Am 11.30 grunfeld

Care of the Cancer Survivor

Eva Grunfeld, MD, DPhil, FCFP

Ontario Institute for Cancer Research, andDept of Family and Community Medicine,

University of Toronto

No conflicts of interest

Objectives of the Presentation

1. Definition and epidemiology of cancer survivors

2. Overview of cancer-related healthcare needs of cancer survivors

3. Overview of general medical and preventive healthcare needs of cancer survivors.

4. Review the role of PCPs and survivorship care plans

5. Conclusions



2. Overview of cancer-related care needs of cancer survivors

3. Overview of general medical and preventive care needs of cancer survivors.

4. Review the role of PCP and survivorship care plans

5. Conclusions

Definitions of Survivorship

From the time of diagnosis through the remaining years of life.

National Action Plan for Cancer Survivorship, Centers for Disease Control and Lance Armstrong Foundation,

USA, 2004

versus The period following first diagnosis

and treatment and prior to the development of a recurrence of cancer or death.

Source: From Cancer Patient to Cancer Survivor,

Institute of Medicine, USA, 2006

Cancer Care Trajectory

Source: IOM, 2006

Source: J. Natl. Cancer Inst. 2008 100:236; doi:10.1093/jnci/djn018

Breast Cancer:Conditional relative

survival

Source: IOM Report, 2006

Colorectal Cancer: Conditional relative survival

Source: IOM Report, 2006

Summary

50% of cancer patients will be long-term survivors

Breast and colorectal are among the most prevalent cancers

Between 60 to 80% are long-term survivors

approximately 3% of the population are cancer survivors

most are elderly and most have multiple comorbidities



2. Overview of cancer-related healthcare needs of cancer survivors (focus on breast and colorectal cancers)

3. Overview of general medical and preventive healthcare needs of cancer survivors.


5. Conclusions

Case : Breast Cancer

Your patient is a 48 y.o. with T2N1M0 carcinoma of the left breast. Primary treatment consisted of lumpectomy, chemotherapy, and radiotherapy. She is on extended adjuvant treatment with an aromatase inhibitor.

Now what?Her oncologist recommends the following protocol for

follow-up:Visits every 3-4 months for 10 yearsAnnual CT and bone scanCBC, LFTs each visitTumour markers (CA-15, CA-27, CEA) each visitBilateral mammogram biennially (as per screening

recommendations) Do you agree?

Survivorship Issues

Routine follow-up care Surveillance for recurrence Surveillance for late effects of treatment Surveillance for new primary cancer Psychosocial issues Special concerns

(social/economic/occupational)

General medical and preventive care

Special Issues

Ongoing adjuvant hormonal therapy

Weight control Lymphoedema Menopausal Symptoms Osteoporosis Cognitive functioning Psychosocial functioning

Breast Cancer: surveillance for recurrence

Distant recurrences occur within 5 yearscan occur 10 years

Most frequent sites of recurrence:breast, bone, liver, lungs

69% of recurrences are interval events and present with signs or symptoms, not routine tests Source: Grunfeld et al., BMJ, 1996

Diagnosis of RecurrenceInterval or symptomatic (%)

Tomlin 1987 64 Zwaveling 1987 73 Rutgers 1989 77 (distant) Ciatto 1985 58 Ormistan 1985 78 Valagussa 1981 78 Stierer 1989 40 (distant) Pandya 1985 54 Scanton 1980 73 Winchester 1979 91 Grunfeld 1997 69* Woster 1995 77* Donnelly 2002 74* te Boekhorst 2001 63

* Identified as interval event Source: Tomiak, Ann Oncol, 1993

Adjuvant hormonal treatment

Extended adjuvant treatment with Aromatase Inhibitors (AI) and/or Tamoxifen (for hormone receptor +ve)

Several scenarios: immediate Tam (maximum of 5 years) immediate AI (maximum of 5 years) AI after 2 to 3 years, or after 5 years of

Tamoxifen AI followed by 2nd AI AI for postmenopausal only s/e = loss of BMD, fracture (2-4%), bone/joint pain

Tam for pre, peri, or postmenopausal s/e = uterine cancer (1%), hot flashes, DVTs (1-2%)

Source: Burstein, J Clin Oncol, 2010

Breast Cancer:ASCO Guidelines for Follow-

Up History and physical, including breast

examEvery 3 to 6 months for Years 1-3Every 6-12 months for Years 4-5Annually thereafter

Annual mammogram, unless otherwise indicated

Other lab tests and scans NOT recommended in asymptomatic patients

Source: Khatcheressian et al., JCO, 2006

Surveillance Mammography

PurposeDetection of ipsilateral recurrenceDetection of contralateral new primary

RCTs of follow-up regimens control for mammography

Guidelines recommend annual

Source: Grunfeld, Noorani et al., The Breast, 2002

Prevalence of Late Toxicities

Common Less Common

Premature menopause

Depends on age and regimen; 70% of women over 40 CMF

Cardiovascular Disease

CHF 1-5%

Hot flashes 40-50% Second Primaries

Leukemia 1-2%

Weight gain 50% gain 6-11 lbs; Endometrial cancer <1%

Fatigue 30% 1-5 yrs Sarcoma <1%

Cognitive Impairment

30% Bone health 2% fracture on AI

Lymphedema 12-35% Blood clots 1-3%

From Cancer Patient to Cancer Survivor, IOM Report 2006

Outcomes related to exercise

in breast cancer survivors

Level of Exercise (MET hours/week)

Source: Adapted from Holmes et al., 2005

Outcomes related to weight gain

in breast cancer survivors

Change in Body Mass Index (BMI)

Source: Adapted from Kroenke et al., 2005

Case: Colon Cancer

Your patient is a 65 year old otherwise healthy woman who has just completed adjuvant chemotherapy for Duke’s C colon cancer.

She wants to know what happens now. She asks you:- how often do I need to see the doctor?- do I not to go to the oncologist or my PCP?- what kind of regular tests do I need?- what problems should concern me?

What do you tell her?

Colorectal Cancer: surveillance for recurrence

early stage – 90% 5 year survival Stage III – 65% 90% of recurrences in first 5 years most common sites

liver, lung, local, abdomen Metachronous new primary

3 to 5% in first five years Meta-analysis of RCTs show that

intensive follow-up results in improved survival

Colorectal Cancer:ASCO Guidelines for

Follow-upASCO 2005 update

History and physical: - q 3 to 6 months x3 years; q 6 months years 4+5 CEA

- q 3 months ≥ 3years; if stage II or III, eligible for Sx or CTx

LFTS, FOBT, CBC - no CT chest and abdo; CT pelvis for rectal cancer - annual if eligible for Sx or CTx Colonoscopy - perioperative; year 3; year 5; more frequently if polyps






5. Conclusions

Cancer prevalence by age

0.6% 0.9% 1.4%2.2%

3.5%

5.4%

8.0%

11.3%

14.8%

17.8%

19.3%18.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Percentage

30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Age

Number of comorbidities by age

6.4 4.6

21.1

13.68.8

22.5

19.2

15

18.4

20.1

16.9

12.7

12.5

16.4

16.1

12.824.3

38.6

55-64 65-74 75+Age

Percentage

0 1 2 3 4 5

Severity of comorbidity by cancer site

45.5

55.3 53.6 52.246

3831.2 30.6

29.8

31.627.6 27.3

29.8

32.9

29.328.6

17.3

10.313.3 16.1

17.320

25.4 28.8

7.42.9 5.5 4.4 6.8 9

14.2 14.1

All PatientsProstate

Breast

GynecologicalHead and NeckDigestive System

Lung

Urinary System

Percentage

None

Mild

Moderate

Severe

Competing Causes of Death

Yancik, R. et al. JAMA 2001;285:885-892. Source: Yancik et al., JAMA, 2001p 30 months

General Medical and Preventive Care

Management of comorbid conditions heart disease, diabetes

Early diagnosis of chronic diseases Preventive health care

Screening for other primary cancersnew breast primary, colorectal cancer,

ovarian cancer

Screening for other chronic diseasesosteoporosis, hypertension,

hyperlipedemia

Never screened over 4 years

1. Females age 50-69

2. Females age 20+

3. Age 50 to 74; FOBT, Barium enema, sigmoidoscopy or colonoscopy

4. Size of sample varies based on age/sex eligibility for screening modality

Source: Grunfeld et al., Can Fam Phys In Press

Screening

Index Cancer 4 %

Breast (n=11,219 )

Hodgkin’s Lymphoma (n=2,322)

Endometrial (n=3,473)

Colorectal (n=1,833)

Mammogram 1 - 36.6 24.4 38.4

Pap2 50.7 37.0 - 63.2

Colorectal cancer 3

65.3 76.1 65.6 -

Summary

Cancer survivors are at risk for late complications

Complex interactions between late effects of treatment, other medical conditions, and cancer

Focus on medical care for conditions other than the index cancer is crucial, particularly for older cancer survivors






5. Conclusions

Breast cancer patients: mix of physician visits

Follow -up Year

% of patients with at least one visit Physician Specialty

Year 2 (n=11,219)

Year 3 (n=10,026)

Year 4 (n=9,297)

Year 5 (n=8,624)

Primary Care Only * 8.0 12.3 17.3 23.0

Oncology Only* 8.8 7.7 7.5 6.4

Multiple 4.9 3.6 3.0 2.2

PCP and Onc ology* 81.1 77.0 71.8 66.6

PCP and Medical 11.3 16.5 18.4 17.6

PCP and Radiation 7.5 8.2 9.2 9.3

PCP and Surgical 13.1 13.9 14.7 15.9

PCP and Multiple 49.2 38.4 29.5 23.8

* P < 0.001 Source: Grunfeld, J Oncol Pract, 2010

Mix of Physician Specialties Visited:

Breast Cancer Survivors

0

10

20

30

40

50

60

70

Both PCP Only OncologistOnly

Neither

Year 1

Year 2Year 3

Year 4Year 5

*p<0.0001 for change over timeSource: Snyder et al., JGIM, 2009

Testing a Primary Care Model of

Breast Cancer Follow-up CareSTUDY YEARS METHODS SUBJECTS

Phase I

1991-1992 Focus Groups Patients (England)


1992-1993 Survey FPs (England)

1992-1993 Survey Specialists (England)

Phase II 1993-1994 RCT (n=296) English Patients

Phase III 1997-2003 RCT (n=968) Canadian Patients

Phase IV 2007-2011 RCT (n=400) Canadian Patients

Testing a Primary Care Model of Breast Cancer Follow-up CareSTUDY YEARS METHODS SUBJECTS

Phase I



1992-1993 Survey PCPs (England)





Randomized Trial(18 months follow-up)

Trial GroupDifference

(95%CI) PCP

n = 148

Specialist

n = 141

Time to diagnosis of recurrence (days)

22 days 21 days 1.5 (-13 to 22)

Total time with the patient (min)

35.6 20.7 14.9* (11.3 to18.4)

Cost per patient (£s) 65 195 - 130 * (-149 to -112)

Time cost to the patient (min) 53 82 - 29 * (-37 to -23)

No difference in health-related quality of life over time No difference in anxiety or depression over time PCP patients more satisfied

Results – Phase II

*p<0.001 Source: Grunfeld et al., BMJ, 1996


Phase I



1992-1993 Survey PCPs (England)





Follow-Up Guideline Sentto Primary Care Physicians

Outcome Event

Family Physician

(FP) Group(n=483)

Cancer Centre

(CC) Group(n=485)

Risk Difference

CC – FP(95% CI)

Number of Patients (%)

RecurrenceDistanta

Locala

Contralaterala

54 (11.2%)361011

64 (13.2%)381215

2.02% (-2.13, 6.16)

Death (All Causes) 29 (6.0%) 30 (6.2%) 0.18% (-2.90, 3.26)

Serious Clinical Events

17 (3.5%) 18 (3.7%) 0.19% (-2.26, 2.65)

Spinal Cord compressionb

Pathological fractureb

Uncontrolled local recurrenceb

KPS ≤ 70b

Brachial plexopathyb

Hypercalcemiab

0321402

1801802


Phase I



1992-1993 Survey FPs (England)





Evaluating a survivorship care plan

Overall Objective:To determine if a survivorship care plan

and educational intervention for breast cancer survivors ready for transition from specialist care to primary care improves patient and health service outcomes

From Cancer Patient to Cancer From Cancer Patient to Cancer Survivor: Lost in TransitionSurvivor: Lost in Transition

Institute of Medicine, 2006

Recommendation 2:

Patients completing primary treatment should be provided with a comprehensive care summary and follow-up plan that is clearly and effectively explained. This “Survivorship Care Plan” should be written by the principal provider who coordinated oncology treatment.

What is a care plan

Identifying information (patient and provider)

Cancer treatment summary Diagnostic tests completed Risk of recurrence Signs and symptoms Recommended surveillance

guidelines Potential late effects Preventive care recommendations

Design and SettingDesign and Setting

Design: Multicenter randomized

controlled trial

Setting: 400 breast cancer patients on

active follow-up through tertiary cancer centers throughout Canada

Study InterventionStudy Intervention

All Patients Received:

Transfer to patients’ own FP for exclusive follow-up (i.e., all oncology providers agree to transfer)

Discharge visit with oncologist according to usual practice

Patients and FPs instructed to schedule the first follow-up visit in approximately 3 months

Statement that follow-up now provided by FP

Study InterventionStudy Intervention

Intervention Group Only Received:

Patient received:30 minute educational session with nurseSurvivorship care plan

Patient’s FP received:Survivorship care planGuideline on follow-upUser friendly abbreviated versionReminder table of visits and tests

Survivorship Care PlanSurvivorship Care Plan

Red dashed line = SCP, Black solid line = No SCP

Patient-reported Outcomes: Change Scores over Time

Source:Grunfeld, J Clin Oncol, 2011

Who should provide long-term care?

ASCO guideline - 2005 updateBased on two RCTs .. follow-up by a PCP appears to lead to the same health outcomes as specialist follow-up with good patient satisfaction. There is no reason to think that US patients will be any different.

Canadian guideline - 2005“responsibility for follow-up should be formally allocated to a single physician, with the patient participating as much as possible”

Percent willing to provide exclusive cancer follow-up: results from a Canadian national

survey of FPs1

Cancer 2yrs

3 to 5 yrs 10+ or never

Prostate 55.3 35.4 8.1

Colorectal 49.8 33.4 15.4

Breast 50.0 40.5 7.7

Lymphoma 42.0 41.6 15.4

1. Current experience providing exclusive follow-up most significant predictor of willingness. Source: Del Giudice, Grunfeld, et al,, J Clin Oncol, 2009

Usefulness of various modalities to help PCPs provide exclusive

cancer follow-upRan

kModality %

1 Patient-specific standardized letter with guidelines

95.4

2 Printed guidelines 91.8

3 Expedited rates of re-referral 92.7

4 Expedited access to test for suspected recurrence

91.1

5 Ability to telephone\email specialist for advice

86.1

Source: Del Giudice, Grunfeld, et al J Clin Oncol, 2009






5. Conclusions

Conclusions

Growing prevalence of cancer survivors Change in perspective from acute life threatening

disease to chronic disease Growing body of research shows that PCPs can,

are, & wish to play a key role in post-treatment cancer care

For breast cancer patients, a standard discharge visit with the oncologist achieved similar results as a survivorship care plan and educational session

Quality of general preventive care is a concern Involvement of PCPs in post-treatment cancer care

is essential but need guidelines, access, and education

Niagara Falls, CanadaNiagara Falls, Canada

Am 11.30 grunfeld

Health & Medicine

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