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Working Beyond Cancer Dr Eliot Chadwick Consultant Clinical Oncologist

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1 Working Beyond Cancer Dr Eliot Chadwick Consultant Clinical Oncologist
Nottingham University Hospitals NHS Trust & The Nottingham Oncology Group Trent Occupational Medicine Annual Symposium 2014

2 Macmillan – the scene In the UK, over 100,000 people of working age are diagnosed with cancer each year. More than 700,000 people of working age are living with a cancer diagnosis. The HR department of a large employer will see more new cancer diagnoses in a year than a GP.

3 Cancer Incidence (CRUK)

4 Cancer Incidence (CRUK) The Big 4

5 Cancer survival (CRUK)

6 Cancer survival (CRUK) …and then there were 3

7 Why Toxicity? Normal tissue reaction to chemotherapy and radiotherapy.
Relates to cell turnover. Early vs late broadly correlates with α/β ratio

8 Timelines - toxicity Long term Short term 4/52 8/ / yrs

9 DECISION The Return to Work Finance Denial Identity Fear of relapse
Pragmatism Denial Time DECISION Independence Guilt Empowerment Finance Self worth Self Employment Identity

10 Breast Cancer Surgery Chemotherapy Hormones Radiotherapy
Biological agents (Herceptin®)

11 Fatigue “...5 years after....I've been off sick from work since then...and, being completely honest, I have no desire of returning. I don't feel I can't work full time and, I can't survive on a part time wages. I have chronic fatigue, chemo brain and PSD. So far, nobody seems to care about the devastating effects of the aftermaths of cancer. The unrealistic expectations of employers, colleague and friends and, maybe my own, really puzzled me.”

12 Longitudinal patient case rates for persistent fatigue over 12 months (n = 218).
(A) Longitudinal patient case rates for persistent fatigue over 12 months (n = 218). Patients classified as having no fatigue (n = 91), fatigue after surgery only (n = 10), or transient fatigue (n = 48) are not included. Outcome for the 69 women reporting fatigue at end of treatment is shown. (B) Longitudinal patient case rate for persistent mood disturbance over 12 months (n = 218). Patients classified as having no mood disturbance (n = 117), mood disturbance after surgery only (n = 23), or transient mood disturbance (n = 35) are not included. Outcome for the 43 women reporting mood disturbance at end of treatment is shown. Goldstein D et al. JCO 2012;30: ©2012 by American Society of Clinical Oncology

13 Lymphœdema Stiffness Pain

14 BrCa Side effects 6/52 3/12 2yr 10yrs 20yrs
ACUTE Peri-operative complications, seroma, infection Poor wound healing, infection, nausea, mucositis, alopecia Neuralgia, shoulder stiffness, fatigue Lymphœdema, cardiac, depression 6/52 3/ yr 10yrs 20yrs

15 Success & morbidity of treatment
Prostate Cancer Success & morbidity of treatment Risk of treating a non-lethal disease

16 Hormones LHRHa EBRT 3/ / /12 2yrs 3yrs

17 Hormones Insulin resistance* / cardiovascular morbidity ↓muscle mass
Cognitive impairment Hot flushes *LGI diet advised (but see Pelvic RT)

18 Hormones - summary Effects as long as administered, and months to years beyond. Probably underplayed. Impact on occupation not necessarily direct.

19 Pelvic Radiotherapy

20 Pelvic RT effects EBRT * ”Beige” diet advised
ACUTE Fatigue, *proctitis, cystitis, prostatitis nausea, skin reaction EBRT CHRONIC / LATE *Proctitis, cystitis, arthritis, hip fracture 6/52 3/ yr 10yrs 20yrs * ”Beige” diet advised

21 Case 1 – 38yrs female, anal Ca
}EBRT 50.4Gy /28# Mitomycin C D1 5-fluorouracil D1-4 Coronary artery spasm from 5-FU. D22-25 not given. 5.4Gy boost given in lieu. At 18m, ongoing discomfort in perineum, frequency of stool 5-10/day, with urgency and occ. incontinence. Works at check-out in supermarket.

22 Case 2 – 56yrs male, peri-anal Ca, vegetarian.
}EBRT 50.4Gy /28# Mitomycin C D1 5-fluorouracil D1-4, D22-25 Electron boost of 20Gy/10# At 12m, ongoing discomfort in perineum, frequency of stool 5/day, with urgency. Struggles to maintain wt. Pre treatment, worked for council – refuse, gardens. Now medically retired.

23 Radiotherapy - summary
Can cause significant long term effects. Functional deficit. Not easily treated.

24 Chemotherapy

25 Chemotherapy effects 6/52 3/12 2yr 10yrs 20yrs
ACUTE Multiple, disparate effects. Not all intuitive. Fatigue, myalgia, arthralgia dysgeusia Wt gain, Neuropathy, cardiac 6/52 3/ yr 10yrs 20yrs

26 Case 3 – 48yrs male, rectal Ca, node positive on MRI.
Capecitabine 825mg/m2/bd + EBRT 50.4Gy / 28# Works in abattoir. Develops palmar-plantar erythema (PPE). Capecitabine stopped during RT. Post-op (stoma). Pathologically node positive. For further capecitabine + oxaliplatin adjuvantly. Pt declines oxaliplatin. Starts capecitabine, but stops early due to PPE.

27 Case 4 – 65yrs male, colon Ca, Duke’s C
Referred for adjuvant chemotherapy 5-fluorouracil / oxaliplatin q2/52 for 12 cycles. Loses sense of taste and smell. Develops PPE. Continues to work as Michelin star chef but finds it increasingly difficult.

28 Chemo - Summary Most chemo effects acute.
Fatigue most common long term. Subjective. Pts occupational circumstance may dictate chemo given.

29 Surgery

30 Surgery effects ACUTE Peri-operative complications
Fatigue, poor wound healing, TED Anterior resection syndrome Hernia, stoma, incontinence 6/52 3/ yr 10yrs 20yrs

31 Case 5 – 28yrs female, sigmoid Ca, emergency Hartmann’s.
pT4b tumour Referred for adjuvant chemotherapy. Receives 8 cycles of capecitabine / oxaliplatin within SCOT study Regular FU post-chemo for SCOT data collection. Regular discussion regarding stoma. Pt works in clothes shop. Gaining weight, as finds it difficult to exercise. Stoma reversal on hold until 1 year CT performed. 1 year CT ?Ovarian mass

32 Surgery - summary Surgery usually irreversible.
Implications for lifestyle should be explored, particularly if options available. Can have significant body image as well as functional effects.

33 Are we doing enough?

34 Challenges Patients not informed about impact of cancer on their working lives. Many patients do not have access to vocational rehabilitation services. Employers don’t know how to support staff with cancer. (Cancer specialists don’t know how to support employers.)

35 Questions?


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