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Louis S. Constine, MD, FASTRO Professor of Radiation Oncology and Pediatrics

Curing Patients with Cancer, But At What Cost: The Double-edged Sword of Cancer Therapy --- May the best of what we have done in the past, be the worst of what we will do in the future. Louis S. Constine, MD, FASTRO Professor of Radiation Oncology and Pediatrics. Multiple primary cancers

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Louis S. Constine, MD, FASTRO Professor of Radiation Oncology and Pediatrics

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  1. Curing Patients with Cancer,But At What Cost: The Double-edged Sword of Cancer Therapy ---May the best of what we have done in the past, be the worst of what we will do in the future Louis S. Constine, MD, FASTRO Professor of Radiation Oncology and Pediatrics

  2. Multiple primary cancers Prostate Breast Lung and bronchus Colon /rectum Urinary bladder Melanomas of the skin Non-Hodgkin lymphoma Uterine corpus Kidney Pancreas Ovary Thyroid Stomach Brain & CNS Multiple myeloma Cervix Esophagus Liver Larynx Hodgkin lymphoma Testis Soft tissue including heart Bone and joint Cancer Incidence – Distribution by Site SEER Program, 2006 2 0 4 6 14 16 18 8 12 10 Percent Total invasive cancers: 129,552

  3. 1993-98 1987-92 1981-86 1975-80 5-Year Survival of Patients with Cancer by Era, SEER, 1975-1998 80 Year of Diagnosis 2004 Projected 70 Survival (%) 60 Peak to Valley Transformation 50 40 0 10 20 30 40 50 60 70 Age at Diagnosis (Years)

  4. National Progress against Cancer In patients diagnosed with cancer before age 15, the 5-year survival rate improved from 58% in 1975 to 80% in 1997 --- an average annual change of 1.68%

  5. National Progress against Cancer Less well known is the remarkable improvement in prolonging survival in adult patients, especially those between 50 and 80 years of age

  6. Estimated Number of Cancer Survivors in the United States Over Time

  7. 12.1 Million Cancer SurvivorsUnited States: 2007 Source: http://dccps.nci.nih.gov/ocs/prevalence/prevalence.html. Last accessed Oct. 2009

  8. Cancer Survivorship • U.S.: 12 million cancer survivors • 3.5% population • Impact on public health • Increases in cancer survival • Earlier diagnosis (screening) • More effective treatment • Prevention of secondary disease • Decreases in mortality from other causes

  9. Caring for Cancer Survivors ASCO Prevention Survey, 2004

  10. Essential Elements Of Survivorship Care • Education of the cancer survivor, family, health care providers • Care plan based on future health risks • Promotion of healthy lifestyles • Possible genetic predispositions for counseling • Surveillance for cancer spread, recurrence, or second cancers and for long-term adverse physical, psychosocial, socioeconomic effects • Intervention to prevent or treat consequences of cancer or therapy • Communication between specialists and primary care providers to ensure that the survivor’s health needs are met • Research focused on understanding, preventing, treating adverse consequences of cancer or its therapy • Patient advocacy to address problems related to employment, insurance, and disability

  11. Components of Treatment Summary • Contact information for key individual providers • Dates of treatment initiation and completion • Diagnostic tests and results • Tumor characteristics • Therapies provided, including specific agents, title of clinical trials (if any), treatment response, and toxicities experienced • Psychosocial and nutritional services provided • Identification of a coordinator of continuing care

  12. Components of Care Plan • Likely course of recovery from treatment • Recommended surveillance • Possible long-term effects of treatment and symptoms • Possible signs of recurrence and second tumors • Possible effects of cancer on daily life (personal relationships, work, mental health) and available resources for support • Potential insurance, employment, and financial consequences of cancer and referrals to counseling, legal aid, and financial assistance if needed

  13. Treatment Summary Concordance with IOM

  14. Survivorship Care Plan concordance with IOM

  15. Survivorship Program Components Across Four Health Care Organizations

  16. SCP Components Across Four Health Care Organizations Abbreviations: SCP, survivorship care plan, EMR, electronic medical record; PCP, primary care provider; ob/gyn, obstetrician/gynecologist

  17. Cancer Diagnosis & Treatment Health & Quality of Life Long-Term Survival Survivorship begins at diagnosis!

  18. What are the physical costs of survivorship?

  19. General Considerations • Risk of late effects depends on the tissue and age of patient at time of treatment • Late effects are dose and modality specific (e.g., surgery, radiation, chemotherapy) • Combined modality therapy can have additive risks

  20. Bone/soft tissues Cardiovascular Dental Endocrine Gastrointestinal Hepatic Hematological Immune system Nervous system Neuropsychologic Ophthalmologic Pulmonary Renal Reproductive Tissues at Risk for Late Toxicity

  21. Factors Contributing to Morbidity Premorbid Conditions Genetic Host Factors BRCA, ATM, p53 polymorphisms Age Gender Race Tumor Factors Health Behaviors Histology Site Biology Response Tobacco Diet Alcohol Exercise Sun Treatment Factors Aging Surgery Chemotherapy Radiation therapy Treatment Events Cancer-Related Morbidity

  22. Why, a four-year old child could understand this. Someone get me a four-year old child! -- Groucho Marx

  23. Radiation therapy is getting complicated

  24. Tables and data and lines, oh my...

  25. Know Your Cancer-Related Health Risks Surgery for Solid Tumors • After removal of one of paired organs, the remaining organ usually maintains function: • Enucleation (removal of eye) • Nephrectomy (removal of kidney) • Oophorectomy (removal of ovary) • Orchiectomy (removal of testes) • It’s important to take precautions to preserve the health of the remaining organ

  26. Know Your Cancer-Related Health Risks Surgery for Solid Tumors • Surgery to remove tumors of bones or soft tissue may affect strength, function, mobility • These surgeries may also cause chronic pain that limits activity • Examples include: • Amputation • Limb-sparing surgery

  27. Know Your Cancer-Related Health Risks Chemotherapy for Cancer Prednisone and Methotrexate affect bone strength Bleomycin, BCNU, CCNU, and busulfan can cause lung scarring Anthracyclines (drugs like doxorubicin and daunorubicin) affect heart muscle function

  28. Know Your Cancer-Related Health Risks Chemotherapy for Cancer Cisplatin, carboplatin and ifosfamide can affect kidney function Cyclophosphamide can cause injury to the bladder lining

  29. Know Your Cancer-Related Health Risks Chemotherapy for Cancer Cisplatin and carboplatin can cause hearing loss Vincristine and cisplatin can affect nerve function

  30. Know Your Cancer-Related Health Risks Chemotherapy for Cancer Methotrexate and Cytarabine (Ara C) given by vein or into the spinal fluid can affect learning, concentration and memory

  31. Know Your Cancer-Related Health Risks Chemotherapy for Cancer • Alkylating agents chemotherapy affects testicular and ovarian function • Risk of injury is related to total dose of medication received • Alkylating agents most often used for childhood cancer: • cyclophosphamide, procarbazine, nitrogen mustard, ifosfamide

  32. Know Your Cancer-Related Health Risks Radiation for Cancer Brain radiation can affect learning & memory, motor function and sensation Endocrine gland radiation can affect growth, metabolism, and reproduction

  33. Know Your Cancer-Related Health Risks Radiation for Cancer Lung scarring from radiation leads to stiff lungs that restrict air flow during breathing Scarring from radiation can affect heart rhythms, heart muscle and valve function and blood vessel flow

  34. Know Your Cancer-Related Health Risks Radiation for Cancer • Radiation cause kidney damage and bladder scarring • Some of the signs of radiation injury of the urinary tract are: • High blood pressure • Blood in urine • Incontinence • Problems voiding

  35. Know Your Cancer-Related Health Risks Radiation for Cancer • Decreased testosterone • Decreased, damaged or absent sperm • Damage to duct system to transport sperm • Sexual dysfunction from damage to pelvic nerves

  36. Decreased estrogen Damage or depletion of eggs in ovaries Scarring of lining of the uterus (womb) Scarring of blood supply to uterus Know Your Cancer-Related Health Risks Radiation for Cancer

  37. Multiple Primary Cancers Etiologic Factors Treatment Cancer #2 Cancer #1 Interactions andother influences Lifestyle Environment Host factors • Age and gender • Genetics • Immune function • Hormonal, other • Tobacco • Alcohol • Diet • Other • Contaminants • Occupation • Viruses • Other • Gene-environment • Gene-gene Modified from Travis LB. Acta Oncologica 2002; 323-333.

  38. Subsequent Malignant NeoplasmsDCCPS and DCEG • SEER Program (1973-2000) • 2 million cancer survivors • 185,000 subsequent cancers • Young adults, children especially prone to late effects of radiotherapy • Chemotherapy effects less defined • Sizeable proportion are related to tobacco and/or alcohol use (35% of total excess risk) Surveillance, Epidemiology and End Results Program Source: Curtis RE, Freedman DM, Ron E, Ries LAG et al. (editors). New Malignancies Among Cancer Survivors: SEER Cancer Registries, 1973-2000, NIH Publ. No. 05-5302, Bethesda, MD, 2006.

  39. Age at treatment Sex/race of survivor Type/strength of therapy Chemotherapy Radiation therapy Transplant Time from treatment Type of cancer History of relapse Family history Health habits Who is at risk? When to worry?

  40. Age at Treatment Matters… • Learning problems after brain radiation • Younger patients at higher risk compared to older patients • Infertility after alkylating chemotherapy • Olderfemales at highest risk compared to younger females

  41. Chemotherapy Dose Matters…

  42. Combination of Treatments Matters… • Chest radiation: scarring of heart lining, heart valves, or blood vessels • Anthracycline chemotherapy: weakening of the heart muscle Risk of heart problems is greater if cancer treatments have similar risks for health problems.

  43. Lung scarring can occur after chest radiation and bleomycin Stiff lungs restrict air flow during breathing Thick scarred air sacs do not release oxygen to the tissues as well Smoking increases the risk of lung injury Health habits matter…

  44. Heart disease High cholesterol High blood pressure Diabetes Arthritis Osteoporosis Kidney problems Cancer Genes & Family History Matter… Cancer treatment may result in an earlier onset of diseases that “run” in families, especially those that usually present in adulthood

  45. Important Facts About Late Effects • The chances of having late effects after cancer is high • The chance of having serious or life-threatening late effects after modern cancer therapy is low • Knowing your cancer history and possible health risks can help you and your doctorwork together to prevent late effects or diagnose health problems early • Regular check-ups are needed to diagnose and prevent late effects

  46. Design cancer treatments to reduce the risk of late effects Develop therapies to protect normal tissues Monitor childhood cancer patients for late effects Prescribe corrective therapy What Doctors Can Do…

  47. Have regular check-ups so late effects can be prevented or detected in earlier stages Follow doctor’s advice about medications and other interventions that can reduce the risk of late effects Practice health behaviors that reduce the risk of late effects What Survivors Can Do…

  48. Habits that affect risk • Smoking • Sun exposure • Diet • Physical activity • Alcohol intake

  49. Tobacco Use • Don’t smoke. If you do smoke, QUIT! • Don’t use any tobacco products • Avoid smoke-filled rooms • Exercise regularly to keep your lungs fit • Check out: 1.877.4SJ.QUIT

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