What Happens Next? Managing the Care of Long-Term Cancer Survivors House Call: Relieving Symptoms with Acupuncture 50 Years of OncoLoghttps://openworks.mdanderson.org/oncolog/1179/thumbnail.jp

Chalaire, Dawn

Morrison, Martha

English

OpenWorks @ MD Anderson

University of Texas MD Anderson Cancer Center OpenWorks @ MD Anderson OncoLog MD Anderson's Report to Physicians (All issues) OncoLog MD Anderson's Report to Physicians 3-2006 OncoLog Volume 51, Number 03, March 2006 Dawn Chalaire The University of Texas MD Anderson Cancer Center Martha Morrison The University of Texas MD Anderson Cancer Center Follow this and additional works at: https://openworks.mdanderson.org/oncolog  Part of the History of Science, Technology, and Medicine Commons, and the Oncology Commons Recommended Citation Chalaire, Dawn and Morrison, Martha, "OncoLog Volume 51, Number 03, March 2006" (2006). OncoLog MD Anderson's Report to Physicians (All issues). 184. https://openworks.mdanderson.org/oncolog/184 This Newsletter is brought to you for free and open access by the OncoLog MD Anderson's Report to Physicians at OpenWorks @ MD Anderson. It has been accepted for inclusion in OncoLog MD Anderson's Report to Physicians (All issues) by an authorized administrator of OpenWorks @ MD Anderson. For more information, please contact rml-help@mdanderson.org. C E L E B R A T I N G 50 Y E A R S O F O N C O L O G A Publication of 4 5 M. D. Anderson In Brief House Call Cancer CenterRole of UVB rays Acupuncture: Tiny in melanoma needles, big impact Making Cancer History• REPORT TO PHYSICIANS :'I 6� /,� .• --� i.,.:�-t;:I'-- ·· An OncoLog Anniversary l M. D. Anderson's voiceI to physicians for 50 yearsWhat Happens Next? Managing the Care of Long­Term Cancer Survivors by Dawn Chalaire Cancer-as well as many of the treatments for it-can have long, term medical conse, quences for survivors. With more people than ever surviving cancer today, M. D. Anderson Cancer Center is look, ing at how to best meet their long,term medical needs. (Continued on next page)TI-E lNIVERSllY OF TEXAS MD .AN)ERSON CANCERCENIBR 2    OncoLog • March 2006Managing the Care of Long-Term Cancer Survivors(Continued from page 1)A42-year-old woman tellsher doctor that she isexperiencing chest pains.Echocardiography revealsno abnormalities, and the woman isotherwise healthy, so her doctorsuspects that she has heartburn.He prescribes Zantac and tells herto modify her diet. She follows hisadvice, but the pain continues andworsens. Months later, during aroutine follow-up visit, the womanis found to have chronic pericarditis.What went wrong? The physician’sdiagnosis was competent, basedon the information he had at thetime, but he was missing one key fact:25 years ago, the woman was treatedwith radiation therapy for Hodgkin’sdisease.The scenario described above isn’tan unusual one. Improvements in thescreening, diagnosis, and treatmentof cancer mean that more peoplethan ever are surviving the disease.In February, the American CancerSociety reported that the numberof annual cancer deathsfell by 369 from 2002 to2003, the first such declinein more than 70 years,and according to the latestestimate from the NationalCancer Institute, therewere almost 10 millioncancer survivors in theUnited States in 2001.Today, 64% of adults withcancer will survive at least 5 years,and 75% of children will survive atleast 10 years. But amid all the goodnews is the recognition that there isno comprehensive model for themedical care of cancer survivors.Survivors, and their primary carephysicians, often find themselvesnavigating the complicated terrainof cancer survivorship alone.Once they reach the 5-yearsurvival mark, most cancer survivorsleave the care of their oncologistsand return to their primary carephysicians—often with a host ofpotential problems related to thecancer and its treatment. It isn’t thattoday’s cancer treatments carry greaterrisks than previous therapies (in fact,many have less toxicity), but people areliving longer now, which gives theproblems more time to materialize. Theside effects of cancer and its treatmentcan include fatigue, pain, lymphedema,oral problems, weight loss or gain, lossof bladder or bowel control, menopausesymptoms, and sexual problems. Inaddition, cancer surgery can lead tophysical limitations such as loss ofmobility and weakness; chemotherapycan damage the testes, ovaries, heart,lungs, or bone marrow; and radiationtherapy can damage normal tissue andglands in the radiation treatment field.Most cancer survivors are at riskfor recurrence, and many also have anincreased risk of developing secondcancers. Many types of chemotherapyput patients at higher risk of developingleukemia or the bone marrow failuredisease, myelodysplastic syndrome.Survivors of childhood cancers notonly have a higher-than-average riskof new cancers as adults but also arefive times more likely to have a chronicdisease as adults. More than one thirdof these survivors can expect to havea life-threatening illness or seriouschronic disease (i.e., heart problems,dialysis or kidney transplant, paralysis,or mental retardation) by age 45.In addition to physical problems,cancer survivors face a variety of issuesthat can affect their quality of life.Many experience depression and livewith the ongoing fear of recurrence.Some have cognitive problems suchas memory loss or attention problems.Children who have been treated forcancer often find themselves behindin school and may have delays in socialdevelopment.For the primary care physician, allof these issues combine to create a verycomplex patient. Managing the lateeffects of cancer and its treatment andrecommending an appropriate screeningregimen require the analysis of interre-lated factors that are different for everypatient. And to make things even moredifficult, patients who have moved orchanged primary care doctors sincebeing treated for cancer may not thinkto tell their new physician about theirbout with cancer.Toward a survivorship care planA report published last year from theInstitute of Medicine titled From CancerPatient to Cancer Survivor: Lost inTransition states that there is no clearbest practice for caring for patients witha history of cancer and that primary carephysicians are seldom given explicitinstructions by oncologists. The reportrecommends that oncologists develop a“survivorship care plan” for each cancersurvivor that would include informationsuch as the cancer diagnosis, treatment,and potential consequences; recom-mend the timing and content of follow-up visits; offer tips for staying healthyand preventing recurrences or secondcancers; and inform survivors of theirlegal rights regarding employment andinsurance and the availability ofpsychological and support services.Rena Sellin, M.D., a professor in theDepartment of Endocrine Neoplasia andHormonal Disorders at The Universityof Texas M. D. Anderson Cancer Center,calls the report “sort of a little Bible” forThe field of oncology has only recentlybegun to address the issue of “what happens next,” afterthe 5-year cancer survival threshold, when a patientis considered cured. “This is part of the evolution ofthe field of cancer care,” says Dr. Rena Sellin.Dr. Sellin (l) and Martha Beck, R.N., (r) talkwith-aboutmakinglife after cancer as healthy and productive as possible. those who are interested in improving the care of cancer survivors. ''From the perspective of the primary care physician, what this report recommends is that each patient leaving the oncologist's office be provided with a detailed document that describes the type of cancer, type of treatment, and the follow-up recom, mended. That would help the primary care physicians know when they are dealing with a routine issue and when the cancer history becomes relevant and they need to consult the cancer center or the oncologist," said Dr. Sellin, who heads M. D. Anderson's Life After Cancer Care clinic. Such a plan, according to Dr. Sellin, should also provide an individualized summary of the patient's relative risks of recurrence, late effects, and second cancers. "So, for instance, for someone who was treated with radiation therapy and doxorubicin, the chart should note that there is a 'moderate risk of early cardiac events,"' Dr. Sellin said. An individualized care plan is necessary because of the many variables involved, including the type of cancer; disease stage, grade, and molecular characteristics; patient characteristics such as age, comorbidities, and overall health; and treatment, including its timing, dosage, and duration. "Many survivors don't need anything special," Dr. Sellin said, "but the oncologist should help the patient and the primary care physician determine that." If pieces of a patient's cancer history puzzle are missing or misinterpreted, the risk of recurrence can be overestimated as well as underestimated, possibly leading to unnecessary tests and proce, dures. Another consequence of putting too much emphasis on a patient's cancer history is that other important health recommendations, such as diet, exercise, and routine screening tests, may fall by the wayside. "What happens sometimes is that because you had cancer and you're focused on that, you don't think the other things are as important," Dr. Sellin said. In fact, cancer survivors with a low risk of recurrence are often more likely to die of another disease. Developing a chronic care model According to Dr. Sellin, the field of oncology has only recently begun to address the issue of "what happens next," after the 5-year cancer survival threshold, when a patient is considered cured. "This is part of the evolution of the field of cancer care. We are now beginning to develop a model for what happens after the cancer is controlled," she said. Dr. Sellin chairs a task force charged with determining M. D. Anderson's role in caring for cancer survivors. "We are comprehensively assessing what a cancer center should be offering to cancer survivors in the coming decades and seriously rethinking what is the right way to do it," Dr. Sellin said. One possible model of survivor care would be to coordinate the patient's follow-up through a clinic like M. D. Anderson's Life After Cancer Care clinic . Patients would visit the clinic every year or two for screening and to receive any new information about their disease. They could also be referred by their primary care physicians for evaluation of any problems that may be related to their history of cancer. "The clinic screens and evaluates patients and either refers them to the appropri­ate specialist at M. D. Anderson for further treatment or back to their community physician," Dr. Sellin said. Because a clinic specializing in the needs of cancer survivors would only be feasible in large cancer centers, additional models of treatment are needed. One option is to offer outreach programs that support primary care physicians and inform them about issues that may arise in their patients who are cancer survivors. In Texas, the Physician Oncology Education Program, funded by the Texas Cancer Council, has sponsored a series of physician seminars in various parts of the state focused on cancer survivorship topics, including screening and follow, up care, late effects of cancer, nutrition and physical activity, pain and symptom management, dental care, and end-of, life planning. The program has also produced a series of information modules, including one on cancer survivorship, which will soon be available on the M. D. Anderson Web site. In addition, M. D. Anderson's Office of Physician Relations is working (Continued on page 4) OncoLog • March 2006 3

OncoLog Volume 51, Number 03, March 2006

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OncoLog Volume 51, Number 03, March 2006

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