Download pptx - Developing a cancer survivorship research agenda - Prof Patricia Ganz

DEVELOPING A CANCER SURVIVORSHIP RESEARCH AGENDA: CHALLENGES & OPPORTUNITIES

Patricia A. Ganz, MD

UCLA Schools of Medicine & Public Health

Jonsson Comprehensive Cancer Center

Survivorship Research Day

Dublin, September 19, 2013

“Three More Months” bySharon Gough RN and Paul Roseingrave CCA

Treatments are over, healing established. Physically easy, mentally challenging.

A fresh beginning; a new normal begins.Unusual aches and pains…same worries and

concerns.Blood work and scans along with doctor

appointments. Life continues with no evidence of disease.

Goal achieved for another three months.Oncology Times, Poetry by Cancer Caregivers, July 25, 2013; authors are also cancer survivors

Overview

The changing face of cancer: the challenge of an aging population

Limited resources for delivery of health care; increased fragmentation of care—how do we respond?

What are the research opportunities?

Where to start?

Pal & Hurria, JCO, 2010----US data

Aging & the Cancer Epidemic

From 2010-30, total cancer incidence will increase from 1.6 to 2.3 million

Increase is driven by the aging of the population (67% increase from older adults vs. 11% in younger adults)

A 99% increase is anticipated for minorities, compared with 33% for whites

Percentage of all cancers diagnosed in minorities will increase from 21% to 28%Smith et al, JCO, 2009

Who are the Cancer Survivors?

More than 1 in 3 Americans will be diagnosed with cancer in their lifetime

Almost 14 million Americans have a personal history of cancer; 4% of US population

More than 25 million people are survivors world wide

The number of cancer survivors will increase sharply during the next 25 yrs with aging of the population

18 Million U.S. Cancer Survivors Projected in 2022

U.S. Cancer Survivor Facts

60% of survivors are currently over the age 65 years.

Breast, Prostate, and Colorectal, are the 3 most prevalent cancer sites.

Approximately 14% of the 13.7 million estimated cancer survivors were diagnosed over 20 years ago.

The current average age of male and female cancer survivors is 69 and 64 respectively.

Trends in Five-year Relative Cancer Survival Rates (%), 1975-2008

Irish Cancer Statistics- courtesy A. O’Connor

30,000 new cases every year, with >40,000 expected in 2020

1in 3 men and 1 in 4 women (U.S. 1 in 2 men, 1 in 3 women)

5 yr cancer survival: 60% of men, 62% of women

280,000 people diagnosed between 1995-2009 have survived their cancer

Comparison of cancer survivors and age-matched individuals from the National Health Interview Survey (NHIS) in 2000

Multiple measures of burden embedded within the survey

JNCI 96:1322, 2004

Health Status is Significantly Poorer in Cancer Survivors

Excellent

VeryGood

Good

Fair

Poor

Excellent

VeryGood

Good

Fair

Poor

Yabroff, JNCI 2004

Cancer Survivors (N=1817) Noncancer Controls (N=5465)

P <.001

18% Fair & Poor31% Fair & Poor

Number of Comorbid ConditionsBurden of Illness is Greater

0

10

20

30

40

50

60

0 1 2 >= 3

Ca Surv

Noncancer

P<.001

%

Yabroff et al. JNCI 2004

Cancer survivorsN=1817

Noncancer controlsN=5465

Needs help with instrumental ADLs

11.4% 6.5%

P <.001

Any limitation in any way

36.2% 23.8%P <.001

Needs help with ADLs 4.9% 3.0%P=.003


Cancer Survivors Need More Help with Activities of Daily Living (ADLs)

Comorbid Conditions Causing Limitation in Cancer Survivors

Condition causing limitation, % CA Survivor Control P-value

Arthritis/rheumatism 21.9 18.4 .005

Back/neck problem 12.0 9.5 .01

Fracture/bone/joint injury 7.0 5.3 .03

Heart problem 5.8 4.8 .17

Stroke 2.1 1.8 .50

Hypertension 3.6 2.6 .02

Diabetes 2.6 2.3 .57

Lung/breath problem 4.8 3.6 .03

Depression/anxiety/emotional problem 2.5 1.9 .21

Weight problem 1.9 1.5 .34

Musculoskeletal problem 4.3 3.5 .18


Examining the Interaction of Age, Comorbidity, and Cancer

What is the impact of comorbid conditions on survival after cancer?

Cancer will soon be the Leading Cause of Death in the U.S.

Mean Age by Phase of Care forCancer and Comorbid Conditions

Yabroff, Med Care, 2007 using NHIS Data

R. Yancik, et al. JAMA, 2001


Comorbid Conditions & Breast Ca


HTN

Heart disease


About half of all deaths are due to causes other than breast cancer!

Survivorship research….

A requirement for development of treatments to improve quality of life for cancer survivors

Necessary for prevention of late effects, through understanding of biological mechanisms and modification of cancer treatments

Need to attend to comorbid conditions as well

Opportunities…

Need for translational teams of researchers—move the observations from the clinic and population back to the lab—to understand biological mechanisms

Focus on primary, secondary and tertiary prevention of long-term and late effects

Assume each patient you treat will be a survivor—treat for cure AND treat for long-term survivorship!

Diagnosis and Staging


Palliative Treatment


Treatment With Intent to CureTreatment With Intent to Cure

Cancer-FreeSurvival

Cancer-FreeSurvival

ManagedChronic or Intermittent

Disease


Disease

Recurrence/Second Cancer


Cancer Care Trajectory

DeathDeath

Treatment FailureTreatment Failure

Start Here

IOM, 2005

Survivorship Research & Survivorship Care

Why is cancer different from other chronic diseases?

Cancer treatment is…. Complex Multi-modal Multi-disciplinary Toxic Expensive And often poorly coordinated

Cancer treatment usually occurs in isolation from primary health care delivery

Other Challenges

Limited systematic study of the late effects of cancer therapy

Follow-up care plans have been ad hoc, with focus on surveillance for recurrence

When should health promotion and chronic disease prevention become the focus?

Infertility? “Dear, you should just be happy to be alive.”

Survivorship Health Care Delivery: A need for systematic research

The Three P’s of Survivor Care Palliation Prevention Health Promotion

Ganz, P A. (2011). The 'three Ps' of cancer survivorship care. BMC medicine, 9, 14-14.

Symptom Management/Palliative Care:An Integral Part of Survivorship Care Definition of Palliative Care:

Medical care or treatment that concentrates on reducing the severity of disease symptoms (particularly if there is not a curative medical treatment)

Goal is to prevent and relieve suffering and to improve QOL for people facing complex illness

Focus on the most severe and prolonged symptoms

Common Palliative Care Concerns

Pain Fatigue Depression Physical limitations Cognitive changes Lymphedema Sexual dysfunction Menopause related symptoms Body Image

Why is it important to understand biological mechanisms of symptoms? Identification of underlying biology

provides support/validity for complaints Leads to possible interventions

(pharmacological or behavioral) Potential for prevention, if at-risk

individuals identified Possible relationship to tumor biology and

progression

Antoni et al. Nature Reviews Cancer 6, 240–248 (March 2006) | doi:10.1038/nrc1820

A Biobehavioral Model of Cancer

Prevention

Systematic ongoing follow-up required for screening Goal: early detection and early intervention

for potentially serious late-onset complications e.g., cataracts, osteoporosis, cardiac disease

Chemoprevention when available Life style modification to prevent second

cancers

Health Promotion

Health promotion counseling Goal: promote risk reduction for health

problems that commonly present during adulthood ( esp. for childhood cancer survivors)

Avoid weight gain Increase physical activity Avoidance of exposures that are harmful Decrease risk of other chronic diseases,

e.g. diabetes, heart disease

How to deliver the 3 P’s?

New research is needed on models of care delivery

One size will not fit all; different settings and different patients will have different requirements

What is right for Ireland may not be right in other settings






Cancer-FreeSurvival

Cancer-FreeSurvival


Disease


Disease



Research Focused on the Late Effects of Cancer Treatment

DeathDeath

Treatment FailureTreatment Failure

Descriptive studies; what happens after cancer treatments

Start Here

IOM, 2005




Cancer-FreeSurvival

Cancer-FreeSurvival

InfertilityInfertility


Start Here




Cancer-FreeSurvival

Cancer-FreeSurvival

Infertility Infertility


Start Here

Fertility preservationFertility preservation




Cancer-FreeSurvival

Cancer-FreeSurvival



Start Here


Treatment changeTreatment change




Cancer-FreeSurvival

Cancer-FreeSurvival



Start Here


Treatment changeTreatment change Infertility “Treatment”Infertility “Treatment”




Cancer-FreeSurvival

Cancer-FreeSurvival


Disease


Disease




Start Here

Risk assessment and intervention at diagnosisRisk assessment and intervention at diagnosis

Safer or more targeted therapies

Safer or more targeted therapies




Cancer-FreeSurvival

Cancer-FreeSurvival

Medical Outcomesand Quality of Life Medical Outcomesand Quality of Life




Start Here


Safer therapies

Safer therapies




Cancer-FreeSurvival

Cancer-FreeSurvival

Medical Outcomesand Quality of Life Medical Outcomesand Quality of Life




Start Here


Safer therapiesSafer therapies Survivor health care delivery: Palliation, Prevention and Health Promotion

Where to start?

What populations do you have access to?

What is the setting of care? What existing expertise can be

applied to the cancer survivorship research agenda?

Potential Strategies

Develop transdisciplinary teams focused on common symptoms or chronic conditions

Engage social and behavioral scientists Work closely with researchers who work

with the aging population Work with your health system and

examine new models of care delivery Study diseases other than breast cancer!!

T1

T2

T3T4

T0

Survivorship Research & The Translational Science Process

Modified from Khoury MJ et al; Am J Epidemiol 2010; 172:517-524

PopulationHealth; Disease

Burden; Public health impact (Surveillance

indicators)

Scientific Discovery (preclinical,

epidemiologymechanism studies)

Evidence basedRecommendations

& policies (Guidelines)

Tests of promising Interventions (Phase I, II, &

III trials)

Implementation into Practice,

Organizations, &Communities

Knowledge

Integration

(Managemen

t, Synthesis and Stakeholder

Engagement)