1. Copyright 2008 UC Regents Cancer Survivorship Curriculum for Medical Students

2. Copyright 2008 UC Regents Cancer Survivorship Cancer survivorship is a fairly new concept; however, it encompasses a large and growing population. Of the approximate 10 million cancer survivors today, about seven million have survived for five or more years. These numbers will continue to grow. Issues of survival need to be addressed, i.e., long-term effects from cancer treatment. Follow-up care and tracking of survivors from a wellness perspective needed. Some of the consequences of treatment are well-known so it makes sense to develop special clinics to study, document, and assist patients with the long-term and late effects of cancer. Some of these potential effects include:

3. Copyright 2008 UC Regents Physiologic Effects: Organ damage or failure or premature aging caused by therapy, can result in cardiomyopathy, renal insufficiency, bladder damage, carotid artery disease, cataracts, muscle atrophy, problems with memory and information processing. Compromised immune systems. Damaged endocrine systems leading to thyroid dysfunction, premature menopause, reproductive problems, and sexual disruption. Increased risk for second cancers with certain therapies. Increased risk for associated other cancers. Functional problems: incontinence, immobility, lymphedema, sleep disturbances, pain syndromes Cosmetic changes

4. Copyright 2008 UC Regents Psychological Effects anxiety mood changes depression living with uncertainty sexuality and relationship problems

5. Copyright 2008 UC Regents Social effects health insurance availability of jobs consequences of cancer therapy

6. Copyright 2008 UC Regents Cancers with increasing survival:  Breast  Childhood cancers  Prostate  Colo-rectal  Uterine and cervical

7. Copyright 2008 UC Regents Background Increased survivorship of many cancers Need for primary care physicians to care for cancer survivors Specific competencies for education  Attitudes  Knowledge  Skills

8. Copyright 2008 UC Regents Attitudes Comfortable prescribing medications for pain control, including opioids Comfortable asking new patients routinely about previous cancers Willing to ask oncologists for consultation when appropriate Considers general preventative issues as well as those related to cancer survivorship in cancer survivors

9. Copyright 2008 UC Regents Knowledge Understands that all cancer survivors are at increased risk for other cancers as well as recurrence of the original cancer, and need to avoid tobacco, eat right, and use sunscreen Understands how genetics contribute to risk of cancer (simplified) Understands common uses of the terms “cure”, “disease free survival”, and “cancer survivor” Understands the differences in outcome of cancer survivors by gender, ethnicity and socio-economic status

10. Copyright 2008 UC Regents Definitions Cure: To heal or restore health; a treatment to restore health. Disease Free Survival: Length of time after treatment during which no cancer is found. Can be reported for an individual patient or for a study population. Cancer Survivor: Dr. Fitzhugh Mullan, the original founder of the National Coalition for Cancer Survivorship (NCCS), a physician and cancer survivor notes, "From the time of its discovery and for the balance of life, an individual diagnosed with cancer is a survivor" ; "Survivorship is the experience of living with, through or beyond cancer.“ The NCCS describes three seasons of survival -- Acute Stage, Extended Stage, and Permanent Stage - and notes that different concerns characterize each season.

11. Copyright 2008 UC Regents Definitions Acute Stage: substantial amounts of fear, anxiety, pain/discomforts, and concerns about mortality. Extended Stage: a period of uncertainty after therapy and during remission where there may be physical limitations, changes in body image and issues of trust due to a life-altering event. The Permanent Stage: when one wakes up each morning, and cancer isn't the first thing one think about.

12. Copyright 2008 UC Regents Knowledge Understands the variety of social consequences of cancer on survivors, including difficulty getting employment and insurance, stigma, and the impact on the family and friendships Knows the elements to obtain about a cancer history, how to get information the patient can’t give them, and interpret the health implications of the history Understands consequences of cancer treatment seen as different developmental stages, including growth, osteoporosis, learning issues, sexual disorders and fertility

13. Copyright 2008 UC Regents Skills Able to identify people at higher risk for cancer, using key screening guidelines Able to work on secondary prevention with survivors in an appropriate and individualized manner, including recommendations regarding sunscreen, diet, obesity, exercise, alcohol, and tobacco Able to tailor pain medication and other interventions for pain to the source and type as well as the severity of pain Able to explain and help patients make decisions about a Living Will, do not resuscitate (DNR) orders, durable Power of Attorney, and an Advance Healthcare Directive

14. Copyright 2008 UC Regents Skills Able to give bad news about second malignancy or relapse; move to an appropriate palliative approach without saying “there is nothing we can do” Able to partner with patients in decision-making, according to what is important to the patient Able to work as the primary care provider with a specialty team, providing continuity of care, and working with family as well as patient Able to get current cancer information for cancer survivors at the appropriate reading level and language (e.g. from the Cancer Information Service and National Cancer Institute)

15. Copyright 2008 UC Regents Assessment Pre and post tests will be done by looking at knowledge, as well as experience and competence in the skills and attitudes

16. Copyright 2008 UC Regents National Coalition for Cancer Survivorship National Coalition for Cancer Survivorship formed in 1986. Its goals today are to identify and address issue that influence quality living for people who have or have had cancer, regardless of the date of diagnosis. It also works to address public policy issues and cancer-related bias through testimony before Congress, media appearances and providing up-to-date information about the legal rights of cancer survivors. It is a clearing house for information, publications and programs and a voice for the many common recurring issues of survivorship. It also advocates for continuing clinical research on the medical and psychosocial impact of cancer and its treatments among long-term survivors. http://cancerresources.mednet.ucla.edu/index.htm