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Cancer Survivorship

Catherine Marshall MD MPH and Neda Frayha, MD
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With the number of cancer survivors growing and the longer lasting effects of newer treatments, how well equipped are primary care clinicians to care for cancer survivors over the long haul? Dr. Cathy Handy Marshall, an oncologist at Johns Hopkins, joins Neda for a conversation about cancer survivorship in primary care.

Pearls:

  • National Comprehensive Cancer Network and American Society of Clinical Oncologists are a good resource for primary care providers that have survivorship care plans for a variety of cancers.
  • Why important?
    • Number of cancer survivors is 15 million and growing
    • Survivors are living longer because treatment is getting better
    • Immunotherapy has effects years down line after treatment
  • Considerations for cancer survivors:
    • 1. Are they at increased risk of cancer coming back?
      • Varies widely by cancer
        • Hormone positive breast cancer has increased risk of recurrence post-menopause
        • Diffuse large B-cell lymphoma recurrence drops dramatically after 5 years
    • 2. Are they at risk of a second cancer?
      • The exposure that led to the first cancer can put them at increased risk for another cancer (ie: smoking that lead to throat cancer also puts them at risk for lung cancer)
    • 3. Are there late effects of treatment?
      • Childhood survivors of cancer are at increased risk of cardiovascular disease and age prematurely as a result of treatment
    • 4. Are they at increased risk of other cancers due to genetics?
      • With more genetic testing coming online, we are learning more about certain risk it poses for other cancer types
  • Resources:
    • American Society of Clinical Oncologists
    • National Comprehensive Cancer Network
    • Both have documents and templates for survivorship plans that oncologists fill out to aid the primary care doctor
  • Diseases to worry about in cancer survivors:
    • CV disease is the number one cause of death in cancer patients
    • Immune-related disease can be triggered by immunotherapy long after treatment. For example, DM1 can develop with these drugs.
    • Neuropathic pain and fatigue may be long-term effects of cytotoxic drugs
    • Fertility is an issue that can come up with childhood survivors of cancer
  • Other preventative measures:
    • Vaccines
    • Exercise
    • Healthy eating
      • Obesity is set to overtake tobacco as the leading preventable cause of cancer

 

REFERENCES:

  1. Bober SL, Recklitis CJ, Campbell EG, et al. Caring for cancer survivors. Cancer 2009; 115:4409-4418. doi:10.1002/cncr.24590
  2. Brudno JN, Kochenderfer JN. Toxicities of chimeric antigen receptor T cells: recognition and management. Blood 2016; https://doi.org/10.1182/blood-2016-04-703751.
  3. Chaput G, Med CP, Sussman J. Integrating primary care providers through the seasons of survivorship. Curr Oncol2019; 26(1):48–54. doi:10.3747/co.26.4687
  4. Del Giudice ME, Grunfeld E, Harvey BJ, et al. Primary care physicians’ views of routine follow-up care of cancer survivors. J Clin Onc 2009; 27(20):3338-3345.
  5. Grunfeld E, Earle CC. The interface between primary and oncology specialty care: treatment through survivorship. JNCI Monographs 2010; 2010(40): 25–30. https://doi.org/10.1093/jncimonographs/lgq002
  6. Handy CE et al. Synergistic opportunities in the interplay between cancer screening and cardiovascular disease risk assessment. Circulation 2018; 138:727-734.
  7. Hodi FS et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med 2010; 363:711-723. DOI: 10.1056/NEJMoa1003466
  8. Marshall HT, Djamgoz MBA. Immuno-oncology: emerging targets and combination therapies. Front Oncol 2018; 8:315. doi: 10.3389/fonc.2018.00315.
  9. Potosky AL, Han PKJ, Rowland J, et al. Differences between primary care physicians’ and oncologists’ knowledge, attitudes, and practices regarding the care of cancer survivors. JGIM 2011; 26(12):1403-1410. 
  10. Shapiro CL. Cancer survivorship. N Engl J Med 2018; 379:2438-2450. DOI:10.1056/NEJMra1712502

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