Oncology for Family Medicine Residents Anna N Wilkinson, MD, MSc, CCFP

1.Work up of suspected malignancies 2.Oncology Basics Chemotherapy and Radiation Therapy 3.Oncology Emergencies 4.Survivorship care Ongoing monitoring of patients and management of sfx treatment and longer term drugs Objectives

4. Survivorship Care

 Mrs XX, is returned to your care after treatment for her breast cancer. She received FEC-D chemotherapy, radiation therapy, herceptin, and is now mantained on Femara. She is discharged from the cancer clinic.  What do you need to monitor?? Case 1

 Well follow-up care and rehabilitation following cancer treatment and lasting until recurrence or death from other causes  Usually co-managed by oncologist and family physician  5-year relative survival rate (RSR)  Breast: 88%  Lung: 17%  Colorectal: 64%  Prostate: 96% What Is Survivorship Care?

 All cancer survivors are at increased risk for  New primary cancers  Recurrent cancer  Long-term and late-onset effects from both the cancer and its treatment  Many face an increased risk for other co- morbidities (DM, CV disease) Survivorship Care

 A cancer diagnosis can provide physicians with the opportunity of a "teachable moment”  Healthy diet  Smoking  ETOH consumption  Exercise Survivorship Care

 Screen for depression and anxiety or cancer-related fatigue  Screen for local recurrence or metastatic disease  Screen for new cancers Surveillance

 Symptoms suggestive of distant metastases  Bone pain  Cough  Shortness of breath  Chest pain  Abdominal pain  Nausea  Weight loss  Headaches  Confusion Surveillance

Breast Cancer

 Local recurrence in the ipsilateral breast is expected to occur in ~1% of women annually  New cancer in the contralateral breast is expected to occur in 15% of women within 20 years Breast Cancer

Surveillance Schedule for Breast Cancer Period Post TxFrequency Year 1,2,3Every 3-6 months Year 4,5Every 6-12 months After 5 yearsAnnually  Physical Exam  Include breasts, chest wall, axillae, regional nodes, abdomen, pelvis  Mammography  Begin 6-12 months post treatment, not sooner  Annually thereafter

 Ultrasound of the liver  CT scanning  FDG-PET scanning  Breast MRI  Use of CA 15-3 or CA  CEA testing  Blood work  Chest x-rays  Bone scans Testing NOT recommended for Breast Ca Surveillance

Treatment Side Effects: Breast Cancer  Chemotherapy  Ovarian Failure  30% of woman <25 yrs  90% of woman >35 yrs  Menopausal sx, increased risk osteoporosis  Infertility  Cardiac dysfunction  Especially with anthracyclines and herceptin  “Chemo Fog”  Fatigue  Secondary malignancies  Leukemias  Radiation  Skin Cancers  Pulmonary Fibrosis  Cardiac Dysfunction

Treatment Side Effects: Breast Cancer  Hormonal therapy  Tamoxifen  Increased risk endometrial ca  Increased risk VTE  Vaginal d/c  Flushing and sweating  Positive effect on lipid profile and bone density  Aromatase Inhibitors  Osteoporosis  Arthritis  Arthralgia/Myalgias  Hyperlipidemia

 Lymphedema  Affects 20-30% of woman with axillary dissection  Especially in those woman who received radiation therapy  Rates improving with sentinel node Treatment Side Effects: Breast Cancer

Colorectal Cancer

 80% recurrences occur within the first 2 years  Local recurrence occurs in only 10% of cases  Liver and lungs are the most common sites for metastases to occur Colorectal Cancer

TestRecommendation ColonoscopyAs soon as possible after cancer treatment if complete colonoscopy NOT done at time of dx 1 yr after diagnosis, then in 3 yrs, then q5 yrs CT scanChest, Abdomen +/- Pelvis annually for 3 yrs CEAEvery 3-6 months for at least 5 years SigmoidoscopyEvery 6 months if rectal ca and no RT Surveillance Schedule for Colorectal Cancer

 Expect to see elevated CEA values immediately following surgery and during chemo  CEA returns to normal within 4-6 weeks of successful surgery CEA

 Chest x-ray  PET scans  Ultrasound  Blood work  FOBT Testing NOT recommended for routine colorectal cancer surveillance

Symptoms suggestive of recurrence of Colon/Rectal ca  Abdominal pain, particularly RUQ  Dry cough  Constitutional symptoms  Fatigue  Nausea  Unexplained weight loss  Signs and/or symptoms specific to rectal cancer  Pelvic pain  Sciatica  Difficulty with urination or defecation

Treatment Side Effects: Colon/Rectal Ca  General  Fatigue  Anxiety, depression  Chemotherapy  Peripheral neuropathy  “Chemo brain”  Surgery  Frequent and/or urgent bowel movements or loose bowels (may improve)  Gas and/or bloating  Incisional hernia  Increased risk of bowel obstruction  Adjustment to ostomy (if present)

Treatment Side Effects: Colon/Rectal Ca  Radiation  Localized skin changes  Rectal ulceration and/or bleeding (radiation colitis)  Incontinence  Bowel obstruction (from unintended small bowel scarring)  Infertility  Sexuality dysfunction (e.g., vaginal dryness, erectile dysfunction, retrograde ejaculation)  Second primary cancers in the radiation field (typically about seven years after radiotherapy)  Bone fracture (e.g., sacral)

Lung Cancer

Surveillance schedule for Lung Cancer Period post treatmentHistory and PhysicalImaging Year 1, 2Q 3months CT at 3,6,12,18, 24 months CXR all other visits Year 3Q 6 months CT annually CXR all other visits Year 4+Annually CT annually  Smoking Cessation!!!

 Constitutional symptoms  Dysphagia  Fatigue (new onset)  Nausea or vomiting (unexplained)  New finger clubbing  Suspicious lymphadenopathy  Sweats (unexplained)  Thrombosis  Weight loss or loss of appetite Symptoms suggestive of recurrence of Lung ca

 Pain  Bone pain  Chest pain  Shoulder pain not related to trauma  Neurological symptoms  Persistent Headaches  New neurological signs suggestive of brain metastasis or cord compression such as leg  Weakness or speech changes  Headache or focal neurological symptoms Symptoms suggestive of recurrence of Lung ca

 Respiratory symptoms:  Cough (despite use of antibiotics)  Dyspnea  Hemoptysis  Hoarseness  Signs of superior vena cava obstruction  Stridor  If disease recurrence is suspected, CT Chest with contrast including upper abdomen should be done. Symptoms suggestive of recurrence of Lung Ca

Treatment Side Effects: Lung Ca  Constitutional Issues  Anxiety  Cough  Decline in appetite  Decrease in general health  Depression  Dysphagia  Esophageal stricture  Fatigue  Pain  Physical ability restrictions  Reduced sleep quality  Shortness of breath  Long -Term Chemotherapy Effects  Hearing loss  Neuropathies  Renal impairment

Treatment Side Effects: Lung Ca  Long-Term Radiation Effects  Breathing complications (fibrosis, strictures)  Breathlessness/Dyspnea  Long-Term Surgery Effects  Empyema  Oxygen dependence  Post-thoracotomy pain syndrome  Reduced exercise tolerance or activity limitations  Shortness of breath

Prostate Cancer

Type of TreatmentPSA SurgeryEvery 3 months in year 1 Every 6 months in year 2 Annually thereafter XRT6 months after treatment completion Every 6 months until end of year 5 Annually thereafter PSA Monitoring Use discretion in discontinuing monitoring for those patients who would not be appropriate for further treatment More frequent monitoring required if PSA becomes detectable

 Radical prostatectomy  PSA should decline to zero within 3-6 weeks  External Beam XRT  PSA should drop to a “nadir” level, generally between 0.2ng/mL and 0.5 ng/mL  3 months post XRT, PSA should be half of pretreatment level  It can take as long as 18 to 36 months to reach the nadir  Nadir level is predictive of treatment success  A “PSA Bounce” can be seen: as much as 5% increase in PSA in up to 30% of patients, as long as 60 months after treatment PSA

 Increasing PSA after curative treatment, without any evidence of recurrent disease is called a “Biochemical Recurrence (BCR)”  Not all men with BCR will go on to develop metastatic disease  The velocity at which the PSA rises “PSA doubling time (PSADT)” is one of the best predictors of mortality  PSADT >12 months: likely local recurrence  PSADT <6 months: likely metastatic disease  Bone Mets are rarely present with PSA<20 PSA Kinetics

 Bone Scan  CT  ??MRI?? – only if local salvage planned after previous radiotherapy Workup with biochemical recurrence

Symptoms suggestive of Prostate Ca recurrence  Severe and progressive axioskeletal bone pain  Weight loss  Leg Edema  New Urinary symptoms  Hematuria  Incontinence  Urgency  Obstructive symptoms  Voiding discomfort  Nocturia  New Bowel Symptoms  Rectal bleeding  Rectal pain  Urgency  Change in bowel movement  Fatigue  Tiredness unrelated to sleep disturbance  Physical, emotional and/or cognitive exhaustion

Treatment Side Effects: Prostate Ca  Sexual Dysfunction  Erectile Dysfunction  Loss of Libido  Anorgasmia  Dry Ejaculate  Penile shortening or curvature  Infertility  Urinary Dysfunction  Obstructive sx  Urgency  Hematuria  Incontinence

Treatment Side Effects: Prostate Ca  Bowel Dysfunction (RT)  Rectal Bleeding  Urgency and frequency  General  Anemia  Fatigue  Gynecomastia  Hot flushes  Osteoporosis  Depression/anxiety  Cognitive slowing  Worsening of lipid profile

 Mrs. XX post breast cancer tx  Surveillance for dz recurrence  Surveillance for sfx of tx  Cardiotoxicity  Lymphedema  Depression/anxiety/fatigue  Surveillance for sfx of ongoing tx  BMD  Lipid profiles Case 1

 6 month FP Oncology program  Rotations in  Palliative care  Medical oncology inpatients  Medical oncology outpatients  Gyne oncology  Hematology  Radiation oncology PGY-3 FP-Onc program

 Cancer Care Ontario   National Comprehensive Cancer Network   Wilkinson et al, Can Fam Physician Feb; 54(2): 204–210 References