1. Caring for patients in primary care after cancer treatments are done Moving Forward after Cancer Moving Forward after Cancer

2. Developed by: Brent Kvern MD, CCFP, FCFP Associate Professor, Department of Family Medicine, University of Manitoba Jeff Sisler MD, MClSc, CCFP, FCFP Director - Primary Care Oncology, CCMB 2

3. Conflict of Interest Disclosure  No consultant or speaker fees  Received a grant from the Canadian Partnership Against Cancer to develop this session

4. A question… A 61 year old patient of yours who completed treatment for breast cancer 3 months ago is your next patient. A 61 year old patient of yours who completed treatment for breast cancer 3 months ago is your next patient. What is on your mental “to-do” and “to-talk- about” list for this and upcoming visits? 4

5. 5 Define survivorship phase of cancer. Define survivorship phase of cancer. Apply a new framework to consider the care needs of cancer patients in follow-up Apply a new framework to consider the care needs of cancer patients in follow-up Be familiar with important tasks in breast and colorectal cancer follow-up care Be familiar with important tasks in breast and colorectal cancer follow-up care Objectives

6. 1 Bell K, Scalzo K, Stephen J, BC Cancer Agency, 2007 6 Cancer Survivorship A distinct phase in the cancer trajectory following primary treatment, lasting until recurrent or end-of-life. 1 Diagnosis Acute Phase Survivorship or Chronic Phase

7. The survivorship phase Number of adult cancer survivors is > 1 million and will double by the year 2050 7 Age of cancer survivors 2

8. 8 A new perspective  Think about patients who’ve finished cancer treatment like your patients with a recent MI

9. 9 A new perspective  Survived something potentially lethal  Need close monitoring for recurrence.  Need an aggressive approach to risk reduction  Lifestyle issues very important  Your role as a FP/NP is critical to rehabilitation

10. 10 4 essential physician tasks Our framework of survivorship HEALTH PROMOTION / PREVENTION FAMILY CANCER RISKS CANCER RELATED MONITORING MANAGEMENT P 2 FRiM 2

12. 12 Health Promotion Prevention  Promotion of healthy behaviours  Screening for new cancers  Age appropriate screening for other medical conditions

13. 13 Family Cancer Risks Assessing the risk of family members Modifying THEIR risk factors Modifying THEIR risk factors Recommending a screening plan Recommending a screening plan Referring for genetic testing Referring for genetic testing Assessing family and marital health

14. 14 Monitoring Watching for recurrence of the primary cancer Watching for recurrence of the primary cancer Monitoring for worrisome “late effects” Monitoring for worrisome “late effects” – Cardiomyopathy Monitoring rehabilitation and recovery Monitoring rehabilitation and recovery

15. 15 Management  Side-effects of cancer treatments Physical Physical Psychological Psychological Social Social  Ongoing care for any non-cancer conditions

16. 16 Colorectal Cancer Sunga AY, et al. Am Fam Physician, 2005

17. 17  Most recurrences in the first 3 years Liver – most common site metastases o 20% of those with liver metastases are candidates for resection 10%- local recurrence at original site 30% - no rise in CEA No delayed / late effects of chemotherapy Colorectal cancer Background information

18. 18  Exercise 4 hours a week of activity associated with 53% reduced recurrence and CRC mortality regardless of stage, age, BMI or previous activity level.  Smoking Cessation  Medications for secondary prevention No role yet for NSAIDs, ASA  BMD of hip if pelvic radiation therapy given Colorectal cancer Health promotion & prevention

19. 19 Colorectal cancer Family Cancer Risks

20. If index patient is diagnosed… Recommendations Before age 60 yearsAll asymptomatic 1 st degree relatives, starting at age 40 (or 10 years earlier than patients age at diagnosis) need colonoscopy Q5 years After age 60 yearsAll asymptomatic 1 st degree relatives, starting at age 40 yrs are at slightly above average risk. FOBT Q2 years followed by colonoscopy if any one sample if positive. After age 60 years & another 1 st degree relative also has a diagnosis of CRC at any age All asymptomatic 1 st degree relatives, starting at age 40 (or 10 years earlier than patients age at diagnosis) need colonoscopy Q5 years Family history of known hereditary syndrome Referral for specialist assessment

21. 21 Colorectal cancer Monitoring

22. Monitoring Visit frequency Q3 months for 3 years following treatment Q6 months for next 2 years Annually thereafter Test to DO CEA at each visit for first 3 years CT chest and abdomen – annually for first 3 years Colonoscopy – 1 year after initial diagnostic scope, then at 3 years, then every 5 years afterward Tests NOT TO DO routine CBC, LFTs routine CXR FOBT

23. 23  Cancer related fatigue Consider other etiologies Physical activity works!  Peripheral neuropathy from oxaliplatin  Radiation proctitis  Diarrhea  Sexual dysfunction Colorectal cancer Management

24. 24  Anxiety Consider possibility PTSD like reaction  Employment difficulties  Insurance difficulties  Social well-being “How are things going between you and your partner?” Colorectal cancer Management

25. 25 Breast Cancer Sunga AY, et al. Am Fam Physician, 2005 Non survivors 12% 5 year survival rates

26. All Oral Cancer Treatments now fully covered!  Tamoxifen and AIs free for patients as of April 19, 2012  Existing patients should already be identified by the DPIN system  Pharmacare registration needed Call the Provincial Drug Program at 786- 7141 or 1-800-297-8099 Call the Provincial Drug Program at 786- 7141 or 1-800-297-8099  Help! ? Call the CCMB Pharmacy at 787-4591

27. 27  Recurrences usually occur within five years. Peaks at 2 nd yr after surgery o Risk declines with time but continues for at least 20 years. Non-specific symptoms are common indicators of relapse o Weight loss / Persistent cough / Breast changes / Chest wall changes / Adenopathy 75% recurrences found by the women themselves Breast Cancer Background information

28. 28  Exercise Cohort studies suggest a 50% survival advantage for breast cancer survivors over those not physically active Most beneficial in ER+ tumours Most beneficial in ER+ tumours  Diet  Medications for secondary prevention Tamoxifen, aromatase inhibitors (AIs)  BMD and/or bisphosphonates if AIs used Breast cancer Health promotion & prevention

29. 29 Breast cancer Family Cancer Risks

30. Inherited Risk for Breast Cancer Mutations of BRCA1 or BRCA2 cause about 5-10% of breast cancers Usually cancer occurs early in life. Strong family history Criteria for referral for genetic counselling Breast cancer at age <35 yrs Bilateral breast cancer at age <50 yrs Ovarian cancer <60 yrs Breast and ovarian cancer <50 yrs Two or more ovarian cancers, any age Male breast cancer Ashkenazi Jewish or Icelandic descent If patient BRCA +ve Family members need to know Initiate screening at age 25 with MRI (or five years younger than earliest reported cancer in the family)

31. 31 Breast cancer Monitoring

32. Monitoring Visit frequency Careful history and physical exam Q3 -6 months for 3 years Q6-12 months for next 2 years Annually thereafter Test to DO Mammograms annually for life. Tests NOT to do routine CBC, LFTs routine CXR routine bone or liver scans routine tumour markers

33. 33  Breast cancer survivors have an increased risk of a second primary cancer Often involving ipsilateral breast contralateral breast colon? Breast cancer Monitoring

34. Monitoring Congestive Cardiomyopathy From anthracyclines (doxorubicin, epirubicin, trastuzumab) Can present 10-15 years after chemo Be alert for CHF symptoms Myelodysplasia or Leukemia Associated with cyclophosphomide Rare No screening recommended.

35. 35  Cancer related fatigue Rule out other etiologies (drugs, depression, cardiac, thyroid, anemia) Physical activity, yoga  Menopause Related to chemotherapy Retrospective studies have not shown harm with HRT no RCT has been performed to allow confident use  Osteoporosis Check for AI use Breast cancer Management

36. TamoxifenHot flashes and night sweats SSRIs can partially alleviate Avoid paroxetine, fluoxetine, bupropion Venlafaxine drug of choice Aromatase inhibitors Anastrozole Letrozole Exemestane Post-menopausal women only Arthralgias and aches: NSAIDs, time Switch to a different AI or Tam if not tolerable

37. 37  Peripheral neuropathy  If treated with taxanes (docetaxel)  Use gabapentin*, pregabalin, tricyclics*  Post treatment cognitive impairment or “Brain fog” Rule out or address other aetiologies (drugs, depression)  Chronic Pain Breast cancer Management

38. Breast cancer Management   Sexual dysfunction   Anxiety Fear of recurrence: Consider CBT   Employment and insurance difficulties   Social wellbeing “How are things going between you and your partner?”

39. 39 In closing: Caring for Cancer Survivors  A distinct phase in the cancer continuum.  Increasingly a responsibility of primary care  Cancer survivors are at increased risk – think of them like post-MI patients

40. 40 4 essential physician tasks Our framework of survivorship HEALTH PROMOTION / PREVENTION FAMILY CANCER RISKS CANCER RELATED MONITORING MANAGEMENT P 2 FRiM 2

41. Dr Jeff Sisler jeff.sisler@cancercare.mb.ca Questions? Call the UPCON Helpline at (204) 226-2262 Moving Forward after Cancer Moving Forward after Cancer