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Cancer Survivorship Erika L. Rager, MD, MPH FPN Breast and Melanoma Specialists Medical Director, Breast Program Medical Director, Cancer Quality of Life
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American Cancer Society. Cancer Treatment and Survivorship Facts and Figures 2016-2017. Atlanta: American Cancer Society; 2016
Cancer Survivors
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Survivors, by Site
breast 22%prostate 19%colorectal 10%gyn 9%heme 7%urinary tract 7%melanoma 7%lung 3%other 16%
Source: NCI SEER
Cancer Survivors
• More than 66% of patients diagnosed with cancer will be alive in 5 years.
• Increasing number of survivors attributable to: Better screening Better treatment Aging population
• Current follow up care often does not meet
recommendations Underuse of appropriate screening Overuse of testing for metastatic disease
4 Earle et al. Underuse of necessary care. Cancer. 2004.
Cancer Survivors
• Cancer survivors are less likely to get general medical and preventive care.
• Poorly controlled diabetes and hypertension, heart failure and chronic lung disease.
• Less likely to get screenings Breast cancer survivors have lower rates of colorectal and
cervical cancer screening than the general population.
• More likely to smoke
5 Earle et al. Underuse of necessary care. Cancer. 2004.
Opportunities to Improve Care
• “Teachable moment” for patients.
• High level of interest in health behavior changes: Smoking cessation (60%) Diet (54%) Exercise (51%)
• Only 20% of oncologists routinely offer health promotion
guidance.
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Demark-Wahnefried et al. Riding the crest of the teachable moment. JCO. 2005
LIVESTRONG Survivor Survey
• Survey of cancer survivors
• In 2006, N=2307 • In 2010, N=3129
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LIVESTRONG Report 2010
Long term and late effects
• Long term Arise during treatment and remain problematic
• Late effects Come on months or even years after treatment has ended
• Examples: Chronic pain Cognitive problems Cardiac damage Decreased bone density Decreased lung function Lymphedema Sexual problems
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Survivorship in Older Adults
• Aging population 2008: 13% of UD adults aged
65 or older 2030: 19.3%
• 80% have at least one chronic
health condition, 50% at least 2 HTN, arthritis, cancer, diabetes
• Greater risk of developing
subsequent cancers 10-12% of survivors over age 60
have more than one cancer.
9 Parry C et al. Cancer Epidemiol Biomarkers Prev 2011;20:1996-2005.
Adolescent and Young Adult Survivors
• Aged 15-29 at time of diagnosis
• Most healthcare provided by PCP’s, not oncologists
• Most common diagnoses: Lymphoma Leukemia Melanoma Cervical cancer Testicular cancer Thyroid Brain Breast Colorectal
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Adolescent and Young Adult Survivors
• At risk for late effects of treatment, recurrence, second malignancies
• Higher prevalence of unhealthy behaviors Current smoking (26% vs 18%) Obesity (31% vs 27%)
• Higher prevalence of chronic conditions CV disease (14% vs 29%) HTN (35% vs 29%) Asthma (15% vs 8%)
• Higher prevalence of other problems Disability (36% vs 18%) Poor mental health (20% vs 10%) Poor physical health (24% vs 10%) Not receiving care due to cost (24% vs 15%)
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Tai E et al. Cancer 2012.
Cancer Caregivers
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American Cancer Society. Cancer Treatment and Survivorship Facts and Figures 2016-2017. Atlanta: American Cancer Society; 2016
Transitions of Care
• More than half of PCP’s rate transitions of care as fair to poor
• More than 90% report a care plan is helpful
• Over 70% would like more CME on care of cancer patients
• Only 24% of PCP’s provide multidimensional
survivorship care. Barriers include: Lack of well defined guidelines Inadequate preparation for managing effects of treatment
13 Bober et al. Caring for Cancer survivors. Cancer. 2009.
Recommendations to Improve Communication
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CA Cancer J Clin 2017;67:156–169. 2016 American Cancer Society.
Care Plan
• For post-treatment cancer survivors
• Treatment summary
• Possible future symptoms or side effects • Details about follow up
What to do Who to see
Information about healthy living
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LIVESTRONG Report 2015
Care Plan
• 68% use it to understand treatments
• 61% use it to plan follow up care
• 58% use it to understand side effects
• 58% use it to understand health behaviors
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LIVESTRONG Report 2015
References
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American Cancer Society. Cancer Treatment and Survivorship Facts and Figures 2016-2017. Atlanta: American Cancer Society; 2016 Earle et al. Underuse of necessary care. Cancer. 2004 Demark-Wahnefried et al. Riding the crest of the teachable moment. JCO. 2005 Parry C et al. Cancer Epidemiol Biomarkers Prev 2011;20:1996-2005 American Cancer Society. Cancer Treatment and Survivorship Facts and Figures 2016-2017. Atlanta: American Cancer Society; 2016 Bober et al. Caring for Cancer survivors. Cancer. 2009. CA Cancer J Clin 2017;67:156–169. 2016 American Cancer Society.