Cancer survivorship. What is survivorship? Issues after cancer treatment Cancer and beyond Co-survivorship 06/02/2018

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1 Cancer survivorship Helen Hatcher and TV Ajithkumar Cambridge University Hospitals NHS Trust What is survivorship? Issues after cancer treatment Cancer and beyond Co-survivorship 1

2 Survivorship The time from the understanding of being given a diagnosis of cancer Previously used to relate to the cure remission terms that can be used after successful treatment However the effects start from the point of diagnosis and are unrelated to a clinical opinion of the severity of that diagnosis Impact of successful cancer treatment 1 in 250 adults of working age are survivors of childhood or TYA cancer More than 70% adults with cancer survive 5 years or more Late effects are often multiple 30% of survivors report 2-3 long term effects The new normal 2

3 The many facets of survivorship Physical Psychosocial Health behaviours Medical late effects Cancer Treatment Family genetics Developmental stage of individual 3

4 Paediatric Radiation Oncology: Are children small adults? Target volumes 4

5 Beam arrangement Beam size Beam shape Beam weight Beam energy Human brain development Neural connection for different functions develop sequentially 5

6 Persistent stress changes brain architecture Neurocognitive dysfunction 40-90% develop cognitive dysfuntion Global cognitive functioning (IQ) Academic achievement Executive function High level task goals Psychomotor skills Ullrich et al. Seminars Pediatr Neurol 2012, 19:35 Padovani et al. Nat Rev Neurol 2012, 8:578 Ajithkumar et al. Lancet Oncol, 2017,18:e91-e100. 6

7 Neurocognitve dysfunction Risk factors Correlation between individual genetic characteristics and cognition e.g. GST, COMT, MTR genes Wefel et al. Lancet Oncol, 2016; 17: e97 Side-effects of radiotherapy Acute (during and within 6 weeks of treatment) Predominantly fast proliferating tissues Skin, mucosa and haemopoetic system Late (6 weeks after treatment) Slow proliferating Lung, kidney, heart, liver & CNS 7

8 Radiotherapy for radiologists Side-effects of radiotherapy Skin Erythema, desquamation, ulceration Atrophy, fibrosis, telangiectasia Mucosa Lung Heart CNS Mucositis Ulceration, atrophy, fibrosis, necrosis Pneumonitis, fibrosis Pericarditis, cardiomyopathy Somnolence, myelitis, necrosis Challenges of RADIOTHERAPY IN CHILDREN 8

9 Childhood tumours Larger tumour Radiation tolerance Normal organs Growth Epiphyseal plates (18 Gy), muscle Hormone: Pituitary (20 Gy) Fertility Testis and ovary (5 Gy) Other organs Brain, heart, lung, genital system etc. Challenges of Radiotherapy 9

10 Challenges of radiotherapy Conformal plan to cover PTV can lead to asymmetrical growth Target near vertebrae: include vertebrae in the field leading to compromise with sparing Issue of second cancer Craniospinal radiotherapy 10

11 Reality Ideally Dose (%) T 5 10 cm Depth 11

12 Why protons? Spreading of Bragg peak (SOBP) Proton beam energies The Bragg Peak Dose (%) 65MeV 140meV 200MeV 5 10 cm Effective range varies with proton Energy Depth Wilson R. Radiological use of fast protons Radiology 1946;47,

13 Proton therapy Conventional IMRT Proton Nervous system Chemo-brain Respiratory system Cardiovascular Coronary disease Cardiomyopathy Renal Reproductive system Infertility Skeletal Osteronecrosis Osteoporosis Late effects BMJ Sep 7;354:i

14 Late-mortality among 5-year survivors Primary cancer:58% Second cancer: 19% Cardiac: 7% Respiratory: ~3% Ann C. Mertens et al. JNCI J Natl Cancer Inst 2008;100: Second cancer 2 nd most common cause of death after curative treatment Second cancer Leukaemia Sarcoma Lung Breast Uterine Identified or potential risk factors Chemotherapy e.g. etoposide, anthracyclines Radiotherapy for e.g. previous sarcoma or retroperitoneal lymph nodes Genetics e.g. Li Fraumeni, hereditary retinoblastoma Radiotherapy especially in smokers Potential risk from multiple CT scans for follow up Radiotherapy e.g. mantle or hemi thorax especially if given in late teens or early twenties (up to 4-7 times the standardised mortality ratio) Tamoxifen (risk 1 in ), increased in those with HNPCC 14

15 Psychosocial issues Psychological Anxiety, depression Fear of recurrence Survivorship guilt Post-traumatic stress Social Isolation Relationships Employment/training I just don t know what to do with myself now. I thought I was going to die, but I think I m okay. I keep wondering-who would I have been if this hadn t happened? 15

16 A systematic approach to survivorship Palliation Prevention or Preservation Health Promotion Individualised treatment summaries and care plans Ganz PA. BMC Med Feb 10;9:14. Palliation Fatigue Pain Depression Physical limitations Cognitive changes Sexual dysfunction Body Image 16

17 Fatigue a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity, interferes with usual functioning and is not improved by rest. Affects 30% cancer survivors long term and over 90% during Tx Measures Manage reversible causes (thyroid/testosterone/anaemia) CBT Short burst of exertion structured exercise routine Prevention Early detection and early intervention Chemoprevention Life style modifications 17

18 Preservation Fertility Female Cryopreservation Embryo Mature oocyte Ovarian tissue (LHRH analogues) Male Sperm cryopreservation Microsurgical testicular sperm extraction followed by ICSI I was treated at the ages of 13 and 17. I only recently found out, from the internet, that it can make you infertile. Health Promotion To minimise problems of second cancer, cardiac problems and others Encourage healthy-life style Diet Weight Regular exercise Avoid risky behaviour alcohol, substance abuse Compliance with screening visits 18

19 BMJ Sep 7;354:i4567. Adult tumours PROSTATE BREAST COLORECTAL MELANOMA UTERINE Slide courtesy A Milano 19

20 Pelvic tumours Local treatment urinary incontinence (50%) sexual dysfunction (95%) bowel dysfunction (50%) Hormonal treatment Women hot flashes, night sweats, atrophic vaginitis, arthralgia and osteoporosis Male menopause : loss of libido, hot flashes, night sweats, irritability, and gynaecomastia risk of osteoporosis, obesity, diabetes Sexual dysfunction 20

21 Challenges of survivorship plans Lack of clear understanding of mechanisms Limited research leading to weak evidence-based approach Poor focus on survivorship Financial constraints Key components of survivorship plan Follow-up plan For detection of recurrence For screening of second primaries Any new, usual and/or persistent symptoms (to detect recurrence) List of likely or rare but clinically significant late and/or long-term effects Emotional or mental health, parenting, work/employment Life style modification: healthy diet, exercise, smoking cessation and alcohol use reduction 21

22 Summary Start addressing issues of survivorship at diagnosis Choosing the optimal treatment Ensure optimal preventative/ preservation strategies Individualised treatment summaries and survivorship advice Participate in research The future for a survivor I have come to learn that cancer is not something I will get over, but something I live with. For some reason I thought I could put it in a neat box and forget about it. But actually when it has been part of your life for so long you should (a) be proud of what you have accomplished and (b) take all you have learned and have fun! 22