Anna C Beck, MD Supportive Oncology & Survivorship Huntsman Cancer Institute University of Utah Humpty Dumpty & Surviving Cancer

Sadly, I have nothing to disclose

So…..why do we need survivorship care anyway?

The Michigan Daily News Nov 20, 1984

De Moor J. Cancer Epid Biomarkers Prev 2013

“It is too easy to be overwhelmed or paralyzed by the comprehensive recommendations of the IOM report— these were lofty goals that were set forth without a detailed game plan for implementation.” Earle JCO 2012

Cancer’s legacy AICR, 2015 Obesity Type 2 Diabetes Heart disease Other cancers Infertility Osteoporosis

Unique health issues  long term morbidity and premature mortality Earlier onset of aging, unusual presentations and  risk of aging related conditions Less robust response to treatments Coexisting morbidities in the elderly may be exacerbated

The Survivorship Care Plan Provide patients and their clinicians with a personalized treatment summary Possible late and long term effects Follow up care guidelines Identification of providers Recommendations for healthy living Available supportive care resources

SCP: Problems Time consuming! – Chart abstraction – Validating – Transfer of information in an accessible format – Takes minimum of 30 minutes, often more than an hour Even at NCI designated cancer centers – Treatment summaries completed 46% – Survivorship care plan 59% (Stricker,J Cancer Surviv, 2011)

Who should own this? Oncologists? Pros Most familiar with – Survivorship issues – Long term toxicities – Appropriate surveillance Established patient relationship – Avoids anxiety of disturbing – Less coordination of care – Carry more authority Cons Time – Too complex – Already overwhelmed with care of treatments Not well reimbursed Shortage of oncologists

How about primary care? Pros Generalists background well suited Background in geriatrics Better geared for ongoing management of chronic problems More convenient Knows patient/caregiver Con s Numbers are diminishing too! Not as well accepted by patients Not as well exposed to survivorship data – Have to compete with medicine general literature Not as cost effective or as reliable for surveillance

NP or PA? Pros More time available Can bill for services Generalist background No shortage of providers Can work collaboratively with oncologists Cons Will require coordination of care between specialties/primary care Reimbursement is less than MD for complex care

Models of Survivorship Care Consultative – One time consultation – Tailored information, referral to specialists – Returns to PCP Longitudinal – Ongoing symptom assessment – Surveillance for disease recurrence a/o secondary malignancies – Counseling and feedback regarding lifestyle modifications

Breast team 36 providers 5 use the SCP 100% noted time was a barrier, and that EMR should have been more helpful Excuses – Should be completed by another type of provider – Need more education on how to complete – Don’t agree with material in SCP

What do survivors want? Documentation of where I’ve been What can I expect in my future? – When will the neuropathy go away? – When will my hair grow back? – How often do I need scans? – When can I say that I am cured? – When will I enjoy intercourse again? Is this covered in the SCP?

Get Cancer

Utah Survivors and QOL Provided by Meghan Balough Utah Cancer Control Program

Making survivorship care count:

Case for cancer rehab

Does physical activity affect chances for cure? Breast – 5 prospective cohort studies increased physical activity was associated with better outcomes Colon – 3 prospective cohort studies show a 50% decrease in cancer specific and overall mortality Uterine, lung, prostate

Survivor Health Threats AICR, 2015 Obesity Type 2 Diabetes Heart disease Other cancers Infertility Osteoporosis

Obesity is the new tobacco

WCRF Policy Report 2015

For the millennials…

Exercise may reduce risk of 2 nd cancers Reduces adipose tissue – Decreased insulin, growth promoting cytokines How can I improve my immune system?

Colon cancer and exercise 30-40% reduction 30 to 60 minutes a day Energy balance, immune function, transit time

Breast cancer and exercise 20-80% reduction Pre- and post- menopausal benefit 30 to 60 minutes a day Lowers hormone levels, insulin, fat tissue, improves immune system

Uterine cancer and exercise 20 to 40% reduction More exercise, greater benefit Reduced levels of estrogen

Lung cancer and exercise 20% reduction in risk ? Effects of smoking

Stress reduction measures Post traumatic stress disorder Mindfulness, CBT and yoga have all been shown to improve QOL and perhaps survival

Thinking ahead

Caregivers Stress for all Risk reduction behaviors Genetically related Social media Wellness programs ACP