Cancer Survivorship Flashcards
Survivorship Issues
- Cancer
- Recurrence of primary cancer
- Secondary Malignancies
- Sexual and Reproductive Health
- Menopausal symptoms
- Sexual dysfunction
- Infertility
- Neurologic
- Cognitive problems
- Neuropathy
- Organ dysfunction
- Cardiac (anthracyclines & trastuzumab)
- Pulmonary (bleomycin)
- Renal (cisplatin)
- Bone Loss
- Mental Health
- Fatigue
- Insomnia
- Depression/anxiety
Cancer Survival Definitions
net survival
cancer survivor
- Net Survival:
- “The survival probability that would be observed in the hypothetical situation
where the cancer of interest is the only possible cause of death” (CCS,
Canadian Cancer Statistics, 2019) - “Cancer Survivor”:
- “An individual is considered a cancer survivor from the time of diagnosis,
through the balance of his or her life” (NIH, National Coalition for Cancer
Survivors, NCCN 2020) - May be living with cancer or free of cancer
- Not meant to be a label.
- NOTE: some patients do not like or identify with the term “survivor”.
Cancer Survival
* Cancer screening & treatment has vastly improved over the past 40 years
- Adult cancers (age 15-99)
- 5 year net survival is 63% (2019 CCS data)
- Prostate cancer – 93%
- Breast cancer – 88%
- Colo-rectal cancer – 65%
- Number of people with a cancer cure experience or cancer as a chronic illness is
growing - Childhood cancers (cancer under the age of 15)
- Overall 5 year survival rate for childhood cancer – 84% (2019 CCS data)
- 5 year survival is highest for Hodgkin lymphoma, retinoblastoma, nephroblastoma, gonadal germ cell tumours
(>95%) - 5 year survival is lower for AML (64%), bone tumours (70%), soft tissue sarcoma (71%)
- Many have a long life ahead!
Cancer Treatment
- Chemotherapy
- Narrow therapeutic window
- Dose limiting toxicity (DLT)
- Kills rapidly dividing cells
- Hormonal Manipulation therapies
- Menopause
- Pharmacologic/Chemical castration
- Targeted therapies
- Chronic treatment
- Radiation
- Consider possible damage to surrounding tissues
- Surgery
- Consider impacts of mastectomy, oophorectomy, colon resection, orchiectomy,
trachelectomy, brain surgery, head and neck surgery
Effects of Cancer and its Treatment
Physical
* Secondary Cancer
* Organ Damage
* Physiologic changes
from treatment
Psychosocial
* Psychologic distress
* Mental health
* Financial burden
* Developmental Issues
Short Term Effects
* Temporary and improve with
time
Long Term Effects
* Progressive
* Permanent
Late effects
* Manifest months to years later
* Example:
secondary malignancy
Chemotherapy Induced Neurotoxicity
- Can be peripheral, autonomic, and/or central neurotoxicity
- Symptoms:
- Sensory symptoms:
- Numbness, tingling, neuropathic pain, increased sensitivity to hot/cold, decreased vibration
and pinprick sensitivity - Motor symptoms:
- Hyporeflexia, weakness, muscle cramps
- Autonomic symptoms:
- Dizziness, hearing loss, constipation
- Long term considerations:
- Peripheral Neuropathy
- Movement disorders, changes in gate/posture, risk of falls
- Estimated that 30% of cancer survivors fall every year
- Evaluations for tinnitus and hearing loss (eg cisplatin)
Anticancer Drugs of Concern
Platinums Taxanes Vinca
Alkaloids IMIDs Proteasome
inhibitor
Ab-Drug
Conjugate
see slide 11
CIPN
Distribution
Glove-Stocking
Duration
Typically ~ 3 months after stopping
treatment
Can persist up to a year or longer with
some medications (IMIDs, brentuximab)
Platinum toxicity can progress for several
months and lead to permanent damage
Taxanes/Vincas duration up to 5-7 years
Risk Factors
Prior chemotherapy
Diabetes
Folate/Vit B12 deficiencies
Smoking history
Decreased creatinine clearance
CIPN Treatment
- Prevention – exercise??
- Goals of pharmacotherapy
- reduction in pain by at least 30%
- Improved function, mood, sleep
- Minimize adverse effects
- Therapeutic options:
- Duloxetine – First line, only agent shown in a RCT to be effective for CIPN
- Other agents where efficacy has been established in other forms of
neuropathic pain can be used as adjunct or if duloxetine ineffective or not
tolerated: - Gabapentin, pregabalin
- TCAs (amitriptyline, nortriptyline, desipramine, or imipramine)
Chemo Brain (aka Brain Fog)\
presentation, Mech, duration
Presentation
↓ in memory
Word-finding difficulty
Difficulty concentrating
↑ time to complete tasks
Mechanism
DNA damage & oxidative stress from cytotoxics
Also seen in targeted agents
Prevalence and Duration
46% prevalence of perceived cognitive
dysfunction in cancer survivors
May go away at end of treatment
In ~ 1/3 patients, may persist for 5-10 years
Chemotherapy related Cognitive Dysfunction
management
- No effective brief screening tool has been identified
- Mini-mental state examination (MMSE) lacks adequate sensitivity for the more subtle decline
in cognitive performance commonly seen in survivors - Management is mostly supportive
- Validation of symptom experience
- Keep in mind the implications to compliance with medications
- Provide strategies for forgetfulness
- Social support and understanding from friends/family is important
- Lifestyle: routine physical activity, limiting use of alcohol, stress management, relaxation
- Consider meditation, yoga, cognitive training (brain games)
- Consider the additive impact of brain radiation, brain cancer/metastases, brain
surgery
Mental Health
- Dealing with fear
- Can have constant and intrusive thoughts (disease, control, independence, dying)
- Managing anger
- Disease, delays, obstacles in health care system
- Guilt
- Cause of illness, impact on family, hereditary component
- Stress
- diagnosis, finances, loss of work, away from school
- Identity and Self Image
- Cancer stigma, changes in appearance
- Pain
- Clinical Mental Health Diagnosis
- Depression, Anxiety, Adjustment Disorder, PTSD
- Cancer survivors use medication for anxiety and depression at a rate about twice that of the general population
Depression and
Anxiety
The RR for depression was highest in those studies
that included patients less than 2 years since
diagnosis (p<0.0001)
The RR for anxiety was highest for patients
diagnosed with cancer more than 10 years
previously (p<0.001)
the pink column is people who were diagnosed with cancer less than 2 years ago. The blue is 2 t0 10 years, and the green is greater than 10 years. So when we look at depression.
we see this relative risk of like 2.2 to have depression.
If you were less than 2 years from your diagnosis,
where we’re looking at anxiety
greater than 10 years, that’s where the highest bar is here. I the anxiety. Is it going to come back.
Treatment depression/anxiety
- Supportive Services
- Psychologists
- Social Workers
- Support Groups
- Counselling
- Pharmacotherapy
- Options:
- SNRIs (consider if concomitant pain
or hot flashes) - SSRIs (watch for drug interactions,
example with tamoxifen) - Appropriate monitoring
- Appropriate education
- May take 2-6 weeks for SSRIs or
SNRIs to take effect
Cancer Treatment Induced Infertility
- Can impact ALL people of parenting or pre-parenting age
- Impaired spermatogenesis
- Reduced ovarian reserve
- Should be discussed BEFORE initiating therapy if possible
- Allows informed decision making for family planning and/or fertility preservation
- All interested and ambivalent patients should be referred to reproductive specialist
as early as possible before treatment. - Should be discussed DURING follow up
- Address timing and safety of potential pregnancy
- Proactively addressing infertility is associated with lower regret and
improved quality of life
