Cancer Survivorship in Primary Care

Colorado Cancer Day November 10, 2012 Linda Overholser, MD MPH University of Colorado School of Medicine

Objectives •  Define cancer survivorship and activities involved in survivorship care •  Discuss principles of health care maintenance and healthy behaviors following cancer therapy

What is “survivorship care?” Activities involved in follow up: 1.  Monitoring for recurrence 2.  Management of late/long-term effects 3.  Surveillance for secondary cancers 4.  Addressing preventative care 5.  Managing co-morbidities (including psychosocial concerns)

The number of survivors is increasing

Data Source: Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Waldron W, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission, posted to the SEER web site, 2011.

Estimated Number of Persons Alive in the U.S. Diagnosed with Cancer on January 1, 2008 by Time From Diagnosis and Gender (Invasive/1st Primary Cases Only, N = 11.9 M survivors)

Data Source: Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Waldron W, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission, posted to the SEER web site, 2011.

Why is survivorship care important? •  Workforce issues—demand/supply •  Treatment comes with late/long term effects ▫  Individuals may not remember treatment

•  Co-morbidities develop/require surveillance ▫  Aging population

•  Care for survivors is fragmented ▫  Anxiety at the end of treatment/fear ▫  Who is responsible for following what?

Baseline projected supply of and demand for oncologist visits, 2005 to 2020

Erickson, C et al, “Future supply and demand for oncologists : challenges to assuring access to oncology services”, Journal of Oncology Practice, J Oncol Pract. 2007 March; 3(2): 79–86

Total annual oncology visits by phase of care, 2005 to 2020.

Warren J L et al. JCO 2008;26:3242-3247

©2008 by American Society of Clinical Oncology

What’s a PCP to do? 1.  2.  3.  4. 

Monitoring for recurrence Management of late/long-term effects Surveillance for secondary cancers Addressing preventative care/health promotion 5.  Managing co-morbidities (including psychosocial concerns) Collaborative/shared care

• 

Earle et al, 2003: Retrospective cohort of breast cancer survivors (n = 5965). Receipt of mammograms highest when followed by oncology; receipt of other preventive care (PAP, CRC screen) better when followed by PCP. Most comprehensive care when pts followed with both PCP and Oncologist

• 

Snyder et al, 2008: Retrospective cohort of 1st year CRC survivors (n = 20,068). Pts followed by both PCP and Oncologist most likely to receive preventive care (flu, lipid, mammogram, bone density), followed by PCP only, then Oncologist only

• 

Haggstrom et al, 2009: Survey of individuals with CRC 2-5 years from dx (n = 303). Those who saw oncologist most frequently reported seeing doctor to receive medical tests; those who saw PCP most frequently reported doing so to receive physical exam, and were more likely to report receiving discussions regarding disease prevention and diet, and help with lifestyle.

Information needed for follow up  Details of cancer and treatment (histology, stage, age/doses/exposures of tx, surgical procedures, complications)  What surveillance?  Current medications  Family history  ROS--perspective of previous dx/tx

“Cancer-focused” review of systems •  •  •  •  •  •  •  •  •  •  •  • 

Constitutional (wt. ∆, fatigue) Skin (esp. w/ radiation history) ENT (dental, hearing, cataracts) Cardiac (CHF, CAD, vascular dz; anthracyclines, XRT) Pulmonary (bleomycin, XRT) Endocrine (thyroid, pituitary, growth, metabolic syndrome) Reproductive (infertility, menopause, sexual functioning) Renal (HTN) GI (cirrhosis, hepatitis, diarrhea, enteritis) Neurologic (neuropathy, cognition, pain) Musculoskeletal (arthralgias, scoliosis, osteoporosis) Psychosocial (depression, anxiety, cognitive)

(Ganz, P “Monitoring the physical health of cancer survivors: A Survivorship Focused Medical History”, Journal Clin Oncol 2006 24(32), 5105-5111)

Surveillance for secondary cancers •  Approx 15% of new cancers are second cancers •  Adults who have had cancer as children may be at particular risk ▫  Breast cancer after chest XRT (ie Hodgkins) ▫  Thyroid cancer after head/neck XRT ▫  Skin cancers ▫  Hereditary cancer syndromes

How are Cancer Survivors Doing? •  Cancer Survivors, BRFSS: general population 15.1% currently smoke

20%*

27.5% BMI ≥ 30 kg/m2 31.5% no leisure time physical activity in last 30 days

26.7%** 24.2%#

Underwood, JM etJM al, “Surveillance of demographic characteristics and health behaviors among adult cancer Underwood, et al, “Surveillance of demographic characteristics and health survivors--Behavioral Risk Factor Surveillance System, United States, 2009,” behaviors among adult cancer survivors--Behavioral Risk Factor Surveillance 2012 MMWR Surveill Summ. 2012 Jan 20;61(1):1-23 Jan 20;61(1):1-23 *CDC, Vital signs: current cigarette smoking among adults aged >18 years—US, 2005-2010. 2011;60:1207-121 *CDC,Vital Vitalsigns: signs: current smokingamong among adults aged >18MMWR years—US, 2005-2010. 2011;60:1207-121 **CDC. state specificcigarette obesity prevalence adults—US, 2009. 2010;59;951-955 #CDC. Physical Activity among BRFSS respondents. Atlanta, GA: CDC, 2011. http://apps.nccd.cdc.gov/BRFSS **CDC. Vital signs: state specific obesity prevalence among adults—US, 2009. MMWR 2010;59;951-955 #CDC.

Physical Activity among BRFSS respondents. Atlanta, GA: CDC, 2011. http://apps.nccd.cdc.gov/BRFSS

Health Behavior Change After Diagnosis   Hawkins, N et al, J Cancer Surv, 2010, 4:20-32

  Cross sectional study of 7,903 survivors at 3, 6, 11 yrs after dx

Behavior

More Same Less

Eating more fruits and vegetables Using sunscreen Trying to lose weight Exercising Avoiding alcohol Avoiding cigarettes

40.4 35.7 35.1 28.7 14.6 7.5

57.4 1.3 43.5 2.0 43.1 4.2 51.2 15.5 42.1 1.3 8.4 1.3

Never/NA 1.0 18.8 17.6 4.7 42.1 82.8

Physical Activity after CRC 68 year old caucasian male with stage II colon cancer s/p low anterior resection 3 years prior •  BMI 35.1 kg/m2 •  BP 142/92 •  Former smoker “What

can I do to reduce my risk of dying from my colon cancer?”

Does exercise post-colorectal cancer diagnosis affect mortality? •  Meyerhardt et al, Arch Internal Med 2009; 169(22): 2102-2108 ▫  Health Professionals Follow Up Study participants   Incident non-metastatic colorectal cancer 1986-2004   Single prospective cohort, n = 668

▫  CRC specific/all-cause mortality   Single physical activity assessment, >6 mo, < 4 yr out

▫  Adjusted HR for death, highest vs lowest tier exercise:   0.47 CRC specific mortality   0.59 all-cause mortality

Physical Activity after BrCa •  55 yo female, Stage II multifocal R intraductal breast carcinoma 18 months previously (ER/PR +, HER2/ neu neg), presents for well-woman exam. ▫  Tx: R modified mastectomy, chemo (TAC), XRT ▫  Hx: Hypothyroidism, Anxiety. RUE Lymphedema ▫  Fasting glucose 113 mg/dL, TC 214, HDL 44, LDL 132, Trig 198

▫  BMI 33.2 ▫  BP 136/84 ▫  Currently not exercising due to fatigue, concerns about lymphedema

“Should I be exercising and it is safe?”

Can exercise after breast cancer diagnosis affect mortality? HAZARD RATIOS FOR POST-DIAGNOSIS PHYSICAL ACTIVITY AND MORTALITY 0

>0-3

3.1-8.9

9+

Ptrend

Moderate to vigorous intensity exercise All-cause mortality

1.00

.42

.72

.54

.001

Br Ca Specific mortality

1.00

.30

.77

.61

.049

Moderate intensity exercise All-cause mortality

1.00

.50

.70

.62

.020

Br Ca Specific

1.00

.43

.74

.66

.18

Irwin, M et al, Cancer Prev Res 2011; 4:522-529

Will increasing exercise once diagnosed help? HAZARD RATIOS FOR CHANGE IN PRE-POST DX PHYSICAL ACTIVITY AND MORTALITY No change

Increase

Decrease

All-cause mortality

1.00

.67

1.06

Br cancer specific mortality

1.00

.91

1.06

Irwin, M et al, Cancer Pr Res 2011; 4:522-529

Exercise and Lymphedema •  Kwan et al, J Cancer Surviv, 2011;(5)320-336

▫  Systematic review of literature 2004-2010   19 articles reviewed, mostly in breast cancer   Categorized into domains (resistance exercises, aerobic + resistance, other—ie PT), graded using ONS PEP®   “…..no adverse effect from safe, slowly progressive exercise of varying modalities on the development or exacerbation of (breast cancer related lymphedema) …..”   Lymphedema risk may persist with time

Therapy for lymphedema •  Poage E, Singer M, Armer J, Poundall M, Shellabarger MJ. Clin J Oncol Nurs. 2008;12(6):951–64. Interventions recommended: decongestive therapy, compression bandaging, treat infections with antibiotics Interventions likely to be effective: Maintain optimal body weight, manual lymph drainage Intervention benefits balanced with harms: exercise, prophylactic antibiotics, surgery Intervention effectiveness not established: compression garments, hyperbaric oxygen, laser therapy, silver dressings to ulcers, pneumatic pumps Interventions not recommended: drug therapy (diuretics, benzopyrenes)

Diet/Exercise Interventions •  Morey, MC et al, JAMA, 2009, 301(18); 1883-1891 ▫  RCT of 65+ yo (mean age 73), overweight, > 5 year cancer survivors, n = 641 ▫  12 month, mail/phone tailored intervention ▫  Statistically significant (p .05) improvements in QOL, exercise, diet, weight/BMI

•  Christy, S et al, J Am Dietary A, 2011, 111(12); 1844-1850 ▫  RCT of sequentially tailored mailed materials vs publicly available materials in breast and prostate cancer survivors (n = 543) ▫  At 2 years, statistically significant decreases in % calories from fat and saturated fat compared w/ controls; improvements in BMI, and # fruit/veggie servings per day not sustained after first year

Exercise Interventions: AACT •  Ligibel et al, Breast Cancer Res Treat, 2012, 132:205-213 ▫  RCT for sedentary breast and colorectal ca survivors (n = 121) ▫  16-week telephone based exercise intervention ▫  At end of 16 weeks, no statistically significant differences in mins/week of exercise ▫  Improvement in fitness (6- minute walk test: +187 vs 82 feet) ▫  Trend towards improvement in exercise self-efficacy

Exercise/Diet and Survivorship •  ACSM Roundtable on Exercise Guidelines for Cancer Survivors Schmitz K et al, American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors, Med Sci Sports Exerc. 2010 Jul;42(7):1409-26. Erratum in: Med Sci Sports Exerc. 2011 Jan;43(1): 195

•  ACS Nutrition/Physical Activity Guidelines Rock, C et al, “Nutrition and Physical Activity Guidelines for Cancer Survivors,” CA Cancer J Clin 2012

Smoking •  58 year old male, with history of nasopharyngeal carcinoma. Presents to you for transfer of care visit on recommendation of oncologist. •  30 pack-year smoking history, still smokes “I was told by my oncologist to discuss my smoking with you”

Current and former smoking by cancer type (%; n = 2,027). *Significant differences in smoking rate when compared with all other cancers.

Mayer D K , Carlson J Nicotine Tob Res 2011;13:34-40 © The Author 2010. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected]

Smoking in Cancer Survivors •  Coups, E et al, JGIM, 2009 Nov 24(Suppl 2): 480-486 ▫  Cross sectional using 2005 NHIS, n = 1825   17.6% current smokers; 96% had with visits to HCP in last year

  41% asked about smoking; 70% HCPs knew smoking status

▫  Physician most often to give advice to quit, 15% dentist ▫  Those who tried to quit most used pharmacotherapy, few (3.8%) used evidence based behavioral treatments

•  Cooley, M et al, Cancer, 2011 July 1 117(13): 2961-2969 ▫  Cross sectional, recent dx of lung/head and neck cancer; n = 160 ▫  79% of participants received advice to quit, 53% were recommended specific therapy; 30% expressed interest in smoking cessation program ▫  Younger age, earlier stage and partner smoking associated with increased interest in smoking cessation program

Smoking and Secondary Cancers •  Reviews of earlier literature indicate that smoking may have more than additive effect on risk (Breast Ca, Hodgkins) ▫  Travis, L et al, JNCI, 2012: Recommendation of National Council on Radiation Protection and Measurement to explore interaction of radiation and smoking ▫  Lorigan, P et al, Lancet Oncol, 2010

•  Kaufman EL et al, J Clin Oncol, 2008 •  Prochazka, M et al, J Clin Oncol, 2005

Take Home Points •  Cancer survivors are at risk for ongoing morbidity and mortality from other causes (incl. second cancers), with common modifiable risk factors •  Collaboration is key—treat as a team •  Moderate physical activity is generally safe and may improve survival (in addition to conferring other benefits), target 150-180 mins/week + strength 2x/ week •  Smoking in addition to treatment related risk factors may multiply risks for morbidity •  Important to regularly assess/address risky behaviors and psychosocial concerns

Helpful resources •  National Comprehensive Cancer Network: http://www.nccn.org •  American Cancer Society: http://www.cancer.org •  National Cancer Institute: http://www.cancer.gov Office of Cancer Survivorship: http://dccps.nci.nih.gov/ocs/ •  Survivorship Programs at University of Colorado Anschutz Medical Campus Kristin Leonardi-Warren, 720-848-0349 •  Children’s Oncology Group Guidelines www.survivorshipguidelines.org •  Childhood Cancer Survivors Study site: ccss.stjude.org •  LIVESTRONG Foundation: www.livestrong.org (including EE brief) •  ASCO (American Society of Clinical Oncology) ▫  Focus Under 40 (ASCO University)

Thank you!! Questions/comments: Linda Overholser, MD, MPH University of Colorado School of Medicine Division of General Internal Medicine [email protected] 303-724-6348