LIFE AFTER CANCER TREATMENT

Transcription

1 LIFE AFTER CANCER TREATMENT Late effects of treatment and survivorship Gayle Groshko RN BSN OCN Lisa D Andrea RN BSN OCN CNBN CPN Metro-Detroit Oncology Nursing Society At the end of this educational session the participant will be able to: Define what a late effect of therapy is List the late effects of surgery, radiation and chemotherapy Define the role of a survivorship care plan as part of the long-term health plan Conflicts of Interest Neither Gayle Groshko or Lisa D Andrea have any conflicts of interest 1

2 Cancer Survivor Defined An individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life. Family members, friends, and care givers are also affected by cancer The National Comprehensive Cancer Network One who remains alive and continues to function during and after overcoming a serious hardship or life-threatening disease. In cancer, a person is considered to be a survivor from the time of diagnosis until the end of life The National Cancer Institute definitions Most often recognized as the process of living with, through, and beyond cancer. 2

3 Why survivorship? The American Cancer Society and the National Cancer Institute, using data from Surveillance, Epidemiology, and End-Results (SEER) and National Cancer Data bases have shown 14.5 million Americans with a history of cancer were alive in January, That number is estimated to grow to 19 million by Survivorship Trends CA: A Cancer Journal for Clinicians Cancer treatment and survivorshkip statistics, 2016 Survivorship Care Plan Mandated by The Commission on Cancer January 1, 2015 Implement a pilot survivorship care plan process involving 10% of eligible patients. January 1, 2016 Provide survivorship care plans to 25% of eligible patients. January 1, 2017 Provide survivorship care plans to 50% of eligible patients. January 1, 2018 Provide survivorship care plans to 75% of eligible patients. January 1, 2019 Provide survivorship care plans to all eligible patients. 3

4 Goals of Survivorship Watch for recurrence Manage long-term and late effects of cancer treatment Long-term effects of therapy are those that develop during treatment and persist for at least 5 years. Late effects are those problems that arise months or years after treatment is given. Cancer treatment can result in a wide range of physical and psychological problems. Every treatment modality may have some long-lasting impact on health and well being. Long term-late effects of surgery Some patients have persistent pain at thoracotomy site. Hodgkin s patients treated before 1988 may have immune compromise from splenectomy Sarcoma and mastectomy patients may have phantom limb pain from amputation, as well as body image issues and depression following amputation. If lymph nodes were removed patients are at risk for lymphedema. This risk increases if post operative radiation was given. 4

5 Dysphagia, dysphonia, loss of speech may occur after head and neck surgery especially laryngectomy Neck dissection for head and neck cancer and lymph node dissection for breast cancer may leave range of motion impaired. Pelvic surgery may result in infertility, early menopause Prostatectomy may result in urinary incontinence and erectile dysfunction. Craniotomy may result in cognitive, or neuro deficits, depending on the site. Esophageal resection may result in long term dysphagia. Long-term, late effects of chemotherapy Second cancers Hearing loss Peripheral Neuropathy Altered kidney function Cardiomyopathy Hypertension Infertility, early menopause 5

6 Long term, late effects of Radiation Cognitive changes Risk of stroke Hearing loss Dysgusia Xerostomia Osteoradionecrosis Dysphonia Hypothyroidism Lymphedema Muscle weakness, limited ROM Esophageal stricture Pulmonary fibrosis Myositis Enteritis Early menopause Infertility Proctitis, rectal bleeding Cystitis Vaginal stenosis Second cancers 6

7 Cognitive Decline Over half of all cancer patients experience some degree of cognitive decline while under treatment. For 35% of patients this is persistent or progresses post treatment. Chemo brain Signs of chemo brain can include: Trouble remembering names Difficulty concentrating or paying attention Lapse in short-term memory Inability to find the right word for something Problems with planning ahead and organizing The mechanism for the formation of chemo brain is unknown Drugs that were thought to not cross the blood brain barrier may be doing so. Thought to be multi-factorial; immune system changes; fatigue; stress; hormonal fluctuations; underlying effects of age 7

8 Management Mindfulness Yoga Mild to moderate exercise Cognitive training-if no formal programs, brain training puzzles-word puzzles, math puzzles. Ocular Changes Cataracts may develop post RT, chemotherapy, hormone therapy, immunotherapy, long-term steroid use. Assess for signs of blurred, cloudy, double vision; sensitivity to light; trouble seeing at night. Trismus, Dyphagia, Dyphonia, Xerostomia Trismus (lock jaw); caused by the development of fibrosis of the masseter muscles following radiation to the nasopharynx and oropharynx. The fibrotic tissue is stiff and can act like a strap holding your mouth closed. It can be prevented by stretching. Speech Pathology consult, treatment with stretching exercises or therapeutic devices like Therabite 8

9 Therabite device to treat Trismus 9

10 Xerostomia Oral dryness resulting in reduced or absent saliva flow Side effects are bad breath, ulcers of the tongue or buccal mucosa Increased risk of dental carries Fluoride Trays Osteoradinecrosis One of the most severe late effects of radiation Occurs due to radiation effect on vascular supply to the bones of the jaw Can occur after dental surgery or tooth extraction Standard treatment has been antibiotics, surgery or hyperbaric oxygen. Recently trials of Vitamin E 1000 IU daily and Pentoxifylline (Trental 400mg tid with meals)* a trial is 3 months-if effective, continue. ** also regimen used for radiation myositis following lung cancer treatment 10

11 Cardiac Complications Cardiotoxicity is a broad category that could describe effects of chemotherapy, targeted therapy and radiation on the myocardium, arrhythmias, pericarditis, hypertension and acute coronary syndrome. Anthracyclines account for the majority of chemotherapy induced cardiotoxicity Radiation can cause mediastinal and pericardial fibrosis, damage to the vascular endothelium and vascular injury. These are most common in lung cancer, left sided breast cancer patients with heart in the field, Hodgkin s and Non-Hodgkin s lymphoma. Management is the same as non-cancer and non-irradiated patients. Management of dyslipidemia, hypertension and diabetes, obesity and smoking cessation important Pulmonary Complications May be due to chemotherapy or radiation therapy. Radiation pneumonitis: inflammation, not pneumonia. Symptoms include dry cough, shortness of breath and low grade fever. May present months after treatment Treatment includes symptom management and long term steroid therapy 11

12 Pulmonary fibrosis may occur months to years after therapy Pulmonary fibrosis results in permanent scarring of the lung tissue limiting pulmonary function. Pelvic Complications Radiation enteritis: Radiation enteritis is caused by inflammation. Chronic enteritis persists months or years after completion of therapy. May cause cramping/urge to defecate/watery diarrhea/mucous discharge from rectum/rectal bleeding/rectal pain Colonoscopy warranted if there is bleeding Treated with antidiarrheals, low fiber diet and steriods Cystitis Radiation cystitis is a complication of radiation therapy to pelvic tumors and may result in urinary frequency, urgency and contracted bladder. Late radiation cystitis can develop months to years after radiation therapy, presents principally as hematuria, which ranges from mild to lifethreatening Treatment may include intravesicle therapies and hyperbaric oxygen 12

13 Menopause-women Defined as no menses for one year or no menses after complete removal of ovarian tissue. This is less clear cut after chemotherapy and Tamoxifen Post chemo and pelvic radiation serial estradiol levels may need to be drawn to determine menopause status Hot flashes Vaginal dryness Mood disturbance Risk for osteoporosis and bone fracture Risk for cardiovascular disease Estrogen replacement contraindicated in survivors of hormone sensitive tumors Menopause-related symptoms-men Hypogonadism my occur as a result of chemo or RT in the pelvis Findings from The Platinum Study Group (spearheaded at Indiana University) reported at ASCO in June /3 of all testicular cancer survivors had hypogonadism; and were found to be on medications for hyperlipidemia, hypertension, erectile dysfunction, diabetes at statisically higher numbers than testicular cancer survivors with normal hormone levels. 13

14 Decreased muscle, increased body fat Gynecomastia Sexual dysfunction Blood Clots Hormone replacement contraindicated in males with prostate and breast cancer Lymphedema Blockage of lymphatic vessels leading to fluid retention More pronounced if surgery and radiation given to the area. 14

15 Breast cancer/pregnancy The worry has always been: would a pregnancy increase risk of cancer recurrence? Worry: do you stop adjuvant treatment that may be given for 5-10 years? Study done in Belgium and presented at ASCO June 2017: short answer? No to recurrence and yes to stopping adjuvant therapy. References pdf CA: A Cancer Journal for Clinicians Cancer treatment and survivorship statistics, 2016 Kimberly Miller MPH, Rebecca Siegel MPH, Chun Chieh Lin PhD, MBA Volume 66, Issue 4, July/August 2016 pages References Radiation Induced Heart Disease: A practical guide to diagnosis and management. Cleveland Clinic Journal of Medicine December; 83(12): Adverse Health Outcomes in Relationship to Hypogonadism after Platinum-based Chemotherapy A Multicenter Study of North American Testicular Cancer Survivors. ASCO proceedings June 3,