Caring for patients in primary care Caring for patients in primary care after cancer treatments are doneafter cancer treatments are done
Moving Moving Forward Forward after Cancerafter Cancer
Developed by:Developed by:
Brent Kvern MD, CCFP, FCFPBrent Kvern MD, CCFP, FCFPAssociate Professor, Associate Professor, Department of Family Medicine, University of ManitobaDepartment of Family Medicine, University of Manitoba
Jeff Sisler MD, MClSc, CCFP, FCFPJeff Sisler MD, MClSc, CCFP, FCFP
Director - Primary Care Oncology, CCMBDirector - Primary Care Oncology, CCMB
22
Conflict of Interest Disclosure
No consultant or speaker fees
Received a grant from the Canadian Partnership Against Cancer to develop this session
A question…A question…
A 61 year old patient A 61 year old patient of yours who of yours who completed treatment completed treatment for breast cancer 3 for breast cancer 3 months ago is your months ago is your next patient. next patient.
What is on your mental What is on your mental “to-do” and “to-talk-“to-do” and “to-talk-
about” list for this and about” list for this and upcoming visits?upcoming visits?
44
55
• Define survivorship phase of cancer.Define survivorship phase of cancer.
• Apply a new framework to consider the Apply a new framework to consider the care needs of cancer patients in follow-up care needs of cancer patients in follow-up
• Be familiar with important tasks in breast Be familiar with important tasks in breast and colorectal cancer follow-up careand colorectal cancer follow-up care
ObjectivesObjectives
1Bell K, Scalzo K, Stephen J, BC Cancer Agency, 2007 6
Cancer SurvivorshipCancer Survivorship
A distinct phase in the cancer trajectory A distinct phase in the cancer trajectory following primary treatment, lasting until following primary treatment, lasting until recurrent or end-of-life.recurrent or end-of-life.11
The survivorship phaseThe survivorship phase
Number of adult Number of adult cancer survivors cancer survivors is > 1 million and is > 1 million and will double by will double by the year 2050the year 2050
7
Age of cancer survivors2
88
A new perspective A new perspective
Think about patients who’ve finished cancer Think about patients who’ve finished cancer treatment like your patients with a recent MI treatment like your patients with a recent MI
99
A new perspectiveA new perspective
Survived something potentially lethalSurvived something potentially lethal Need close monitoring for recurrence.Need close monitoring for recurrence. Need an aggressive approach to risk reductionNeed an aggressive approach to risk reduction Lifestyle issues very importantLifestyle issues very important Your role as a FP/NP is critical to rehabilitationYour role as a FP/NP is critical to rehabilitation
1010
4 essential physician tasks4 essential physician tasks
Our framework of survivorshipOur framework of survivorship
HEALTH HEALTH PPROMOTION / ROMOTION / PPREVENTIONREVENTION
FFAMILY CANCER AMILY CANCER RIRISKSSKS
CANCER RELATED CANCER RELATED MMONITORINGONITORING
MMANAGEMENTANAGEMENT
PP22FRiMFRiM22
1212
Health Health PPromotionromotionPPreventionrevention
Promotion of healthy behavioursPromotion of healthy behaviours
Screening for new cancersScreening for new cancers
Age appropriate screening for other medical Age appropriate screening for other medical conditionsconditions
1313
FFamily Cancer amily Cancer RiRiskssks
Assessing the risk of family membersAssessing the risk of family members• Modifying THEIR risk factorsModifying THEIR risk factors• Recommending a screening planRecommending a screening plan• Referring for genetic testingReferring for genetic testing
Assessing family and marital health Assessing family and marital health
1414
MMonitoring onitoring
• Watching for recurrence of the primary Watching for recurrence of the primary cancer cancer
• Monitoring for worrisome “late effects”Monitoring for worrisome “late effects”– CardiomyopathyCardiomyopathy
• Monitoring rehabilitation and recoveryMonitoring rehabilitation and recovery
1515
MManagementanagement
Side-effects of cancer treatments Side-effects of cancer treatments • Physical Physical • PsychologicalPsychological• SocialSocial
Ongoing care for any non-cancer conditionsOngoing care for any non-cancer conditions
16
Colorectal CancerColorectal Cancer
Sunga AY, et al. Am Fam Physician, 2005
1717
Most recurrences in the first 3 years • Liver – most common site metastases
o 20% of those with liver metastases are candidates for resection
• 10%- local recurrence at original site• 30% - no rise in CEA
• No delayed / late effects of chemotherapy
Colorectal cancerColorectal cancerBackground informationBackground information
1818
Exercise 4 hours a week of activity associated with 53% reduced recurrence and CRC mortality regardless of stage, age, BMI or previous activity level.
Smoking Cessation
Medications for secondary prevention•No role yet for NSAIDs, ASA
BMD of hip if pelvic radiation therapy given
Colorectal cancerColorectal cancerHealth promotion & preventionHealth promotion & prevention
1919
Colorectal cancerColorectal cancerFamily Cancer Risks Family Cancer Risks
If index patient is diagnosed…
Recommendations
Before age 60 years All asymptomatic 1st degree relatives, starting at age 40 (or 10 years earlier than patients age at diagnosis) need colonoscopy Q5 years
After age 60 years All asymptomatic 1st degree relatives, starting at age 40 yrs are at slightly above average risk. FOBT Q2 years followed by colonoscopy if any one sample if positive.
After age 60 years & another 1st degree relative also has a diagnosis of CRC at any age
All asymptomatic 1st degree relatives, starting at age 40 (or 10 years earlier than patients age at diagnosis) need colonoscopy Q5 years
Family history of known hereditary syndrome
Referral for specialist assessment
2121
Colorectal cancerColorectal cancerMonitoringMonitoring
Monitoring
Visit frequency • Q3 months for 3 years following treatment• Q6 months for next 2 years• Annually thereafter
Test to DO • CEA at each visit for first 3 years • CT chest and abdomen – annually for first 3 years• Colonoscopy – 1 year after initial diagnostic scope, then at 3 years, then every 5 years afterward
Tests NOT TO DO • routine CBC, LFTs• routine CXR• FOBT
2323
Cancer related fatigue• Consider other etiologies• Physical activity works!
Peripheral neuropathy from oxaliplatin Radiation proctitis Diarrhea Sexual dysfunction
Colorectal cancerColorectal cancerManagement Management
2424
Anxiety • Consider possibility PTSD like reaction
Employment difficulties Insurance difficulties Social well-being
• “How are things going between you and your partner?”
Colorectal cancerColorectal cancerManagement Management
2525
Breast CancerBreast Cancer
Sunga AY, et al. Am Fam Physician, 2005
Non survivors 12%
5 year survival rates
All Oral Cancer All Oral Cancer Treatments now fully Treatments now fully
covered!covered! Tamoxifen and AIs free for patients as of Tamoxifen and AIs free for patients as of April 19, 2012April 19, 2012
Existing patients should already be Existing patients should already be identified by the DPIN systemidentified by the DPIN system
Pharmacare registration neededPharmacare registration neededCall the Provincial Drug Program at 786-Call the Provincial Drug Program at 786-
7141 or 1-800-297-80997141 or 1-800-297-8099
Help! ? Call the CCMB Pharmacy at Help! ? Call the CCMB Pharmacy at 787-4591787-4591
2727
Recurrences usually occur within five years.• Peaks at 2nd yr after surgery
o Risk declines with time but continues for at least 20 years.
• Non-specific symptoms are common indicators of relapseo Weight loss / Persistent cough / Breast
changes / Chest wall changes / Adenopathy
• 75% recurrences found by the women themselves
Breast CancerBreast CancerBackground informationBackground information
2828
ExerciseCohort studies suggest a 50% survival advantage for breast cancer survivors over those not physically active
Most beneficial in ER+ tumoursMost beneficial in ER+ tumours Diet
Medications for secondary prevention•Tamoxifen, aromatase inhibitors (AIs)
BMD and/or bisphosphonates if AIs used
Breast cancerBreast cancerHealth promotion & preventionHealth promotion & prevention
2929
Breast cancerBreast cancerFamily Cancer Risks Family Cancer Risks
Inherited Risk for Breast Cancer
Mutations of BRCA1 or BRCA2 cause about 5-10% of breast cancers
• Usually cancer occurs early in life.• Strong family history
Criteria for referral for genetic counselling
• Breast cancer at age <35 yrs• Bilateral breast cancer at age <50 yrs• Ovarian cancer <60 yrs• Breast and ovarian cancer <50 yrs• Two or more ovarian cancers, any age• Male breast cancer• Ashkenazi Jewish or Icelandic descent
If patient BRCA +ve • Family members need to know• Initiate screening at age 25 with MRI (or five years younger than earliest reported cancer in the family)
3131
Breast cancerBreast cancerMonitoring Monitoring
Monitoring
Visit frequency • Careful history and physical exam• Q3 -6 months for 3 years• Q6-12 months for next 2 years• Annually thereafter
Test to DO • Mammograms annually for life.
Tests NOT to do • routine CBC, LFTs• routine CXR• routine bone or liver scans• routine tumour markers
3333
Breast cancer survivors have an increased risk of a second primary cancer• Often involving
ipsilateral breastcontralateral breast colon?
Breast cancerBreast cancerMonitoringMonitoring
MonitoringCongestive Cardiomyopathy
• From anthracyclines (doxorubicin, epirubicin, trastuzumab)• Can present 10-15 years after chemo• Be alert for CHF symptoms
MyelodysplasiaorLeukemia
• Associated with cyclophosphomide• Rare•No screening recommended.
3535
Cancer related fatigue• Rule out other etiologies (drugs, depression,
cardiac, thyroid, anemia)• Physical activity, yoga
Menopause• Related to chemotherapy• Retrospective studies have not shown harm with
HRT • no RCT has been performed to allow confident
use Osteoporosis
• Check for AI use
Breast cancerBreast cancerManagementManagement
Tamoxifen •Hot flashes and night sweats•SSRIs can partially alleviate•Avoid paroxetine, fluoxetine, bupropion • Venlafaxine drug of choice
Aromatase inhibitors
AnastrozoleLetrozoleExemestane
• Post-menopausal women only
• Arthralgias and aches: NSAIDs, time
• Switch to a different AI or Tam if not tolerable
3737
Peripheral neuropathy If treated with taxanes (docetaxel) Use gabapentin*, pregabalin, tricyclics*
Post treatment cognitive impairment or “Brain fog”• Rule out or address other aetiologies (drugs, depression)
Chronic Pain
Breast cancerBreast cancerManagementManagement
BreastBreast cancer cancerManagementManagement
Sexual dysfunction Anxiety
Fear of recurrence: Consider CBT
Employment and insurance difficulties Social wellbeing
“How are things going between you and your partner?”
3939
In closing:In closing:Caring for Cancer SurvivorsCaring for Cancer Survivors
A distinct phase in the cancer continuum.
Increasingly a responsibility of primary care
Cancer survivors are at increased risk – think of them like post-MI patients
4040
4 essential physician tasks4 essential physician tasks
Our framework of survivorshipOur framework of survivorship
HEALTH HEALTH PPROMOTION / ROMOTION / PPREVENTIONREVENTION
FFAMILY CANCER AMILY CANCER RIRISKSSKS
CANCER RELATED CANCER RELATED MMONITORINGONITORING
MMANAGEMENTANAGEMENT
PP22FRiMFRiM22
Dr Jeff SislerDr Jeff [email protected]? Questions? Call the Call the UPCON Helpline UPCON Helpline at (204) 226-2262at (204) 226-2262
Moving Moving Forward Forward after Cancerafter Cancer