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.

Transitions of Care

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CA Cancer J Clin 2017;67:156–169. 2016 American Cancer Society.

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

Sample Care Plan

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Sample Care Plan

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Sample Care Plan

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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.