1. Welcome To 24th Scientific Seminar OF MOSB
Dr. Nahid Hossen,
MD 3rd part student
Medical Oncology
NICRH

2. CARE OF CANCER SURVIVORS

3. Overview of Survivorship
Historically, 5 years after diagnosis
From the moment of diagnosis through the balance of life
Including family and caregivers
After active treatment
Historically, a person entered the survivorship phase of the cancer continuum once they were 5 years post-diagnosis. Based on efforts of organizations like the National Coalition for Cancer Survivorship and the LIVESTRONG Foundation, the definition has evolved to define survivorship as starting from the moment of diagnosis. This definition acknowledges that cancer patients begin surviving from the time they are diagnosed. That definition has since been expanded to include family and caregivers.
In practice, the term survivorship often means the time after active treatment. The National Cancer Institute defines survivorship as: “the health and life of a person with cancer post treatment until the end of life. It covers the physical, psychosocial, and economic issues of cancer, beyond the diagnosis and treatment phases. Survivorship includes issues related to the ability to get health care and follow-up treatment, late effects of treatment, second cancers, and quality of life. Family members, friends, and caregivers are also considered part of the survivorship experience.”
It is important to recognize that not all cancer survivors like the term survivor. For some, cancer is not a defining part of their lives. For others, they do not think the term captures their experience. Some terms people may use are thrive, fighter or even diva. Each person’s survivorship experience is different.
Prevention
Detection
Diagnosis
Treatment
Survivorship

4. Focus on Survivorship
2024
2024
2014
2014
Based on the growing baby boomer population, this number is expected to be nearly 19 million by 2024.
American Cancer Society, 2014a

5. Focus on Survivorship – Males
Over 40% of male survivors were diagnosed with prostate cancer.
*Non-Hodgkin
American Cancer Society, 2014a

6. Focus on Survivorship – Females
Similarly, over 40% of female cancer survivors were diagnosed with breast cancer.
*Non-Hodgkin
American Cancer Society, 2014a

7. Survivorship by Time Since Diagnosis
In addition to the types of survivors by gender and site, it’s important to understand survivorship by time since diagnosis.
About 2/3 of all cancer survivors were diagnosed 5 or more years ago.
15% were diagnosed 20 or more years ago.
Almost half of all survivors are 70 years of age or older, while only 5% are younger than 40 years.
This means that we are looking at an older population that is at risk for multiple cancer- and non-cancer-related comorbidities.
American Cancer Society, 2014

8. Impacts of Cancer Treatment
Individual Effects/Risks
Surgical Side Effects
Chemotherapy Side Effects
Radiation Side Effects
Hormonal Therapy Side Effects
Non-Treatment-Specific Side Effects
There are many impacts of cancer, which can be the result of surgery, chemotherapy, radiation and hormonal treatment. They may also be non-treatment-specific.

9. Psychological Well-Being
Cancer Survivor Needs
Quality of Life
Physical Well-Being
Psychological Well-Being
Control
Anxiety
Depression
Fear of recurrence
Cognition/attention
Functional status
Fatigue and sleep
Overall physical health
Fertility
Pain
Social Well-Being
Spiritual Well-Being
Family distress
Roles and relationships
Affection/sexual function
Appearance
Isolation
Finances/employment
Meaning of illness
Religiosity
Transcendence
Hope
Uncertainty
Inner strength
These impacts affect quality of life across these 4 major domains: physical well-being, psychological well-being, social well-being and spiritual well-being. These domains are all interrelated. For example, a survivor who fears recurrence may be less likely to seek treatment for physical issues, which may impact their social and spiritual well-being.
Ferrell & Hassey Dow, 1997

10. The Need for Survivorship Care
Rapidly growing population of survivors
Survivors experience unmet physical, psychosocial, practical and spiritual needs
Inconsistent coordination of care and communication between primary care providers and oncologists
Significant long-term and late effects
Complexity of care, comorbid conditions
According to the American Cancer Society’s Cancer Treatment & Survivorship Facts and Figures, there are approximately 14.5 million cancer survivors in the U.S.
Survivors can experience a wide array of physical, psychological, social, practical and spiritual concerns that linger or show up long after treatment. There is high variability in the way health care services are delivered after cancer treatment and limited, inconsistent care coordination between primary care providers and oncologists. Often there is confusion about what each health care provider is responsible for in terms of health care for the cancer survivor. Additionally, cancer survivors are at risk for significant long-term and late effects, which can be compounded by the complexity of care and the need to deal with multiple comorbid conditions.
American Cancer Society, 2014a
Smith et al., 2008

11. Long-term and Late Effects
Long-term effects are medical problems that develop during active treatment and persist after the completion of treatment
Late effects are medical problems that develop or become apparent months or years after treatment is completed
Two terms are often used to describe effects of cancer and its treatment. Long-term effects are medical problems that develop during active treatment and persist after the completion of treatment, whereas late effects are medical problems that develop or become apparent months or years after treatment is completed.

12. Survivorship Guidelines
There are several survivorship guidelines available that have different areas of focus.

13. ACS Cancer Survivorship Care Guidelines: Key Areas
Key areas of the ACS cancer survivorship care guidelines address:
monitoring for cancer recurrence,
screening and early detection of new cancers,
assessment and management of physical and psychosocial long-term and late effects of cancer and its treatment,
health promotion strategies for nutrition, physical activity and tobacco cessation,
and care coordination among the cancer care team including survivorship care plans, communication with providers, and inclusion of caregivers.
In addition to some survivorship information in its disease-specific guidelines, The National Comprehensive Cancer Control Network (or NCCN) has a survivorship guideline that provides guidance to providers on the assessment and management of common long-term/late effects stemming from cancer and its treatment (ie, anxiety and depression; cognitive function; exercise; fatigue; immunizations and infections; pain; sexual function; and sleep disorder).
Also, the American Society of Clinical Oncology (or ASCO) has disease-specific as well as topic-based guidelines covering neuropathy, fatigue, anxiety and depression and fertility preservation, or symptom-related guidelines, to provide resources for the assessment and management of long-term and late effects.
While the ACS guidelines leverage these resources, the ACS guidelines address survivorship for a specific cancer site, thus allowing the primary care provider to view follow-up care holistically.

14. Cancer Survivorship Clinical Practice Guidelines
National Comprehensive Cancer Network
By Topic:
Anxiety and depression
Cognitive function
Exercise
Fatigue
Immunizations and infections
Pain
Sexual function (female/male)
Sleep disorders
American Society of Clinical Oncology
Neuropathy
Fertility preservation
Breast cancer survivorship care guideline (ACS/ASCO)
American Cancer Society Survivorship Care Guidelines for Primary Care Providers
Holistic:
Surveillance
Screening
Long-term and late effects
Health promotion
Breast (ACS/ASCO), colorectal, head and neck and prostate currently available
In addition to some survivorship information in its disease-specific guidelines, the National Comprehensive Cancer Network has topic-based guidelines for survivors that cover anxiety and depression, cognitive function, exercise, fatigue, immunizations and infections, pain, sexual function (female/male) and sleep disorders. Similarly, ASCO has limited disease-specific guidelines as well as topic-based guidelines covering neuropathy, fatigue, anxiety and depression and fertility preservation. The American Cancer Society released disease-specific guidelines including colorectal, head and neck and prostate, and breast cancer guidelines in partnership with ASCO. These guidelines are holistic and cover multiple domains, including surveillance and screening, health promotion and care coordination.

15. ACS Cancer Survivorship Care Guidelines: CA articles bit
ACS Cancer Survivorship Care Guidelines: CA articles bit.ly/ACSPrCa; bit.ly/acscolorc; bit.ly/BrCaCare; bit.ly/acsheadneck
The first in the new ACS series of cancer survivorship care guidelines, the ACS Prostate Cancer Survivorship Care Guidelines, were published online in CA: A Cancer Journal for Clinicians (or CA) in June 2014 and was selected to be the cover feature of the Jul/Aug print issue. In February 2015, ASCO endorsed the guidelines.
The second guideline in the series, the ACS Colorectal Cancer Survivorship Care Guideline, was published online in CA in September 2015.
The third guideline, the ACS/ASCO Breast Cancer Survivorship Care Guideline, a co-release as the result of a new collaboration with ASCO, was published in the ACS Journal, CA, and in the ASCO Journal of Clinical Oncology (or JCO) in December This guideline received considerable press and was a featured segment on Good Morning America.
The last guideline in the series, the ACS Head and Neck Cancer Survivorship Care Guideline, was published online in CA in March 2016, and was selected to be the cover feature of the May/June print issue.
Visit these direct URLs to access the free CA articles and free CE activities for physicians and nurses to assist with education and training of health care professionals.
The first in the new ACS series of cancer survivorship care guidelines, the ACS Prostate Cancer Survivorship Care Guidelines was published online in CA: A Cancer Journal for Clinicians in June 2014 and was selected to be the cover feature of the Jul/Aug print issue. In February 2014, The ASCO endorsed the guidelines. Since publication in June 2014, the free prostate CA article has almost 4000 (3777) views, almost (15866) downloads, and little over 200 (202) completed CE activities.
The second guideline in the series, the ACS Colorectal Cancer Survivorship Care Guideline, was published online in CA A Cancer J Clin in September Since publication in September 2015, the free colorectal CA article has almost 3000 (2675) views, little over 7000 (7018) downloads, and little over 100 (121) CE activities completed.
The third guideline, the ACS/ASCO Breast Cancer Survivorship Care Guideline, a result of a new collaboration with the ASCO, was published in the ACS Journal and the Journal of Clinical Oncology in December The guideline received considerable press and was a featured segment on the Today Show. Since publication in December 2015, the free breast CA article has almost 4000 (3833) views, almost 6000 (5528) downloads, and almost 200 (161) CE activities completed.
The last guideline in this series, the ACS Head and Neck Cancer Survivorship Care guideline was published online in CA A Cancer J Clin just last week, and was selected to be the cover feature of the May/June print issue. Analytics for the free head and neck CA article will not be available until early April, but already 12 CE activities have been completed.
Visit these URLs to access the free CA articles and free CE activities to assist with education and training of health care professionals.

16. What Oncologists Should Know
Survivorship Care Plans (treatment summary + follow-up care plan) be given to and discussed with patients treated with curative intent who are finishing active treatment, and
Patients to be screened for distress and psychosocial health needs.
As a result, these practices are becoming part of the standard of care.
NCRSC Toolkit pg.9/81

17. ASCO GUIDELINE fOR BREAST CANCER SURVIVORS

18. Breast cancer survivors
2.1 million Americans
Female: Male = 100:1
Increased risk second primary cancer – both breasts, ovaries and colorectal
Most recurrences within 5 years following treatment – but threat persists 20+ years

19. Summary of Guideline Recommendations

20. SURVEILLANCE FOR BREAST CANCER RECURRANCE
History & Physical Examination
Weight loss, persistent cough, bone pain
Breast or chest wall changes, adenopathy
Yearly pelvic exam
Depression
Dowager’s hump or change in height
Lymphedema

21. History and physical exam every 3-6 months for first 3 years
Every 6-12 months in years 3-5
Annually thereafter

22. Annual mammography (starting minimum of 6 mos after completion XRT)
SCRRENING THE BREAST FOR LOCAL RECURRENCE OR A NEW PRIMARY BREAST CANCER:
Annual mammography (starting minimum of 6 mos after completion XRT)
Should not do routine MRI of breast unless the patient meets high risk criteria for increased breast cancer surveillance of ACS guidelines.

23. Lab tests & imaging: NOT RECOMMENDED X CBC X Chemistries X CXR X Bone scans X PET scan X Breast MRI X Tumor markers (CA 15-3, CA27.29, CEA)

24. Signs of Recurrence
Primary care physician should educate & counsel all women about the signs & symptoms of local recurrence.

25. Risk evaluation & genetic counseling
Assess the patient’s cancer family history.
Offer genetic counseling if potential hereditary risk factors are suspected (eg; women with a strong family history of cancer [breast, colon, endometrial] or age 60 y or younger with triple-negative breast cancer)
Endocrine treatment impacts, symptom management
Counsel patients to adhere to adjuvant endocrine (anti estrogen) therapy .

26. Screening for second primary cancers average-risk patient
Should screen for other cancers as they would for patients in the general population; and
Should provide an annual gynecologic assessment for postmenopausal women on selective estrogen receptor modulator therapies

27. Assessment and management of physical and psychosocial long-term and late effects of breast cancer and treatment
Body image concerns
Assess for patient body image/appearance concerns
Offer the option of adaptive devices (eg, breast prostheses, wigs) and/or surgery when appropriate and
Refer for psychosocial care as indicated

28. Lymphedema 30% axillary node sampling or XRT Early management
Certain physical therapists specialize
Meticulous skin care to avoid infection
Avoid instrumenting affected arm
Manual lymphatic drainage, compression, swimming

30. Cardiotoxicity
Monitor Fasting lipid profile & provide cardiovascular monitoring
Educate the breast cancer survivors on healthy life style modifications, potential cardiac risk factors and when to report relevant symptoms (SOB , Fatigue)

31. Cognitive Impairment It is recommended that primary care clinicians
Should ask patients if they are experiencing cognitive difficulties
Should assess for reversible contributing factors of cognitive impairment and optimally treat when possible and
Should refer patients with signs of cognitive impairment for neurocognitive assessment and rehabilitation, including group cognitive training

32. Distress, Depression & Anxiety
Assess the patients for distress, depression & anxiety.
Conduct a more probing assesment for patients at higher risks ( Young pt, H/O psychiatric diseases or a low socioeconomic background).
Should offer in office councelling and/or pharmacotherapy and/or refer to appropriate psycho-oncologists.

33. Fatigue
Should assess the fatigue and treat any causative factors including anaemia, thyroid or cardiac dysfunction.
Treat for factors that may impact fatigue (mood or sleep disturbance, pain)
Should councel patient for regular physical activity

34. Bone Health
Should refer post menopausal breast cancer survivors for a baseline DEXA scan.
Repeat DEXA scan every 2 years for women taking an aromatase inhabitor, tamoxifen and/or GnRH agonist and women who have chemo induced premature menopause.

35. Musculoskeleton Health
Should assess for musculoskeletal symptoms, including pain, by asking patients about their symptoms at each clinical encounter and
Should offer one or more of the following interventions based on clinical indication: acupuncture, physical activity, and referral for physical therapy or rehabilitation.

36. Pain & neuropathy
Should assess for pain and contributing factors for pain with the use of a simple pain scale and comprehensive history of the patient’s complaint
Should offer interventions, such as acetaminophen, nonsteroidal anti-inflammatory drugs, physical activity, and/or acupuncture, for pain
Should assess for peripheral neuropathy and contributing factors for peripheral neuropathy by asking the patient about their symptoms, specifically numbness and tingling in their hands and/or feet, and the characteristics of the symptoms
Should offer physical activity for neuropathy; and
Should offer duloxetine for patients with neuropathic pain, numbness, and tingling

37. Infertility
Should refer survivors of childbearing age who experience infertility to a specialist in reproductive endocrinology and infertility as soon as possible

38. Sexual Health
Should assess for signs and symptoms of sexual dysfunction or problems with sexual intimacy
Should assess for reversible contributing factors to sexual dysfunction and treat, when appropriate
Should offer nonhormonal, water-based lubricants and moisturizers for vaginal dryness
Should refer for psychoeducational support, group therapy, sexual counseling, marital counseling, or intensive psychotherapy when appropriate

39. Premature menopause/ hot flashes
Should offer selective serotonin-norepinephrine reuptake inhibitors,gabapentin, lifestyle modifications, and/or environmental modifications to help mitigate vasomotor symptoms of premature menopausal symptoms

40. Health Promotion Information Obesity reduction Physical Activity
Smoking Cessation

41. Care of Co-ordination Communication with oncology team
Inclusion of family

42. THANK YOU