proactively

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SURVEILLANCE• Fatigue

• Very prevalent and profoundly effects

• Associated with decreased function

• 75% of employed patient with cancer related fatigue changed employment status

• Less likely to be relieved by sleep or rest


SURVEILLANCE• Fatigue • Pain • Emotional distress• Sleep disturbance• Anemia• Nutrition• Activity level• Other : thyroid, DM, medications, etc.…

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SURVEILLANCE

• Fatigue •Psychosocial interventions: Support groups, counseling, stress management, behavioral interventions, coping strategies have strongest evidence in treating fatigue

• Curt GA, Breitbart W, Cella D, et al. Impact of cancer-related fatigue on the lives of patients, Oncology, 2000


SURVEILLANCE• Fatigue •Psychosocial interventions: Support groups, counseling, stress management, behavioral interventions, coping strategies have strongest evidence in treating fatigue

• Curt GA, Breitbart W, Cella D, et al. Impact of cancer-related fatigue on the lives of patients, Oncology, 2000

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SURVEILLANCE

• Depression• More highly correlated with oropharyngeal, pancreatic,

breast and lung

• Difficult to diagnose and must depend on psychologic not somatic complaints

• Prophylactic treatment may be helpful

• Anxiety: may increase at predictable times

• Diagnosis, surgical interventions, etc.


SURVEILLANCE

• General Health Concerns • Nutrition : may already be behind when you see them…

• Smaller frequent meals

• Avoid antioxidants during radiation and chemotherapy

• Food safety

• Weight loss where appropriate

• Obesity associated with recurrence

• Avoid alcohol

• Appropriate vaccines: esp. influenza

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SURVEILLANCE

• Sexuality

• Fertility•Nausea & vomiting •Diarrhea • Alternative therapy • Adverse effects of radiation

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YOUR ROLE, IN SHORT

• Stay involved

• Support, educate and care for intercurrent illnesses as they arise

• Be aware of the common adverse effects of cancer emergencies, radiation and chemotherapy• Make time for discussions around quality of life

including sexual and intimacy issues

Oeffinger et. al. , ASCO.org, 2014

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SURVIVORSHIP CARE PLAN (SCP)

•Brief synopsis of cancer staging, therapy, and plan of care •Portable document •Will exist in some form but a work in progress

DIFFERENT MODELS: MODEL I: ACADEMIC CANCER CENTER

• Consultative model: referred by oncologist for a one time evaluation

• Care plan is created

• Primary care provider and oncologist are sent the plan • Oncologist follows patient from 1-5 years (or

forever…)

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DIFFERENT MODELS: MODEL II: SLOAN KETTERING CENTER MODEL

• Longitudinal model

• Model centered on survivors of childhood cancers

• Created a Long Term Follow Up (LTFU) Program

• Oncologist addressed primary cancer issues

• LTFU Program screened and managed sequelae• Model has spread to large disease groups

DIFFERENT MODELS: MODEL III: SURVIVORSHIP CARE IN THE

COMMUNITY SETTING

•Addressed as a population health issue •National cancer Institute has funded 30 community cancer centers•Creates a sustainable model in where safety-net hospitals are in need•Open to all

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McCabe MS, et al. Semin Oncol, 2013

McCabe MS, et al. Semin Oncol, 2013

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SURVIVORSHIP CLINICS – MODERATE / LOW RISK

• Independent Nurse Practitioner (NP) or Physician Assistant (PA) visit• Focus of visito Surveillance for recurrence of the primary canceroEvaluation and treatment of medical and psychosocial consequences of

treatmento Screening for second cancersoEducation about survivorship issues and availability of community resourcesoHealth promotion, including smoking cessation, diet and exerciseoReview of treatment summary and care planoCommunication with community physician

SURVIVORSHIP CLINICS – HIGH RISK

•MD-APP team• Focus of visitoSurveillance for recurrence of the primary canceroManagement of medical and psychosocial consequences of treatmentoScreening for second cancersoEducation about survivorship issues and availability of community

resourcesoHealth promotion, including smoking cessation, diet and exerciseoReview of treatment summary and care planoCommunication with community physician

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ASCO SURVIVORSHIP CARE PLAN TEMPLATE

http://www.asco.org/practice-research/survivorship-care-clinical-tools-and-resources

RESOURCES

• Disease-specific organizations that provide programs, services, information, and support for people with cancer and their families

• National or local disability rights resources, including employment and insurance coverage rights, such as the United States Equal Employment Opportunity Commission, Cancer Legal Resources Center, and cancerandcareers.org

• National, regional, and community resources, including support groups and local affiliates of national programs

• Referrals to social workers, mental health experts, patient navigators, cancer rehabilitation specialists, and genetic counselors, as appropriate

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Follow-upCareGuidelinesService Cancer

type Interval Visit Testing Stage/PrimaryProvider

Thoracic Lung

Year1Every3- 6months

CTscanw/contrast Surgeon

Year2 Every6months CTscanw/contrastNursePractitioner

≥Year3 Annual CTscanw/outcontrast

Urology Prostate

Year1-2 Every6months PSAEvery6monthsYear1- Surgeon

≥Year1- NursePractitionerYear3-5 Annual PSAEvery6months

>Year5 Annual PSAAnnual

Breast

Breastsurgery,medicine&radonc

Year1-2Every6-12months

Clinicalbreastexam,Annualmammogram Physician

>Year2Every6-12months

Clinicalbreastexam,Annualmammogram PhysicianorNursePractitioner

Colo-rectal

Colon

Year1-2 Every3-6monthsCEA/scopedependingontumorsiteand

CTscandependingonstageYear1- Surgeon

>Year1- NursePractitioner

Year3-5 Every6monthsCEA/scopedependingontumorsiteand

CTscandependingonstageNursePractitioner

Year>5 Annual Scope NursePractitioner

Rectal

Year1-2Every3-6months

CEA/scope Surgeon

Year3- 5 Every6months CEA/scopeYear3- Surgeon

>Year3- NursePractitioner

Year>5 Annual Scope NursePractitioner

• American Society of Clinical Oncology (ASCO)http://www.asco.org/practice-research/asco-cancer-survivorship-compendium

• American Cancer Society (ACS)http://www.cancer.org/treatment/survivorshipduringandaftertreatment/http://www.cancer.org/treatment/survivorshipduringandaftertreatment/nationalcancersurvivorshipresourcecenter/index

• National Comprehensive Cancer Network (NCCN)http://www.nccn.org/

WHERE TO GO FOR INFORMATION

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• Risk estimates are established; being refined as population ages

• High risk groups (partially) identified• Early work showing genetic predictors and

potential pathways in small studies• No studies with ample power to investigate the

interaction of treatment, genetic factors, lifestyle behaviors, and comorbid conditions

• Era of large collaborations

FUTURE DIRECTIONS

FUTURE DIRECTIONS

• Improve database of Clinical guidance

• Increase and improve access to high-quality survivorship care

• Research to refine optimum care delivery and components – by whom, etc.

• Need for standardized Models of care on a system level

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• Study of harms / benefits of surveillance with limitations of small samples

• Development of risk prediction models• Use of models in assessing / determining

surveillance strategies• Testing of patient or clinician education aids and

knowledge translation/transfer incorporating risk prediction

FUTURE DIRECTIONS

Aims of Center

1.Deliver evidence-based, patient-centered, personalized health care across the cancer continuum by enhancing the interface between cancer specialists and primary care clinicians;

2.Conduct innovative research with cutting-edge technology that can be translated to the community setting; and

3.Train and educate the next generationof clinicians and researchers to extend this mission.

DUKE CENTER FOR ONCO-PRIMARY CARE

Center StaffKevin Oeffinger, MD – Director

Cheyenne Corbett, PhD – Administrative Director

Associate Director, MD – in recruitmentJohn Ragsdale, III, MD

3 additional MD or PhD membersMaster-level IT specialist

Master-level research project managerBachelor-level research assistants

Administrative support staff

Collaborative effort between Duke Cancer InstituteDuke Family Medicine

Duke Primary Care

Documents

SURVIVORSHIP - Family Medicine · 04-07-2017 · • Overview of cancer survivorship • Risk-based health care of survivors • Future directions. 7/12/17 2 DEFINITION OF SURVIVOR