Cancer Survivorship: What to Monitor and When to...
Transcript of Cancer Survivorship: What to Monitor and When to...
Cancer Survivorship: What to Monitor
and When to Intervene
Hyman B. Muss, MD
31th Miami Breast Cancer Conference 2014
Breast Cancer 2013
CA: A Cancer Journal for Clinicians
pages 52-62, 1 OCT 2013 DOI: 10.3322/caac.21203
Incidence Mortality
Survivor
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
3
18 Million Cancer Survivors Projected in 2022
4
Breast 20-40%
Essential Components of
Survivorship Care
• 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
5
Deb Mayer 2014
Bumps on the Road of Life (2010) http://www.lillyoncologyoncanvas.com
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?
GIVIO Trial JAMA 271:1587-1592, 1994
1320 women
Stage I-III BC
26 Italian hospitals
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
INTENSIVE CONTROL
OUTCOMES: SURVIVAL AND HR-QOL
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
What is the Value of Intensive
Diagnostic Followup
• Roselli Del Turco, JAMA 1994;271:1593
– 1243 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
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
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
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
What is the Role of Tumor
Associated Antigens? • CEA, CA 15-3, CA 27.29
• Elevated in 30 – 65% of distant recurrences with lead time of about 4-6 months – Measured every 2-3 months:
Chan DW, JCO 1997
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 !
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.
Give all
patients
ASCO
follow-up
guidelines
and
document
it!
Cancer.net
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
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
Monitoring and Treatment
Hayes, NEJM 2007;356:2505
Symptom Management options
Hot flashes SSRIs, SSNRIs, gabapentin
Sexual dysfunction (libido, dyspareunia) Vaginal moisturizer, estring(?),
testosterone (?)
Weight gain
Exercise (Daley et al, JCO
2007;25:1713), Diet
Depression, fatigue Counseling, treat underlying cause, time
Cognitive dysfunction Tools for improving function
Osteopenia/porosis Calcium/vit D, weight bearing exercise,
bisphosphonates as indicated
Cardiovascular disease Monitor lipid panel, evaluate symptoms
Thrombosis Family and personal history
Secondary malignancies Screening, evaluate symptoms
Late Complications for which
Interventions/Education Available
• Endometrial
malignancies
• Thromboembolic
events
• Cerebrovascular
events
• Leukemia
• Cardiac dysfunction
• Menopausal symptoms
• Bone loss
• Weight gain
• Sexual difficulties
• Psychological
problems
• Neuropathy
Should Be Addressed
During Follow-up Visit
All Rare and Typically
Present More Acutely
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. 45-60 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.
Who should do
follow-up?
Primary Care vs Oncologist Multicenter RCT
n=968
9-15 mo after
diagnosis
f/u in cancer center
n=485
f/u with family physician
n=483
Grunfeld E et al. J Clin Oncol 2006; 24:848-55
• Observed 4.5 yrs after diagnosis
• Primary endpoint: Recurrence-Related Serious Clinical Events (SCEs)
• Secondary endpoint: health-related QOL
Primary Care vs Oncologist
Grunfeld E et al. J Clin Oncol 2006; 24:848-55
Family
Practice
Cancer
Center
Recurrences 54
(11.2%)
64
(13.2%)
Deaths 29
(6.1%)
30
(6.2%)
SCEs 17
(3.5%)
18
(3.7%)
No difference in health-related QOL
Copyright © American Society of Clinical Oncology
Grunfeld, E. et al. J Clin Oncol; 24:848-855 2006
A: Health-related quality of life: Medical
Outcomes Study Short Form 36-
Item (SF-36) Physical and
Mental Component Summary
B: Depression and Anxiety
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
“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
In the end it all
comes down to
this…
Mary, do you
think I need a
PET scan?
Thank
You