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© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. in the clinic Care of the Adult Cancer Suvivor
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What are the essential components of follow-up care? Prevent recurrent and new cancers and other late effects Monitor for cancer spread, recurrence, or 2 nd cancers Assess medical and psychosocial late effects Manage consequences of cancer and its treatment Coordinate with other doctors so all health needs met Provide routine health promotion
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. When should patients transition to follow-up care? Sooner If early-stage or low-risk for late effects + recurrence Later If high risk for late effects + recurrence Communication + cooperation is critical Oncology team should provide care recommendations Primary care doctor should manage comorbid conditions + provide health maintenance (even if no transition occurs)
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Which types of clinicians should provide follow-up care? Historically: oncologists Focus on surveillance for disease recurrence Newer approach: shared care model Oncology and primary care teams work together Oncologists lead in coordinating care Focus: health promotion + managing comorbid conditions
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What information should clinicians have when follow-up care begins? Treatment summary Type and location of cancer and type of surgery Drug names and cumulative doses of chemotherapy Types and cumulative doses of radiation therapy Survivorship care plan Describes follow-up scans, lab tests, office visits Identifies potential late effects + surveillance specifics Contains other, individualized information
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Transition to Follow-up Care... Timing varies for transition from oncology care to primary care Shared care model is optimal Information needed for follow-up care Treatment summary Survivorship care plan Communication and collaboration among providers is critical
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What cardiac issues should the clinician consider? Vascular disease Hypertension Myocardial dysfunction Consider the following actions Check lipids, thyroid function, BP, weight Ask about additional familial risk for CV disease Do a stress ECHO if symptoms are present
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What pulmonary conditions should the clinician consider? Bleomycin-induced inflammation of lung (pneumonitis) Dose-dependent, reversible acute toxicity Increased risk of anesthetic complications Radiation-induced pneumonitis Reversible with corticosteroid therapy Manifests many years after treatment Ask about exercise endurance, respiratory symptoms
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What cognitive issues should the clinician consider? Cognitive changes from chemo and endocrine therapy Breast cancer, ovarian cancer survivors Leukemia, lymphoma survivors Prostate cancer survivors (androgen-deprivation Rx) With whole-brain radiation, changes may be delayed Cause may be difficult to determine Aging, depression, or stress — or cancer Rx itself Combination of these factors Neuropsychological testing may help define symptoms
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What sexual and reproductive issues should the clinician consider? Women Menopausal symptoms: chemotherapy or pelvic radiation Infertility: gynecologic surgery, radiation, chemotherapy Men Hypogonadism from some hormonal drugs, chemotherapy, bilateral orchiectomy, or pelvic / cranial radiation Infertility from testicular cancer, systemic chemotherapy, radiation; pelvic and retroperitoneal surgery Both Women and Men Psychological issues can cause sexual dysfunction Anatomical injury can directly cause dysfunction
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What bone health issues should the clinician consider? Osteoporosis ( Screen for bone loss with DEXA scans) Surgical oophorectomy / orchiectomy GnRH agonists / antagonists Chemo-induced ovarian failure Aromatase inhibitors Avascular necrosis of any joint Corticosteroids can affect blood supply If patient reports joint pain, consider MRI
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What other medical issues should the clinician consider? Second malignant neoplasms Endocrinopathies Neurotoxicity, ototoxicity, nephrotoxicity Lymphedema
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Are there specific medical issues for survivors of the most common cancers? Lung cancer Decreased pulmonary reserve Smoking cessation reduces risk for new cancers Colon cancer Second malignant neoplasms Life-altering issues with weight, continence, or bowels Breast cancer Second breast cancers Premature ovarian failure; lymphedema Cardiac toxicity (from chest radiation and some chemo) Prostate cancer Erectile dysfunction; symptoms from androgen ablation Rx Urinary incontinence; GI symptoms related to proctitis
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Are there common medical issues for survivors of lymphoma, leukemia, and hematopoietic cell transplantation? Late effects of chemotherapy or radiation Second malignant neoplasms Cardiac effects Lifelong immunodeficiency and increased infection risk Hypoglobulinemia Functional asplenia Chronic graft-vs-host disease From allogeneic hematopoietic cell transplantation
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Are there specific medical issues for survivors who were treated with surgery, radiation therapy, or chemotherapy? Depends on the dose and field of radiation therapy Depends on specific agents and doses of chemotherapy Chest radiation therapy: surveillance for breast cancer; thyroid testing; cardiac evaluation Chest radiation or doxorubicin: ECHO; yearly lipid screen Anthracyclines + chest radiation: cardiac dysfunction risk Childhood cranial or craniospinal radiation: assess for cognitive, fertility, other endocrine issues Major abdominal or pelvic surgery or radiation: risk for wide array of issues many years after treatment
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Follow-up Medical Care... Know the risks for treatment-related medical effects Collaborate with oncologists to optimize care Use the summary of cancer treatment to guide follow-up care Monitor for late medical effects of treatment Fertility Bone health Cardiac, pulmonary, cognitive, and sexual functioning Secondary malignancy
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Who provides surveillance for recurrent cancer and secondary cancers? Follow-up care clinician if patient has transitioned Communicate with oncologists, seek guidance when needed Schedule appropriate surveillance and screening In the shared care model, assign responsibility to the oncologist or the primary care physician
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What about pain and fatigue? Pain and fatigue are associated with… Sleep disturbance, menopausal symptoms, anxiety, depression Distinguish survivors from those in active treatment Cancer survivors report few physical symptoms after treatment Management can be difficult If the cause is uncertain, involve the oncologist If the problem is a chronic treatment effect, refer patient to pain management team Consider the possibility of psychosocial factors
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What about psychological and emotional problems? Oncologists often prescribe medications for sleep problems, anxiety, and depression during treatment Many patients remain on them after treatment Evaluate and manage as you would in any other patient Refer to appropriate mental health practitioners Concerns about cancer recurrence may be high Suicidal ideation may be increased
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What is the role of exercise and rehabilitation? Maintains healthy body composition and image Improves quality of life, and aids in managing fatigue, mood disorders, and sleep problems The goal is a return to normal activities Low- to moderate-intensity activity doesn’t usually require formal evaluation For more vigorous exercise, follow guidelines for exercise testing before starting
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What is the role of complementary and alternative medicine? Can help survivors take active role in improving health The emphasis on QOL improves mental outlook Acupuncture, meditation, yoga, dance therapy, art therapy Improve menopausal symptoms Relieve fatigue, pain, and sleep problems Help manage fear of recurrence and reduced QOL from long- term treatment
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What about employment, insurance, and disability? Personal and work lives are affected by cancer Survivors may hesitate to disclose their diagnosis because of concerns about Employment and work advancement Insurance Personal relationships Be prepared to discuss these issues
© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Additional Issues in Follow-up Care… Care for cancer survivors can be complicated and challenging Provide surveillance and screening for cancer recurrence Ensure social, psychological, and economic well-being Be familiar with available resources Provide referrals as indicated PT and OT for neurocognitive evaluations Acupuncture and other supportive services Pain management teams Social service agencies
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