Surveillance after Treatment of Malignancies. John M. Burke, M.D. March 2013

Transcription

1 Surveillance after Treatment of Malignancies John M. Burke, M.D. March 2013

2 Disclosures Advisory Boards Spectrum Alexion Genomic Health Dendreon Seattle Genetics

3 Learning Objectives Improve ability to follow patients after treatment of malignancies Understand what constitutes appropriate surveillance after treatment of malignancies Deliver evidence-based cost-effective follow-up care to cancer patients

4 Cancer is a Problem 2 nd leading cause of death in the U.S. (after heart disease), accounting for 1 out of every 4 deaths About 1.6 million new cases of cancer are expected to be diagnosed in the U.S. in In 2012, about 577,000 Americans are expected to die from cancer. In 2008, nearly 12 million Americans were alive with a history of cancer. The problem is going to get worse, not better. Cancer facts and figures pdf; accessed November 29, 2012

5 Projected Growth of the U.S. Population Forecasting the Supply of and Demand for Oncologists; accessed March 1, 2012

6 Incidence of Cancer by Age in 2000 Erikson C et al., J Oncology Practice 2007; 3:79-86.

7 Incidence of Cancer Projected to Increase Forecasting the Supply of and Demand for Oncologists; accessed March 1, 2012

8 Prevalence of Cancer Also Projected to Increase Forecasting the Supply of and Demand for Oncologists; accessed March 1, 2012

9 In the foreseeable future, the cancer problem will get worse, not better Population is aging Incidence of cancer rises with age Improved screening and treatment allowing patients with cancer to live longer Comparing 2020 with 2000, there will be: 48% increase in cancer incidence 81% increase in number of patients living with or surviving cancer Forecasting the Supply of and Demand for Oncologists; accessed March 1, 2012

10 Study Analyzing Oncology Workforce In 2005 the American Society of Clinical Oncology (ASCO) commissioned the Center for Workforce Studies at the Association of American Medical Colleges to analyze the oncologist workforce. Goal was to forecast the supply of and demand for oncologists by the year 2020 Results published in 2007 Forecasting the Supply of and Demand for Oncologists; accessed March 1, 2012

11 Current Oncology Workforce 13,000 oncologists (adult or pediatric medical oncologists or gynecological oncologists) in U.S. in 2005 (14,000 in 2012) 24% female, 76% male 29% international grads 54% over age 50 57% practice, 32% academic 500 graduating fellows per year Most productive years are age Forecasting the Supply of and Demand for Oncologists; accessed March 1, 2012

12 Age Distribution of Oncology Workforce in 2005 Forecasting the Supply of and Demand for Oncologists; accessed March 1, 2012

13 Projected Supply of and Demand for Oncology Visits, Erikson C et al., J Oncology Practice 2007; 3:79-86.

14 Shortage of Oncologists in Future? A disproportionate number of oncologists today are nearing retirement. There are a limited number of oncology fellowship training slots. Number oncologists in U.S. projected to rise by 20% by 2020 and capacity for oncologists visits by 14%. Projected shortfall of 9-14 million patient visits Translates to fewer oncologists than are needed Erikson C et al., J Oncology Practice 2007; 3:79-86.

15 Is there a shortage of oncologists now? In both formal and informal canvassing of oncologists around the country, we found that very few practices are in a situation where they are overrun with patients and the waiting times are exorbitant. I think there is a feeling that there still will be a shortage of oncology specialists, but the magnitude might be different from even the most optimistic projection in the 2007 paper. Michael P. Kosty, M.D., member of Workforce Advisory Group, quoted in Cavallo J, ASCO Reexamines the oncology workforce shortage. ASCO Post June 15, 2012.

16 Hedging on their Bets At the time the study was published, the economic decline hadn t yet started. A lot of physicians who were going to retire have not retired, and some have even come back into the workforce for financial reasons, so the supply projections are probably inaccurate. Michael P. Kosty, M.D., member of Workforce Advisory Group, quoted in Cavallo J, ASCO Reexamines the oncology workforce shortage. ASCO Post June 15, 2012.

17 Assuming the forecast is correct, can we intervene to prevent the storm? Increase number of fellowship training positions Increase efficiency of oncologists e.g. using nurses, scribes Increase number of mid-level providers working with oncologists Increase use of primary care providers to provide oncology care Prescribing oral drugs Monitoring patients after completion of therapy 2/3rds of projected visits to oncologists in 2020 are patients more than a year out from completion of therapy Major problem is shortage of PCPs!

18 What do PCPs know about oncology? Survey of Physician Attitudes Regarding the Care of Cancer Survivors 1072 PCPs and 1130 medical oncologists completed survey Given 4 widely used cancer drugs Doxorubicin Paclitaxel Oxaliplatin Cyclophosphamide Asked to identify the late effects caused by each drug Cardiac dysfunction Peripheral neuropathy Premature menopause Secondary malignancy Nekhlyudov L et al. Oncologists and primary care providers awareness of late effects of cancer treatment: implications for survivorship care. J Clin Oncol 30, 2012 (suppl; abstr 6008)

19 Correct Answers Doxorubicin Paclitaxel Oxaliplatin Cyclophosphamide Cardiac dysfunction Peripheral neuropathy Premature menopause Secondary malignancy Nekhlyudov L et al. Oncologists and primary care providers awareness of late effects of cancer treatment: implications for survivorship care. J Clin Oncol 30, 2012 (suppl; abstr 6008)

20 Results of Survey Percentage of Respondents Answering Correctly by Specialty Oncologists PCPs Doxorubicin-Cardiac Dysfunction 95% 55% Paclitaxel-Peripheral neuropathy 97% 26% Oxaliplatin-Peripheral Neuropathy 96% 22% Cyclophosphamide-Premature menopause 71% 15% Secondary malignancies 62% 17% All correct 65% 6% Nekhlyudov L et al. Oncologists and primary care providers awareness of late effects of cancer treatment: implications for survivorship care. J Clin Oncol 30, 2012 (suppl; abstr 6008)

21 Conclusions Survey Conclusions and Questions Need ongoing education among all physicians who care for cancer survivors about potential late effects If transition of care to be successful, PCPs need education about late effects of cancer treatment Questions Is knowledge about long term chemotherapy side effects related to quality of follow up? Nekhlyudov L et al. Oncologists and primary care providers awareness of late effects of cancer treatment: implications for survivorship care. J Clin Oncol 30, 2012 (suppl; abstr 6008)

22 Drug(s) Bleomycin Cisplatin What are Late Effects of Chemotherapy Drugs? Toxicities Interstitial pneumonitis Hearing loss, tinnitus Peripheral Neuropathy Nephrotoxicity Cyclophosphamide Myelodysplasia (chromosome 5 and 7 abnormalities) Acute myeloid leukemia Doxorubicin, daunorubicin, idarubicin Etoposide Paclitaxel Oxaliplatin Vincristine Dilated cardiomyopathy Acute myeloid leukemia Peripheral neuropathy

23 How Will PCPs Know How to Monitor Cancer Patients?

24 A 57-year-old woman with a history of breast cancer returns to your office two years after her lumpectomy and radiation therapy for a follow up visit. She takes adjuvant tamoxifen. In addition to a physical exam, including breast and pelvic exams, and annual mammogram, which of the following do you recommend? 1. Laboratory tests to include a CA tumor marker 2. Chest x-ray 3. CT scan 4. PET/CT scan 5. None of the above 0% % 0% 0% 0%

25 Following Breast Cancer Patients H&P every 4-6 months for 5 years, then annually Annual mammogram For women on tamoxifen, annual pelvic exam if uterus present Women in menopause and on aromatase inhibitor, bone density evaluation at baseline and periodically thereafter Encourage active lifestyle, maintain ideal body weight Not mentioned in NCCN Attention to vitamin D status Low-fat diet NCCN Guidelines verson , Invasive breast cancer. accessed December 1, 2012

26 A 72-year-old man comes in for an office visit. Three years ago he underwent right upper lobectomy followed by adjuvant chemotherapy for a squamous cell carcinoma of the lung. He has quit smoking. Which of the following do you recommend? 1. CEA blood test 2. Annual chest x-ray 3. Annual CT scan of chest without IV contrast 4. Annual PET/CT scan 5. No imaging or blood tests necessary 0% 0% 0% 0% 0%

27 Following Lung Cancer Patients Non small cell H&P every 6-12 months for 2 years, then annually CT chest +/- contrast with each office visit; no contrast needed after 2 years Smoking cessation counseling Small cell H&P every 3-4 months during years 1-2, then every 6 months during years 3-5, then annually Chest imaging at each visit Smoking cessation counseling NCCN Guidelines version , Non small cell lung cancer. accessed December 1, 2012 NCCN guidelines version , Small cell lung cancer. accessed December 1, 2012.

28 A 67-year-old woman comes to your office. Five years ago she underwent a partial colectomy followed by adjuvant chemotherapy with fluorouracil, leucovorin, and oxaliplatin. She has no symptoms of concern. The CEA is 2.0 (normal). Her last CT scan was 2 years ago. Now that she is 5 years out from surgery, which of the following would you recommend 1. CEA annually 2. Colonoscopy every 3-5 years 3. CT scan of abdomen/pelvis annually 4. PET/CT scan annually 5. None of the above 22 6% 44% 17% 28% 6%

29 Following Colorectal Cancer Patients H&P every 3-6 months for 2 years, then every 6 months until 5 years out, then annually CEA at each office visit until 5 years out Annual CT of chest, abdomen, pelvis for up to 5 years if high-risk nodal involvement, lymphovascular invasion, porrly-differentiated Colonoscopy at 1 year, then every 3-5 years. If advanced adenoma, repeat in 1 year. NCCN Guidelines version , Colon cancer. accessed December 1, 2012.

30 A 68-year-old man is 5 years out from a radical prostatectomy for a Gleason 4+3=7 adenocarcinoma of the prostate. He has erectile dysfunction and stress urinary incontinence. The PSA is 0.8 ng/dl. Which of the following is correct? 1. A detectable PSA after radical 100% prostatectomy is abnormal and suggests persistence of disease. 2. The PSA is normal (less than 4 ng/dl), making it very unlikely that he has prostate cancer. 3. The PSA is abnormal. He should undergo imaging studies and be referred for androgen deprivation therapy. 4. The PSA is normal, but he should undergo a bone scan anyway to monitor for recurrence. 29 0% 0% 0%

31 Following Prostate Cancer Patients After Definitive Therapy PSA every 6-12 months for 5 years, then every year Digital rectal exam every year, except not necessary if PSA undetectable Rising PSA or evidence of recurrence by digital rectal exam requires additional evaluation/consultation NCCN Guidelines version Prostate cancer. accessed December 1, 2012.

32 A 50-year-old woman comes to your office. Ten years ago she underwent TAH/BSO for an early stage ovarian cancer. She completed a short course of adjuvant chemotherapy at that time. She feels well. A CA-125 level is normal. She has two healthy sons. None of her first-degree relatives had cancer. Which of the following would you NOT recommend for her? 1. Breast physical examination 2. Screening mammogram 3. Screening colonoscopy 4. Referral for genetic counseling 5. CT scan of the abdomen/pelvis 25 33% 33% 33% 0% 0%

33 Following Ovarian Cancer Patients H&P every 2-4 months for 2 years, then every 3-6 months for 3 years, then annually after 5 years CA-125 every visit if initially elevated CT chest/abdomen/pelvis, MRI, or PET/CT as clinically indicated Family history evaluation if not already performed NCCN Guidelines version , Epithelial ovarian cancer. accessed December 1, 2012.

34 Following Testicular Cancer Patients Seminoma Depends on prior adjuvant therapy: surveillance vs. chemotherapy vs. radiation therapy In general, office visits every few months labs (AFP, LDH, HCG) with each office visit Imaging (CXR, CT abdomen/pelvis) every 6-12 months Non Seminoma Depends on stage and prior therapy (RPLND, chemo) In general, office visits every few months labs (AFP, LDH, HCG) with each office visit Imaging (CXR, CT abdomen/pelvis) every 6-12 months NCCN Guidelines version , Testicular cancer. accessed December 1, 2012.

35 Long-Term Follow Up of Hodgkin Lymphoma Patients Annual H&P Baseline stress test/echo at 10 years If previous splenectomy or radiation therapy to spleen (rare now), then revaccinate with pneumococcal, meningococcal, and Haemophilus vaccines at 5 years Annual influenza vaccine Annual TSH if previous radiation therapy to neck Annual lipids Annual CXR if prior radiation therapy to the chest If female with prior radiation to the chest between the ages of 10 and 30 years, then annual mammogram AND breast MRI NCCN Guidelines version , Hodgkin lymphoma. accessed December 1, 2012.

36 Evolution of Cancer Survivorship National Cancer Survivorship Resource Center. Systems policy and practice: clinical survivorship care overview pdf, accessed December 1, 2012.

37 Principles of Survivorship Research has lacked in the field. The following need to be corrected: Lack of long-term follow up studies of patients Lack of evidence-based guidelines for management Lack of education and awareness of health care providers of needs of patients Smooth transitions of care need to occur from oncologist to PCP. The leader of the care needs to be well defined. National Cancer Survivorship Resource Center. Systems policy and practice: clinical survivorship care overview pdf, accessed December 1, 2012.

38 Conclusions (1) Trends in population growth and aging and cancer incidence may lead to a relative shortage of oncologists in the next 10 years. The majority of patients seen by oncologists are more than a year out from their cancer treatment. The relative shortage of oncologists, the increase in cancer survivors, and the push to reduce costs of care will almost certainly lead to an increasing role of primary care providers in following cancer survivors.

39 Conclusions (2) Better education about what cancer survivors need and are at risk for is needed for PCPs. Guidelines for survivorship care are sparse; probably the best option currently available is the NCCN Guidelines, available for free at Some patients, such as breast cancer patients who have completed 5 years of adjuvant endocrine therapy, are easy to monitor and can be capably followed by PCPs. Others, such as testicular cancer patients requiring frequent office visits, labs, and imaging studies, are more complicated and may be best managed by an oncologist.