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1、Cancer Survivorshipin Primary Care Arlene ORourke N.P.1971-3 million2012-13.7 million2020-18 million Approximately 15% of the 13.7 million estimated cancer survivors were diagnosed 20 or more years ago67% of patients treated now will be alive in 5 years75% of childhood cancer survivors will be alive
2、 in 10 yearsMost common cancer sites-female breast-22%, prostate-20%, colorectal-9%, gynecologic-8%History of the Development of Cancer Survivorship1985 Fitzhugh Mullen first describes Cancer survivorship1986-NCCS 1996-NCI establishes the office of Cancer Survivorship2004-Presidents Cancer Panel2005
3、-IOM-2006-From Cancer patient to cancer survivor:Lost in TransitionDefinitions“An individual is considered to be a cancer survivor from the time of diagnosis through the balance of his or her life. Family members, friends and caregivers are also affected by the survivorship experience and therefore
4、are included in this definition. NCCS,IOM 2005Definitions5 years after diagnosis without recurrenceLiving with, through and beyond a diagnosis of cancerDeath by other morbidity other then cancerRejection of the term survivorDefinitionIOM RecommendationRecognize cancer survivorship as a distinct phas
5、e of carePatients completing primary treatment should be provided with a comprehensive care summary and follow up planBegins at the end of primary treatment with intention to cure and lasting until a recurrence, a secondary cancer or death. It may include ongoing treatment. “Seasons of Survival”Acut
6、e survivalExtended survivalPermanent SurvivalAcute SurvivalTime of diagnosisDiagnostics, therapeutics, Fear/anxietyDisruption of family and social rolesFinancial issuesFear of deathExtended Survival:Transitional Fallow up Treatment completion- uncertainty of treatment outcomeWatchful waitingPeriodic
7、 examinationsConsolidation/intermittent therapies/hormonal therapiesFear of recurrence/deathFatigue/physical limitations/lingering side effectsPermanent Survival:Extended follow up“Cure”Late effects of treatment may impact QOL, family, workplace and financial areasAbility to return to normalLasting
8、impact of cancerDevelopment of self confidence and self trustGoals of Survivorship carePreventing recurrence and secondary cancersPromoting appropriate disease management following diagnosis and treatment to ensure the maximum number of years of a healthy life Minimizing preventable pain, disability
9、, and psychosocial distressAssisting cancer survivors to access family, peer, community, and other resources they need to cope with their disease. Goals of Survivorship CareEmpower survivors and familiesProvide enhanced and better coordination of communication around survivorship careImprove quality
10、 of lifeFocus of Survivorship CareSurveillancePreventionInterventionCoordinationSurveillance Recurrent cancer and late effectsGuidelinesBased on type of cancer, stage at diagnosis, tumor characteristics,related risk of recurrencePreventionNew cancersRecurrent cancerLate effectsGuidelinesIntervention
11、sManaging long term and late effects of treatment-organ dysfunction, mobility, fatigue, lymphedema, hormone/sexuality/fertility, secondary cancersImprove medical and psychosocial outcomes.CoordinationImprove communication between providers to promote best practiceSubspecialty referralsPsychosocial r
12、eferralsResources to support patient and familyQuality of life:Physical well beingFunctional activitiesStrength/fatigueSleep and Restoveral physical healthFertilityPainQuality of Life:PsychosocialControlAnxietyDepressionEnjoyment/LeisureCognition/attentionDistress of diagnosisFear of recurrenceContr
13、ol of treatmentQuality of Life:Social well beingFamily distressRoles and relationshipsAffection/sexual functionAppearanceEnjoymentIsolationFinancesWorkQuality of Life:Spiritual well beingMeaning of illnessReligiosityTranscendenceHopeUncertaintyInner strengthTreatment related Toxicities:Long term and
14、 Late effectsLong term-effects that persist after completion of treatmentLate-occur after treatment has completedLong and late effects can be tumor, treatment or host related.Late effectsOccur months to years following treatmentRelated to organ injury that occurred from treatmentFailure of repair me
15、chanisms over time and organ ageMore prevalent as treatments have become more complex.Tumor Related FactorsDirect tissue effectsTumor related organ dysfunctionMechanical effectsTreatment Related FactorsChemotherapy-agent, dose schedule and intensityRadiation Therapy-Total dose and fraction size, rad
16、iated fieldsurgery-site and techniqueHost Related FactorsGenetic predispositionInherent tissue sensitivities and capacity for normal tissue repairFunction of organs not effected by treatment Co-morbid conditionsPre treatment psychosocial statusSurgeryorgan impairmentSecondary side effectsloss of fun
17、ctionChemotherapyEffects all organs- systemic therapyMost side effects can resolve within 3-6 months of completing therapyCardiotoxicityNeuropathyFatiguePainSexual dysfunctionFertilityBlood dyscrasiaPulmonary ToxicityBone LossCognitive dysfunctionLiver dysfunctionSecondary MalignancyChemotherapy: Ca
18、rdiac ToxicityAnthracyclines-adriamycin-diastolic dysfunctionPlatinums-cisplatin-artherosclerosis, endothelial damageHer-2neu agents-Trastuzumab(Herceptin)-cardiac receptors-CHF/CardiomyopathyAntiangiogenesis agents-Bevacizumaub(Avastin)-CHF/Acute coronary SyndromeChemotherapy:Cardiotoxicity1st mani
19、fests as diastolic dysfunction 5 years after treatment completionCHF/CardiomyopathyHigh risk 65, pre-existing cardiac disease, pregnancy, extreme sports/exerciseLeads to increased morbidity and mortalityChemotherapy: CardiotoxicityEarly intervention can improve LVEFIf left untreated for more then 6
20、months subclinical LV dysfunction is irreversible.Pulmonary ToxicityChemotherapy and xRT toxicityLung, BMT, Hodgkins lymphoma, testicularBleomycin,Gemcitiabine,BCNU, Mtx,Interstitial pneumonitis,scarring, inflammationNot reversibleNeuropathyVinca AlkaloidsTaxanes-may be reversiblePlatinums-tinnitus/
21、hearing lossnumbness/tingling/painFoot DropParasthesiasWeaknessDecreased reflexesNeuropathyBaseline exam- previous or current neurological diagnosisInitiate therapy with Vitamin B therapy and Glutamine PT/OT/AcupunctureNeurontin/CymbaltaBone LossSteroids, hormone therapies-aromatase inhibitors; andr
22、ogen deprivation, Ovarian failure, radiation therapyBaseline bone density, vit D therapy, weight bearing exercises, biophosphatase therapyRadiation TherapyField/total doseBreast, Hodgkins, prostate, lung,colorectal, bone mets, BMTIncidence-10-30% within 5-10yrs post treatmentLatent- 10-20yrs post tr
23、eatmentVascular-Reynauds, artherosclerosisSkin changesHeart-valve dysfunction, myocardial/pericardial changes, electrical conduction disruptionThyroid changesDental changesGI changesCancer Survivors have a 14% higher risk of secondary malignanciesSecondary MalignanciesPrior therapy exposuresCancer s
24、yndromes- geneticHost environment-lifestyle choicesPsychosocial Impact:Risk factorsPre-treatment risk factors-pre-existing mental health diagnosisnumber of life stress eventsPost treatment risk factors-Decreased physical functionDecreased cognitive function40% of oncologists and 50% 0f PCPs feel con
25、fident to manage psychosocial distressInterventions to decrease Psychosocial distressRehabilitationEducationTherapy- group or individualSupport groupsEventsExerciseDemands of Cancer SurvivorshipAverage of 3 specialists per patientTreatments may be inpatient and outpatientTime intensive and in specia
26、lized treatment facilitiesCancer treatment usually occurs in isolation from primary health care - communication, multiple medical recordsOncologists Challenges2001-2007-total patients increased by 6%Continuing patients 93% increaseNew patients up by 23%- breast cancer patients-continuing - 126%!Text
27、TextSupply and DemandOncologists struggle with competing needs of patients undergoing active treatment and essentially well cancer survivors.Growing shortage of PCPs will be faced with an aging population with acute needs who will compete with essentially well appearing cancer survivorsSupply and De
28、mand2010-43 million supply/47 million demand2015-45 million supply/55 million demandTextChallenges of the Primary Care ProviderInadequate information about the cancer and treatmentSome cancers are rarely seen in the primary care settinglack of knowledge and confidence about survivorship carePatients
29、 lack of confidence in the knowledge of the primary care providerCompeting demands of time Co-morbidities/Chronic illness 60% of cancer survivors have at least 1 co-morbid condition vs 45% without cancerWorse oncologic outcomes with poorly managed co-morbidities1PCP per 10,000 decreases mortality ra
30、te in a community by 5.3%85% o f cancer care is provided in community settingsHigher rate of screening and vaccinations in cancer survivors with PCP careMore Primary Care Providers =Better cancer Survivor careShared careRisk based follow upDisease specific clinicsInstitution based programsModels of
31、CareShared CareProven to improve outcomesPCP/Oncologist share careRule of thirdsCommon with other specialties in mamagement of co-morbiditiesPrimary Care SupportSurveillance planRisk based cancer screeningPrevention GeneticsResources Coordination of careSurvivorship Care PlansDemographicsTreatment S
32、ummaryFollow up Care PlanGuidelinesNCCN-ASCO-Livestrong-Journey Forward-Barriers to Survivorship careFinancesEducated and dedicated providersLack of acceptance and/or integration with disease based or general oncology programsSpaceComplexity of survivorship careLack of clear, evidence based guidelines on proper managementLimited knowledge of evolving management of co-morbiditiesNext Steps.Coordination of careMedical HomeEHREducationResearch
