Primary Care for Survivors Flashcards
Define Cancer Survivor
Anyone who has been diagnosed with cancer from the time of initial diagnosis until the end of their life
Types of Sequelae of Cancer Treatment
Physical/Medical
Psychological
Social
Existential & spiritual issues
Physical/Medical Sequelae of Cancer Treatment
Second cancers Cardiac dysfunction Pain Lymphedema Sexual impairment Infertility
Psychological Sequelae of Cancer Treatment
Depression Anxiety Uncertainty Isolation Altered body image
Social Sequelae of Cancer Treatment
Changes in interpersonal relationships Concerns regarding health or life insurance Career issues Return to school Financial burden
Existential & Spiritual Sequelae of Cancer Treatment
Sense of purpose or meaning
Appreciation of life
How many pediatric cancer survivors experience at least 1 late effect?
2/3 or 66%
Why is there a need for a systemic plan for lifelong surveillance?
Incorporate risks based on therapeutic exposures, genetic predisposition, health-related behaviors, & co-morbid health conditions
What components should be included in surveillance of survivors of cancer?
Longitudinal care plan
Continuity
Emphasis on the whole person
Survivors at Highest Risk for Late Term Effects
Bone tumors
CNS tumors
Hodgkin’s lymphoma
Late Term Effects with Bone Tumors
Disfigurement & functional limitations caused by amputations & other surgeries
Problems with fertility, heart, & kidney damage & secondary cancers
Late Term Effects with CNS Tumors
Cognitive impairment Short stature Hearing loss Problems with balance & coordination Hypothyroidism Thyroid nodules Kidney damage Secondary cancers
Later Term Effects with Hodgkins Lymphoma
Lung damage Abnormal skeletal growth & maturation infertility Hypothyroidism Increased risk for breast cancer
Disabilities Secondary To Pediatric Cancer Treatment
Secondary malignancies Growth complications Endocrine complications Cardiopulmonary complications Renal complications Neuropsychological/ psychosocial complications
Secondary Malignancies in Pediatric Cancer Survivors
12% within 20 years
Exposure to alkylating agents + radiation most common causes
Genetic & Familial conditions increase risk of retinoblastoma, neurofibromatosis, nevoid BCC, etc.
Growth Complications in Pediatric Cancer Survivors
Direct damage to endocrine tissue
Highest risk: ALL, brain tumors, orbital tumors, nasopharyngeal CA with radiation
Children
Endocrine Complications in Pediatric Cancer Survivors
Early puberty
Premature close of epiphyses
Thyroid dysfunction: normal thyroxine, abnormal TSH
Gonadal dysfunction: azospermia, low testosterone, delayed sexual development
Ovarian dysfunction: failure to undergo menarche, increased FSH & LH levels, low estrogen
Delayed menses
Risk for early menopause
Pregnancies considered high-risk
Perinatal death or low-birth-weight, premature infants
Methods of Causing Cardiopulmonary Complications in Pediatric Cancer Survivors
Bleomycin: pulmonary fibrosis Nitrosoureas: pulmonary fibrosis Cyclophosphamide: pulmonary fibrosis Methotrexate: pulmonary fibrosis Antracyclines: CHF, arrhythmias Radiation: increased risk of CAD & chronic restrictive pericarditis
Renal Complications in Pediatric Cancer Survivors
Abnormal glomerular filtration rate: cisplatin
Persistent tubular dysfunction: cisplatin
Hemorrhagic cystitis: cyclophosphamide
Fanconi syndrome: ifosfamide
Define Fanconi Syndrome
Proteinuria
Glycosuira
Phosphaturia with hypophosphatemia
Neuropsychological Complications in Pediatric Cancer Survivors
Highest risk: ALL, brain tumors
Severity: dose, size & location of radiation field, child’s age, gender
Main effects: visual processing speed, visual motor integration, sequencing ability, short-term memory
Psychosocial Complications in Pediatric Cancer Survivors
Absence from school Frequent medical appointments Hospitalizations Social isolation Increased sense of physical fragility Vulnerability manifested by hypochondria or phobic behaviors
Medical Goals with Cancer Surveillance
Early recognition & treatment of late effects
Improve QOL
Decrease healthcare costs
Psycho-Social Goals with Cancer Surveillance
Establish “new normal”
Social life
School & work
Surveillance Caveats
Over Screening: undue fear, unnecessary screening, high costs
Under screening: missed late effects, missed early intervention, missed chance to minimize morbidity, long run have higher healthcare costs
What every survivor should know
What kind of cancer they had What kind of chemo they received What kind & how much radiation they received Any adjunct therapy Name of med & rad oncologist
Routine Monitoring with CNS Radiation in Pediatric Patients
Growth: height, weight, growth velocity, scoliosis screening, growth hormone testing
Neuro-psych screening yearly
Routine Monitoring with Chest Radiation in Pediatric Patients
Thyroid monitoring
PFTs
Cardiac workup for cardiac toxicity
Breast CA monitoring
Routine Monitoring with Abdominal/pelvic Radiation in Pediatric Patients
Renal: UA, CMP, eGFR, blood pressure, renal US, cystoscopy
Males: testicular size, semen analysis, testosterone levels, FSH & LH levels
Females: detailed menstrual history, FSH & estrogen levels, uterine US
Low Risk for Cardiac Toxicity in Pediatric Patients
Anthracyclines 5 y.o. at treatment
Moderate Risk for Cardiac Toxicity in Pediatric Patients
Radiation to chest or neck
Anthracyclines 250-400 mg
Age
High Risk for Cardiac Toxicity in Pediatric Patients
Anthracyclines + radiatin to chest
Anthracyclines > 400 mg
Pre-existing cardiac disease + anthracyclines
Goals of Follow Up Care in Adults
Prevent premature mortality
Prevent/detect early physiologic or psychosocial sources of morbidity
Management of co-morbidities
Screen for 2nd cancers
Surveillance After Breast Cancer
Recurrence Secondary CA PE Psychosocial Other considerations
Recurrence Surveillance After Breast Cancer
Monthly SBE
CBE every 6 months for 5 years then annually
Mammogram annually
Secondary Cancer Surveillance After Breast Cancer
Increased risk for ipsilateral & contralateral breast CA, ovarian & colorectal CA
PE Surveillance After Breast Cancer
Lymphedema
Premature menopause Osteoporosis
Uterine CA
Psychosocial Surveillance After Breast Cancer
Distress about risk of recurrence Sexuality Body image Depression Anxiety
Other Considerations for Surveillance After Breast Cancer
Assess age at diagnosis
Family cancer history
Referral for genetic counseling
Annual pelvic
Screening for colorectal & cervical cancer
Pneumococcal & influenza vaccinations
Assess Psychosocial function
Surveillance After Prostate Cancer
Recurrence Secondary cancers PE Psychosocial Other considerations
Recurrence Surveillance After Prostate Cancer
Clinical evaluation
PSA every 6 months for 5 years, then annually
DRE annually
Secondary Cancer Surveillance After Prostate Cancer
Increased risk of bladder CA
PE Surveillance After Prostate Cancer
Sexual dysfunction
Bowel/urinary incontinence
Radiation proctitis
Diarrhea
Psychosocial Surveillance After Prostate Cancer
Depression
Anxiety
Other Considerations for Surveillance After Prostate Cancer
Asses age at diagnosis Family cancer history Referral for genetic counseling Colorectal cancer screening Pneumococcal & influenze vaccinations Assess psychosocial function
Surveillance After Colorectal Cancer
Recurrence Secondary Cancers PE Psychosocial Other considerations
Recurrence Surveillance After Colorectal Cancer
CEA
Clinical exam every 3 months for 2 years, then 6 months for 3-5 years
CT scan every 3-6 months for 2 years, then every 6-12 months for total of 5 years
Colonoscopy after 1 year, then 3 years, then 5 years
Secondary Cancer Surveillance After Colorectal Cancer
Colorectal cancer at a different site
PE Surveillance After Colorectal Cancer
Ostomy care Rectal incontinence Radiation proctitis Diarrhea Adhesions
Psychosocial Surveillance After Colorectal Cancer
Sexuality
Body image
Depression
Other Considerations for Surveillance After Colorectal Cancer
Assess family cancer history for FAP & HNPCC
Refer for genetic counseling & assessment
Breast & cervical cancer screening
Pneumococcal & influenza vaccinations
Assess psychosocial functions
