SURVIVORSHIP GOALS & OBJECTIVES. Define survivorship Overview of cancer survivorship Risk-based health care of survivors Future directions 7/12/17

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1 SURVIVORSHIP John W. Ragsdale III, MD Associate Professor Duke Family Medicine July 2017 GOALS & OBJECTIVES Define survivorship Overview of cancer survivorship Risk-based health care of survivors Future directions 1

2 DEFINITION OF SURVIVOR A patient is considered a survivor at the time of diagnosis, through the balance of his or her life. Family members, friends and caregivers are also impacted CANCER SURVIVORS IN U.S. By 2020 there will be 18 million There were There more are than million million survivors cancer in survivors the U.S. in today the United States today. This number is expected to exceed 20 million by De Moor JS, et al. Cancer Epidemiol Biomarkers Prev,

3 TRENDS IN CANCER DEATH RATES AMERICAN CANCER SOCIETY Women Men LATE MORTALITY AMONG 5+ YEAR SURVIVORS CHILDHOOD CANCER SURVIVOR STUDY (N=20,483) Causes SMR Second cancers 15.2 Cardiac 7.0 Pulmonary 8.8 Mertens AC, et al. J Natl Cancer Inst,

4 CUMULATIVE INCIDENCE BY CAUSES OF DEATH FOR PATIENTS WITH STAGE I TESTICULAR SEMINOMA SEER Registry: N=9193 men; Diagnosed Beard CJ, et al. Cancer 2013 PROBABILITY OF DEATH FROM BREAST CANCER OR OTHER CAUSES AMONG WOMEN AGE 50 AND OLDER WITH ER+ EARLY STAGE BREAST CANCER SEER: Hanrahan EO, et al. J Clin Oncol,

5 ACHIEVING HIGH QUALITY CANCER CARE: CHALLENGES & OPPORTUNITIES Population is heterogeneous Increased risks for long term morbidity and mortality Cancer itself Pre-existing co-morbidities Exposure to therapy Atypical presentations Premature development of common health conditions Poor response to treatments that are usually effective HL at age 13 (1979) Stage IA Mantle RT October 2005 Esophageal strictures Moderately severe AI Severe restrictive disease Severe 3 vessel CAD Asplenic Kyphosis Died, August 22,

6 System Exposures Potential Late Effects Cardiac Pulmonary Renal/Urological Endocrine CNS Radiation therapy Anthracyclines Radiation therapy BCNU/CCNU Bleomycin Radiation therapy Platinums Ifosfamide/Cyclophos Radiation therapy Alkylating agents Radiation therapy Intrathecal chemotherapy Valvular disease Pericarditis Myocardial infarction Congestive heart failure Restrictive lung disease Exercise intolerance Atrophy or hypertrophy Renal insufficiency or failure Growth failure Pituitary, thyroid, adrenal disease Ovarian or testicular failure Delayed 2 o sex characteristics Infertility Learning disabilities Cognitive dysfunction Psychological Cancer Post-traumatic stress Employment & educational problems Insurance discrimination Adaptation/problem solving Second malignancies Radiation therapy Alkylating agents Epipodophyllotoxins Solid tumors Leukemia Lymphoma 6

7 FACTORS CONTRIBUTING TO LATE EFFECTS Aging Health Behaviors Tobacco Diet Alcohol Exercise Sun Host Factors Age Gender Race Premorbid conditions Late Effect Risk Treatment Events Genetic BRCA, ATM, p53 polymorphisms Treatment Factors Tumor Factors Surgery Chemotherapy Radiation therapy Histology Site Biology Response Hudson MM. Cancer, 2005 ACHIEVING HIGH QUALITY CANCER CARE: ACTIVE TREATMENT A challenging time : lots of information about treatment, inadequate understanding Apprehension about the future primary provider is transitioning to oncologist Often primary care provider withdraws except for ACV PCP and patient may uncertainly around PCP s role during this critical time 7

8 How we can and do help PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE Decision making : solicit questions on what to expect Increased variety of options: Risks and benefits Symptom management Nausea/vomiting (most common related to therapy) Symptom cluster : pain, fatigue, sleep Depression, anxiety, panic Pain management: 30-50% of all patients PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE More prevalent in pancreatic, lung and individuals with bone metastasis 1-10 scale and qualify : neuropathic, bone pain, compression Sever uncontrolled pain is an emergency Early referral to palliative care or pain clinic as indicated is critical Treat pain and anxiety/depression together and proactively 8

9 Fatigue PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE Very prevalent and profoundly effects Associated with decreased function 75% of employed patient with cancer related fatigue changed employment status Less likely to be relieved by sleep or rest Fatigue Pain Emotional distress Sleep disturbance Anemia PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE Nutrition Activity level Other : thyroid, DM, medications, etc. 9

10 PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE Fatigue Psychosocial interventions: Support groups, counseling, stress management, behavioral interventions, coping strategies have strongest evidence in treating fatigue Curt GA, Breitbart W, Cella D, et al. Impact of cancer-related fatigue on the lives of patients, Oncology, 2000 Fatigue PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE Psychosocial interventions: Support groups, counseling, stress management, behavioral interventions, coping strategies have strongest evidence in treating fatigue Curt GA, Breitbart W, Cella D, et al. Impact of cancer-related fatigue on the lives of patients, Oncology,

11 PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE Depression More highly correlated with oropharyngeal, pancreatic, breast and lung Difficult to diagnose and must depend on psychologic not somatic complaints Prophylactic treatment may be helpful Anxiety: may increase at predictable times Diagnosis, surgical interventions, etc. PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE General Health Concerns Nutrition : may already be behind when you see them Smaller frequent meals Avoid antioxidants during radiation and chemotherapy Food safety Weight loss where appropriate Obesity associated with recurrence Avoid alcohol Appropriate vaccines: esp. influenza 11

12 Sexuality Fertility PCP ROLE IN ACTIVE TREATMENT & SURVEILLANCE Nausea & vomiting Diarrhea Alternative therapy Adverse effects of radiation 12

13 YOUR ROLE, IN SHORT Stay involved Support, educate and care for intercurrent illnesses as they arise Be aware of the common adverse effects of cancer emergencies, radiation and chemotherapy Make time for discussions around quality of life including sexual and intimacy issues Oeffinger et. al., ASCO.org,

14 SURVIVORSHIP CARE PLAN (SCP) Brief synopsis of cancer staging, therapy, and plan of care Portable document Will exist in some form but a work in progress DIFFERENT MODELS: MODEL I: ACADEMIC CANCER CENTER Consultative model: referred by oncologist for a one time evaluation Care plan is created Primary care provider and oncologist are sent the plan Oncologist follows patient from 1-5 years (or forever ) 14

15 DIFFERENT MODELS: MODEL II: SLOAN KETTERING CENTER MODEL Longitudinal model Model centered on survivors of childhood cancers Created a Long Term Follow Up (LTFU) Program Oncologist addressed primary cancer issues LTFU Program screened and managed sequelae Model has spread to large disease groups DIFFERENT MODELS: MODEL III: SURVIVORSHIP CARE IN THE COMMUNITY SETTING Addressed as a population health issue National cancer Institute has funded 30 community cancer centers Creates a sustainable model in where safety-net hospitals are in need Open to all 15

16 McCabe MS, et al. Semin Oncol, 2013 McCabe MS, et al. Semin Oncol,

17 SURVIVORSHIP CLINICS MODERATE / LOW RISK Independent Nurse Practitioner (NP) or Physician Assistant (PA) visit Focus of visit o Surveillance for recurrence of the primary cancer o Evaluation and treatment of medical and psychosocial consequences of treatment o Screening for second cancers o Education about survivorship issues and availability of community resources o Health promotion, including smoking cessation, diet and exercise o Review of treatment summary and care plan o Communication with community physician SURVIVORSHIP CLINICS HIGH RISK MD-APP team Focus of visit osurveillance for recurrence of the primary cancer omanagement of medical and psychosocial consequences of treatment oscreening for second cancers oeducation about survivorship issues and availability of community resources ohealth promotion, including smoking cessation, diet and exercise oreview of treatment summary and care plan ocommunication with community physician 17

18 ASCO SURVIVORSHIP CARE PLAN TEMPLATE RESOURCES Disease-specific organizations that provide programs, services, information, and support for people with cancer and their families National or local disability rights resources, including employment and insurance coverage rights, such as the United States Equal Employment Opportunity Commission, Cancer Legal Resources Center, and cancerandcareers.org National, regional, and community resources, including support groups and local affiliates of national programs Referrals to social workers, mental health experts, patient navigators, cancer rehabilitation specialists, and genetic counselors, as appropriate 18

19 Service Thoracic Urology Breast Colorectal Cancer type Lung Prostate Breast surgery, medicine & rad onc Colon Rectal Follow-up Care Guidelines Interval Visit Testing Stage/Primary Provider Year 1 Every 3-6 months CT scan w/contrast Year 2 Every 6 months CT scan w/contrast Year 3 Annual CT scan w/out contrast Year 1-2 Every 6 months PSA Every 6 months Year 3-5 Annual PSA Every 6 months > Year 5 Annual PSA Annual Year 1-2 >Year 2 Year 1-2 Year 3-5 Every 6-12 months Every 6-12 months Every 3-6 months Every 6 months Clinical breast exam, Annual mammogram Clinical breast exam, Annual mammogram CEA/scope depending on tumor site and CT scan depending on stage CEA/scope depending on tumor site and CT scan depending on stage Surgeon Nurse Practitioner Year 1- Surgeon Year 1- Nurse Practitioner Physician Physician or Nurse Practitioner Year 1- Surgeon > Year 1- Nurse Practitioner Nurse Practitioner Year >5 Annual Scope Nurse Practitioner Year 1-2 Every 3-6 months CEA/scope Year 3-5 Every 6 months CEA/scope Surgeon Year 3- Surgeon >Year 3- Nurse Practitioner Year >5 Annual Scope Nurse Practitioner WHERE TO GO FOR INFORMATION American Society of Clinical Oncology (ASCO) American Cancer Society (ACS) ent/ ent/nationalcancersurvivorshipresourcecenter/index National Comprehensive Cancer Network (NCCN) 19

20 7/12/17 20

21 FUTURE DIRECTIONS Risk estimates are established; being refined as population ages High risk groups (partially) identified Early work showing genetic predictors and potential pathways in small studies No studies with ample power to investigate the interaction of treatment, genetic factors, lifestyle behaviors, and comorbid conditions Era of large collaborations FUTURE DIRECTIONS Improve database of Clinical guidance Increase and improve access to high-quality survivorship care Research to refine optimum care delivery and components by whom, etc. Need for standardized Models of care on a system level 21

22 FUTURE DIRECTIONS Study of harms / benefits of surveillance with limitations of small samples Development of risk prediction models Use of models in assessing / determining surveillance strategies Testing of patient or clinician education aids and knowledge translation/transfer incorporating risk prediction DUKE CENTER FOR ONCO-PRIMARY CARE Aims of Center 1.Deliver evidence-based, patientcentered, personalized health care across the cancer continuum by enhancing the interface between cancer specialists and primary care clinicians; 2.Conduct innovative research with cutting-edge technology that can be translated to the community setting; and 3.Train and educate the next generation of clinicians and researchers to extend this mission. Center Staff Kevin Oeffinger, MD Director Cheyenne Corbett, PhD Administrative Director Associate Director, MD in recruitment John Ragsdale, III, MD 3 additional MD or PhD members Master-level IT specialist Master-level research project manager Bachelor-level research assistants Administrative support staff Collaborative effort between Duke Cancer Institute Duke Family Medicine Duke Primary Care 22