#99 Cancer Survivorship: What to do when the treatment is done

June 11, 2018 | By Matthew Watto, MD

Step up your primary care for cancer survivors with tips from Dr Regina Jacob, Assistant Professor of Medicine at Temple University. Care of the cancer patient does not end when their cancer treatment is over, and there is more to a past diagnosis of cancer than surveillance. We discuss cancer survivorship care, including the changing demographics of survivorship, the importance of survivorship care plans, and how survivorship is largely just good primary care.

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Credits:

Written by: Paul Williams MD
Hosts: Stuart Brigham MD, Matthew Watto MD, and Paul Williams MD
Produced by: Paul Williams MD
Edited by: Matthew Watto MD
Guest: Regina Jacob MD

Clinical Pearls

1. Survivorship is basically everything that happens after a diagnosis of cancer is made.  It’s primary care for cancer survivors.
2. Survivorship care plans exist, and you should ask for them!
3. Adolescent and young adult (AYA) cancer survivors are more likely to smoke, have obesity, or have mental health concerns such as depression or anxiety.
4. Sexual dysfunction (specifically reproductive health) and financial issues are common in AYA survivors and should be addressed!
5. Fatigue is a common concern among cancer survivors and its work-up requires a knowledge of the patient’s specific therapies, as well as good primary care (see episode #40 Pseudoendocrine disorders, fatigue)
6. Late cardiac toxicity: No evidence for screening echocardiograms in asymptomatic patients, but threshold should be low if the patient reports symptoms
7. Awareness of survivorship issues is the key to management!

In-depth Show Notes

Definitions

1. Survivorship is basically everything that happens after a diagnosis of cancer is made.  It’s primary care for cancer survivors
2. Acute survivorship – begins at diagnosis and goes through end of initial treatment
   1. Cancer is more likely to recur early on
   2. Focus tends to be on physical burden of treatment
3. Extended survivorship – First 5 years following initial treatment
   1. Associated with anxiety regarding recurrence
4. Permanent survivorship –  Past first 5 years and in long-term survival phase
5. Chronic survivorship – Patients undergoing long-term treatment for indolent cancers
6. Co-survivorship: Anyone who is there to lend support from diagnosis through treatment and beyond is considered a co–survivor

Stats
There are 15.5 million cancer survivors as of 2016 (compared to 3 million in 1971)

1. 67% diagnosed more than 5 years ago
2. 20% were diagnosed more than 20 years ago

Models of survivorship
Their growth was largely driven by accreditation requirements for large cancer centers.

1. Multidisciplinary clinics
   1. E.g. Oncologist, NP, and mental health expert
2. Disease-specific clinics
   1. Focuses on one type of cancer survivor
3. Consultative clinics
   1. Clinic exists for survivorship consultation. Often run by advanced practice provider
4. Integrated clinics
   1. Integrates a survivorship provider within a treatment team

Survivorship transitions
These remain challenging because care plans exist, but do not seem to be routinely shared with the PCP.

1. Oncologists are better at managing surveillance for their cancer
2. PCPs are better at other preventive care

Survivorship care plans exist, and you should ask for them!
These include the following:

1. Medical providers (Oncologist, surgeon, PCP, etc.)
2. Cancer summary (Type, Date of diagnosis, Stage, Therapies, Surgeries, Radiation given)
3. Recommended cancer surveillance
4. Other comorbidities
5. Survivorship-specific symptoms (e.g. Anxiety, fatigue, sexual dysfunction)

Adolescent -young adult survivors (AYA)

1. Mortality for this age group has not improved in recent years
   1. Data are limited and tend to be rare cancers
   2. Reflect later childhood cancers or early adult cancers
2. AYA survivors more likely to smoke, have obesity, or have mental health concerns such as depression or anxiety
3. Sexual dysfunction remains a concern, particularly fertility issues
4. Financial burden is huge consideration as well
5. Asking about these concerns may go a long way towards helping

Fatigue is a common concern among cancer survivors
Work-up requires a knowledge of the patient’s specific therapies, as well as good primary care

1. Chest radiation could raise concern for thyroid dysfunction, or coronary artery disease
2. Adriamycin could contribute to cardiotoxicity
3. Cyclophosphamide could lead to a secondary malignancy
4. Tamoxifen associated with memory and cognitive decline
5. Delayed recurrence remains a possibility
6. Depression is not uncommon in survivorship patients

Late cardiac toxicity

1. No evidence for screening echocardiograms in asymptomatic patients
2. Threshold should be low if the patient reports symptoms

Survivorship guidelines

1. Many exist-
   1. American Society of Clinical Oncology
   2. American Cancer Society
   3. National Comprehensive Cancer Network
2. “Survivorship is just primary care for cancer survivors”
3. Tailor guidelines to the patient in front of you

Support groups can be very helpful

1. Most areas will have live support groups for many cancers
2. Online support groups exist as well

Take home points:

• “We have more cancer survivors, because our medicine is better”
• Cancer survivorship is primary care for a cancer patient
• Get a care plan from treating oncologists

Goal: Listeners will recognize survivorship as a unique medical concern and develop an understanding of how to effectively support this patient population.

Learning objectives:
After listening to this episode listeners will…

1. Define survivorship
2. Recall the changing demographics of survivorship
3. List the phases of survivorship
4. Discuss the different survivorship clinic models
5. Recognize the importance of survivorship care plans
6. Consider the specific challenges of the adult and young adolescent survivor population
7. Identify the sources for survivorship guidelines

Disclosures: Dr. Jacob reports no relevant financial disclosures.  The Curbsiders report no relevant financial disclosures

Time Stamps

• 00:00 Disclaimer
• 00:35 Intro to the topic and guest bio
• 02:15 Guest one liner, book and app recommendations
• 06:58 Paul’s pick of the week.
• 07:40 Clinical case, definitions, and phases survivorship
• 12:36 Survivorship statistics
• 15:04 Co-survivorship
• 17:41 Care models for survivorship
• 20:56 Assigning roles in care of cancer survivors
• 22:59 Sample survivorship care plan
• 27:39 Childhood, adolescent and young adult cancer survivorship
• 34:18 Sexual dysfunction in cancer survivorship
• Turn down Watto and Regina tracks
• 35:56 Stressors in young adult cancer survivors
• 37:33 Fatigue
• 43:28 Guidelines on survivorship
• 45:06 Late cardiac toxicity
• 46:23 Support groups and resources
• 49:04 Take home points
• 50:29 Outro

Links from the show:

1. It Was A Good Day – Ice Cube (YouTube Link)
2. Cutting for Stone – Abraham Varghese
3. Annihilation – Official website
4. ASCO survivorship care plans:
5. American Cancer Society survivorship guidelines
6. NCCN survivorship guidelines
7. Miller, K. D. et al.  2015. Cancer Survivorship and Models of Survivorship Care: A Review.  American Journal of Clinical Oncology 38(6): 627-633. https://www.ncbi.nlm.nih.gov/pubmed/25635609
8. Miller K, Mehta R, Abraham J, Opneja A, Jain RK. Patterns of Long-term Cancer Survivorship Care in a National Cancer Institute-Designated Comprehensive Cancer Center. Am J Clin Oncol. 2017 Dec;40(6):639-643. doi: 10.1097/COC.0000000000000217. PMID: 26359697
9. GW School of Medicine Survivorship e-Training for Primary Care http://gwcehp.learnercommunity.com/elearning-series