1. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

2. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. in the clinic Care of the Adult Cancer Suvivor

3. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What are the essential components of follow-up care?  Prevent recurrent and new cancers and other late effects  Monitor for cancer spread, recurrence, or 2 nd cancers  Assess medical and psychosocial late effects  Manage consequences of cancer and its treatment  Coordinate with other doctors so all health needs met  Provide routine health promotion

4. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. When should patients transition to follow-up care?  Sooner  If early-stage or low-risk for late effects + recurrence  Later  If high risk for late effects + recurrence  Communication + cooperation is critical  Oncology team should provide care recommendations  Primary care doctor should manage comorbid conditions + provide health maintenance (even if no transition occurs)

5. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Which types of clinicians should provide follow-up care?  Historically: oncologists  Focus on surveillance for disease recurrence  Newer approach: shared care model  Oncology and primary care teams work together  Oncologists lead in coordinating care  Focus: health promotion + managing comorbid conditions

6. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What information should clinicians have when follow-up care begins?  Treatment summary  Type and location of cancer and type of surgery  Drug names and cumulative doses of chemotherapy  Types and cumulative doses of radiation therapy  Survivorship care plan  Describes follow-up scans, lab tests, office visits  Identifies potential late effects + surveillance specifics  Contains other, individualized information

7. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Transition to Follow-up Care...  Timing varies for transition from oncology care to primary care  Shared care model is optimal  Information needed for follow-up care  Treatment summary  Survivorship care plan  Communication and collaboration among providers is critical

8. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What cardiac issues should the clinician consider?  Vascular disease  Hypertension  Myocardial dysfunction  Consider the following actions  Check lipids, thyroid function, BP, weight  Ask about additional familial risk for CV disease  Do a stress ECHO if symptoms are present

9. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What pulmonary conditions should the clinician consider?  Bleomycin-induced inflammation of lung (pneumonitis)  Dose-dependent, reversible acute toxicity  Increased risk of anesthetic complications  Radiation-induced pneumonitis  Reversible with corticosteroid therapy  Manifests many years after treatment  Ask about exercise endurance, respiratory symptoms

10. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What cognitive issues should the clinician consider?  Cognitive changes from chemo and endocrine therapy  Breast cancer, ovarian cancer survivors  Leukemia, lymphoma survivors  Prostate cancer survivors (androgen-deprivation Rx)  With whole-brain radiation, changes may be delayed  Cause may be difficult to determine  Aging, depression, or stress — or cancer Rx itself  Combination of these factors  Neuropsychological testing may help define symptoms

11. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What sexual and reproductive issues should the clinician consider?  Women  Menopausal symptoms: chemotherapy or pelvic radiation  Infertility: gynecologic surgery, radiation, chemotherapy  Men  Hypogonadism from some hormonal drugs, chemotherapy, bilateral orchiectomy, or pelvic / cranial radiation  Infertility from testicular cancer, systemic chemotherapy, radiation; pelvic and retroperitoneal surgery  Both Women and Men  Psychological issues can cause sexual dysfunction  Anatomical injury can directly cause dysfunction

12. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What bone health issues should the clinician consider?  Osteoporosis ( Screen for bone loss with DEXA scans)  Surgical oophorectomy / orchiectomy  GnRH agonists / antagonists  Chemo-induced ovarian failure  Aromatase inhibitors  Avascular necrosis of any joint  Corticosteroids can affect blood supply  If patient reports joint pain, consider MRI

13. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What other medical issues should the clinician consider?  Second malignant neoplasms  Endocrinopathies  Neurotoxicity, ototoxicity, nephrotoxicity  Lymphedema

14. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Are there specific medical issues for survivors of the most common cancers?  Lung cancer  Decreased pulmonary reserve  Smoking cessation reduces risk for new cancers  Colon cancer  Second malignant neoplasms  Life-altering issues with weight, continence, or bowels  Breast cancer  Second breast cancers  Premature ovarian failure; lymphedema  Cardiac toxicity (from chest radiation and some chemo)  Prostate cancer  Erectile dysfunction; symptoms from androgen ablation Rx  Urinary incontinence; GI symptoms related to proctitis

15. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Are there common medical issues for survivors of lymphoma, leukemia, and hematopoietic cell transplantation?  Late effects of chemotherapy or radiation  Second malignant neoplasms  Cardiac effects  Lifelong immunodeficiency and increased infection risk  Hypoglobulinemia  Functional asplenia  Chronic graft-vs-host disease  From allogeneic hematopoietic cell transplantation

16. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Are there specific medical issues for survivors who were treated with surgery, radiation therapy, or chemotherapy?  Depends on the dose and field of radiation therapy  Depends on specific agents and doses of chemotherapy  Chest radiation therapy: surveillance for breast cancer; thyroid testing; cardiac evaluation  Chest radiation or doxorubicin: ECHO; yearly lipid screen  Anthracyclines + chest radiation: cardiac dysfunction risk  Childhood cranial or craniospinal radiation: assess for cognitive, fertility, other endocrine issues  Major abdominal or pelvic surgery or radiation: risk for wide array of issues many years after treatment

17. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Follow-up Medical Care...  Know the risks for treatment-related medical effects  Collaborate with oncologists to optimize care  Use the summary of cancer treatment to guide follow-up care  Monitor for late medical effects of treatment  Fertility  Bone health  Cardiac, pulmonary, cognitive, and sexual functioning  Secondary malignancy

18. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Who provides surveillance for recurrent cancer and secondary cancers?  Follow-up care clinician if patient has transitioned  Communicate with oncologists, seek guidance when needed  Schedule appropriate surveillance and screening  In the shared care model, assign responsibility to the oncologist or the primary care physician

19. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What about pain and fatigue?  Pain and fatigue are associated with…  Sleep disturbance, menopausal symptoms, anxiety, depression  Distinguish survivors from those in active treatment  Cancer survivors report few physical symptoms after treatment  Management can be difficult  If the cause is uncertain, involve the oncologist  If the problem is a chronic treatment effect, refer patient to pain management team  Consider the possibility of psychosocial factors

20. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What about psychological and emotional problems?  Oncologists often prescribe medications for sleep problems, anxiety, and depression during treatment  Many patients remain on them after treatment  Evaluate and manage as you would in any other patient  Refer to appropriate mental health practitioners  Concerns about cancer recurrence may be high  Suicidal ideation may be increased

21. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What is the role of exercise and rehabilitation?  Maintains healthy body composition and image  Improves quality of life, and aids in managing fatigue, mood disorders, and sleep problems  The goal is a return to normal activities  Low- to moderate-intensity activity doesn’t usually require formal evaluation  For more vigorous exercise, follow guidelines for exercise testing before starting

22. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What is the role of complementary and alternative medicine?  Can help survivors take active role in improving health  The emphasis on QOL improves mental outlook  Acupuncture, meditation, yoga, dance therapy, art therapy  Improve menopausal symptoms  Relieve fatigue, pain, and sleep problems  Help manage fear of recurrence and reduced QOL from long- term treatment

23. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What about employment, insurance, and disability?  Personal and work lives are affected by cancer  Survivors may hesitate to disclose their diagnosis because of concerns about  Employment and work advancement  Insurance  Personal relationships  Be prepared to discuss these issues

24. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Additional Issues in Follow-up Care…  Care for cancer survivors can be complicated and challenging  Provide surveillance and screening for cancer recurrence  Ensure social, psychological, and economic well-being  Be familiar with available resources  Provide referrals as indicated  PT and OT for neurocognitive evaluations  Acupuncture and other supportive services  Pain management teams  Social service agencies