Cancer Survivorship: What to Monitor and When to Intervene. Hyman B. Muss, MD 31 th Miami Breast Cancer Conference 2014

Transcription

1 Cancer Survivorship: What to Monitor and When to Intervene Hyman B. Muss, MD 31 th Miami Breast Cancer Conference 2014

2 Breast Cancer 2013 Incidence Mortality CA: A Cancer Journal for Clinicians pages 52-62, 1 OCT 2013 DOI: /caac.21203

3 Survivor 3 An individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life. Family members, friends, and caregivers are also impacted by the survivorship experience and are therefore included in this definition. Adapted from the National Coalition for Cancer Survivorship

4 18 Million Cancer Survivors Projected in 2022 Breast 20-40% 4

5 Essential Components of Survivorship Care 5 Surveillance for recurrence Screening for new cancers Identification and interventions for consequences of cancer and its treatment Health promotion strategies Shared Care coordination between oncology specialists and primary care providers Deb Mayer 2014

6 Bumps on the Road of Life (2010)

7 Follow-up after Breast Cancer The Key Question Does early detection of metastases to other organs before the development of any physical findings or symptoms improve QOL or survival?

8 GIVIO Trial JAMA 271: , women Stage I-III BC 26 Italian hospitals INTENSIVE CONTROL Physical exam q 3 mo x 8, then q 6 mo Chest x-ray q 6 mo x 4, then q 12 mo Bone scan q 12 mo Liver U/S q 12 mo Lab tests at same time as physical exam Physical exam q 3 mo x 8, then q 6 mo Clinically indicated tests OUTCOMES: SURVIVAL AND HR-QOL

9 GIVIO Trial Results (Median follow-up 71 months) 80% compliance to the two protocols 254 distant metastases across 2 arms; 31% asymptomatic in intensive, 21% in control (69-79% presented with symptoms) Intensive Control Deaths 132 (20%) 122 (18%) HR-QOL NO DIFFERENCE AT 6, 12, 24, or 60 MONTHS

10 What is the Value of Intensive Diagnostic Followup Roselli Del Turco, JAMA 1994;271: women from 12 Italian sites Randomized: Intensive: MD visit, mammogram, CXR, bone scan q 6 mo Control: MD visit, mammogram Primary endpoint 5 year survival Results More thoracic and bone mets detected in intensive arm (112 v 70), no impact on survival #Distant Recurrences (%) Mortality (%) Intensive 164 (26.4) 18.6 Control 125 (20.1) 19.5

11 ASCO BC Surveillance Guidelines: Patient Education 30-40% recur between routine visits Instruct pts on signs/symptoms of mets bone; pain and tenderness skin; characteristics of lesions lung; dyspnea, pleurisy CNS; focal findings - loss of function gastrointestinal; pain, fatigue

12 Consensus Recommendations for Follow-up Annual mammography, monthly breast self exam Other routine cancer screening Regular clinic visits for H and P Every 3-6 months for 3 years, every 6 months for 2 years, then yearly Health care maintenance Bone and cardiovascular health No routine testing (labs and xrays). Testing as indicated by clinical findings. Resources: NCCN.org ASCO guidelines (ASCO.org) American Cancer Society

13 Not Recommended! CBC or Chemistry Chest X-ray Bone Scan Ultrasound of Liver CT Scans of chest, abdomen or pelvis CA 27.29, CA 15-3, CEA PET scans MRI of breast

14 What is the Role of Tumor Associated Antigens? CEA, CA 15-3, CA Elevated in 30 65% of distant recurrences with lead time of about 4-6 months Measured every 2-3 months: Chan DW, JCO 1997

15 Follow-up after Breast Cancer The Key Question Does early detection of metastases to other organs before the development of any physical findings or symptoms improve QOL or survival? Not in 2014!

16 Hard concepts to convey. Less is as good if not better My other doctor was so thorough. I have good insurance.. A normal test does not mean no cancer So why is my PET/CT $3000. Tumor markers: May take a long time to be sure a result is a false positive Both you and patient may need therapy.

17 Give all patients ASCO follow-up guidelines and document it! Cancer.net

18 So why do it? Community standard There aren t really any but can be tricky Quality Assurance Probably the key issue in future Monitor side-effects of Rx (adherence) Time to educate and answer questions Can be very helpful but hard to measure Consider new treatments i.e. extended endocrine therapy General health assessment

19 Make a checklist. Are you having problems with: Signs and symptoms of recurrence Lymphedema (breast and arms) Weight gain or loss Fatigue Bone loss (tamoxifen, OA in pre / AIs in post) Cognitive function work, family issues Sexual function Vasomotor symptoms Anxiety or depression

20 Monitoring and Treatment Symptom Hot flashes Sexual dysfunction (libido, dyspareunia) Weight gain Depression, fatigue Cognitive dysfunction Osteopenia/porosis Cardiovascular disease Thrombosis Secondary malignancies Management options SSRIs, SSNRIs, gabapentin Vaginal moisturizer, estring(?), testosterone (?) Exercise (Daley et al, JCO 2007;25:1713), Diet Counseling, treat underlying cause, time Tools for improving function Calcium/vit D, weight bearing exercise, bisphosphonates as indicated Monitor lipid panel, evaluate symptoms Family and personal history Screening, evaluate symptoms Hayes, NEJM 2007;356:2505

21 Late Complications for which Interventions/Education Available Should Be Addressed During Follow-up Visit Menopausal symptoms Bone loss Weight gain Sexual difficulties Psychological problems Neuropathy All Rare and Typically Present More Acutely Endometrial malignancies Thromboembolic events Cerebrovascular events Leukemia Cardiac dysfunction

22 Promoting a Healthy Lifestyle in Cancer Survivors: ACS Guidelines for Cancer Prevention Maintain a healthy weight throughout life. Balance caloric intake with physical activity. Avoid excessive weight gain throughout the lifecycle. Achieve and maintain a healthy weight if currently overweight or obese. Adopt a physically active lifestyle. At least 30 minutes of moderate-to-vigorous physical activity, on 5 or more days of the week minutes of intentional physical activity preferable. Consume a healthy diet, with an emphasis on plant sources. Choose foods/beverages in amounts that maintain a healthy weight. Eat five or more servings of a variety of vegetables and fruits each day, choose whole grains in preference to processed Limit consumption of processed and red meats. If you drink alcoholic beverages, limit consumption. Drink no more than one drink per day for women or two per day for men.

23 Who should do follow-up?

24 Primary Care vs Oncologist Multicenter RCT n= mo after diagnosis f/u in cancer center n=485 f/u with family physician n=483 Observed 4.5 yrs after diagnosis Primary endpoint: Recurrence-Related Serious Clinical Events (SCEs) Secondary endpoint: health-related QOL Grunfeld E et al. J Clin Oncol 2006; 24:848-55

25 Primary Care vs Oncologist Recurrences Deaths SCEs Family Practice 54 (11.2%) 29 (6.1%) 17 (3.5%) Cancer Center 64 (13.2%) 30 (6.2%) 18 (3.7%) No difference in health-related QOL Grunfeld E et al. J Clin Oncol 2006; 24:848-55

26 Copyright American Society of Clinical Oncology Grunfeld, E. et al. J Clin Oncol; 24: A: Healthrelated quality of life: Medical Outcomes Study Short Form 36- Item (SF-36) Physical and Mental Component Summary B: Depression and Anxiety

27 Conclusions For now, use ASCO or NCCN guidelines Document discussion and provide guidelines Use F/U to explore survivorship issues Most pts today will survive breast cancer make a checklist and review, keep in record Refer for problems Doing less is a hard sell but worth it Consider sharing care with colleagues

28 Before I came here I was confused about this topic. Having listened to your lecture I am still confused, but on a higher level. Enrico Fermi,1938 Nobel Laureate in Physics

29 In the end it all comes down to this Mary, do you think I need a PET scan?

30 Thank You