Following the Patient with Prior Malignancy

1
Following the Patient with Prior Malignancy
Greg Friess, DO FACP The Center for Cancer and
Blood Disorders
2
Survivorship? Thats where we alls wants to
be, aint it? Fred, on chemotherapy for stage
III colon cancer, 2002
3
Who is a survivor?
4
Who is a survivor?

• 10,800,000 Americans currently living with a
  prior diagnosis of cancer
• 5 year survival 1996-2003 66
• About 700,000 a year

5

• Annually
• 140,000 women with breast cancer
• 90,000 colon cancer patients
• 10,000 lymphoma patients
• 7,000 Hodgkin's Disease patients
• 5,000 testicular cancer patients
• and many more

Who is a survivor?
6
Who is a survivor?

• Lance Armstrong
• Testicular cancer
• Chemotherapy
• 1996

7

• Mario Lemieux
• Hodgkins Disease
• Radiation
• January 1993

Who is a survivor?
8
Who is a survivor?
Helena and Tammy
9
Who is a survivor?

• Dave Friess
• Paraganglioma of the cauda equina
• Radiation and Surgery
• 1992

10
Recurrence Screening

• Principles in following previous cancer patients
• Recurrence detection
• Screening for asynchronous primary cancers
• Finding late effects of therapy
• Screening for new cancers at different site

11

• A 66 year old woman comes to you after moving
  here to be closer to her grandchildren. She had
  stage I breast cancer in 2002, had a lumpectomy
  and breast irradiation, then took arimidex for
  five years, stopping last year. On exam her
  breasts are unremarkable, other than the surgical
  scars, no lymphedema is present, and no axillary
  nodes are palpable. You order a mammogram and
• A bone scan
• A CT of the chest
• CEA and CA27.29 levels
• All of the above
• None of the above

Recurrence Screening
12
Search for distant metastases in the
asymptomatic patient only when intervention
yields a survival benefit
Recurrence Screening
13

• Search for distant metastases in the asymptomatic
  patient only when intervention yields a survival
  benefit
• Colorectal cancer- CT of the chest and liver
  annually for three years after therapy

Recurrence Screening
14

• Search for distant metastases in the asymptomatic
  patient only when intervention yields a survival
  benefit
• Colorectal cancer- CT of the chest and liver
  annually for three years after therapy
• Prostate cancer- PSA and DRE every 6 months for 5
  years

Recurrence Screening
15

• Search for distant metastases in the asymptomatic
  patient only when intervention yields a survival
  benefit
• Colorectal cancer- CT of the chest and liver
  annually for three years after therapy
• Prostate cancer- PSA and DRE every 6 months for 5
  years
• Testicular cancer- serum markers q 3 mo for two
  years and CT scans of the CAP q6 months for two
  years, then taper

Recurrence Screening
16

• Search for distant metastases in the asymptomatic
  patient only when intervention yields a survival
  benefit
• Colorectal cancer- CT of the chest and liver
  annually for three years after therapy
• Prostate cancer- PSA and DRE every 6 months for 5
  years
• Testicular cancer- serum markers q 3 mo for two
  years and CT scans of the CAP q6 months for two
  years, then taper
• NHL and Hodgkin's- CT scan CAP q6 months for 5
  years, CBC, ESR, chemistry profile and TSH q 6mo
  (if neck irradiated)

Recurrence Screening
17
Presume that whatever the carcinogen was, it hit
the entire organ Presume residual organ is at
higher than average risk (the other breast, the
remaining colon, all skin for melanoma, the other
testicle, the other lung) Follow screening
guidelines rigorously, American Cancer Society is
recommended.
Screening forAsynchronous Primary Cancers
18

• Breast cancer
• Mammogram six months after RT completed and then
  annually for life
• BSE monthly
• Physician exam q 4-6 months x 5 years then
  annually
• MRI of breast(s) annually for risk 20 (BRCA12,
  FH of ovarian cancer)
• Biopsy anything suspicious

Screening forAsynchronous Primary Cancers
19

• Practical advice regarding breast cancer
• Breasts change after radiation. Some are
  thicker, some are denser, some are discolored and
  some are barely different. See the patient enough
  to know.
• Mammograms are harder to read after radiation or
  after an implant is placed
• Radiation has changed a great deal in the last
  thirty years, but some women will have been
  radiated that long ago.

Screening forAsynchronous Primary Cancers
20
Colon cancer Colonoscopy in one year, then
three years then every five years (do within six
weeks if not done preop) Melanoma physical exam
q3mo for two years then annually for life Lung
cancer exam and CT of chest q4-6 mo for two
years, then annually
Screening forAsynchronous Primary Cancers
21
Breast-ovary BRCA 1 and 2 Hereditary
nonpolyposis colon cancer syndromes colon,
ureter, endometrial, gastric Diseases with DNA
repair defects Downs syndrome Klinefelters Gar
tners AIDS NHL Kaposis sarcoma Anal
cancer
Additional Screening
22
Learning from children with cancer
Late Effects of Cancer Treatment
23
Late Effects of Cancer Treatment

24
A 24 year old woman comes to see you for routine
health evaluation. She is working at the local
mall in a retail store, smokes ½ a pack of
cigarettes a day and takes oral contraceptives.
She reports that she had Hodgkin's Disease ten
years ago, had chemotherapy and radiation to her
chest and her neck, and was told she is cured.
She doesnt know what stage it was, and doesnt
know what drugs she got except one was red. Her
exam is unremarkable with no enlarged lymph nodes
and no enlarged spleen. Which would you NOT would
order? 1. CT scans of the chest, abdomen and
pelvis 2. An echocardiogram 3. T4 and
TSH 4. Mammogram 5. Records from her prior
physicians
Late Effects of Cancer Treatment
25
Adult survivors of childhood cancer Oeffinger,
et al NEJM 2006 3551572. 10,397 survivors
compared to 3,034 of their siblings. Treated
from 1970 to 1986 Average age at reporting 27
Late Effects of Cancer Treatment
26
Adult survivors of childhood cancer Oeffinger,
et al NEJM 2006 3551572. Findings 62.3 had
at least one serious health condition 27.5 had
a severe or life threatening condition Relative
to their siblings 3.3X risk of any
condition 8.2X risk of a severe condition
Late Effects of Cancer Treatment
27
Adult survivors of childhood cancer Oeffinger,
et al NEJM 2006 3551572. Health
problems Myocardial infarction Congestive
heart failure Cognitive dysfunction Premature
gonadal failure Second cancer Highest risk CNS
tumors, bone tumors, Hodgkins disease
Late Effects of Cancer Treatment
28

• Think of radiation as a local process with
  problems arising in the irradiated area (the
  port)
• Hypothyroidism
• Ovarian failure
• Accelerated atherosclerosis
• Pericardial illness
• Chronic diarrhea
• Diminished bladder capacity
• Dysphasia
• Xerostomia
• Pulmonary fibrosis
• Lung cancer, breast cancer and sarcoma

Late Effects of Radiation
29
Specific to the chemotherapy drug and number of
doses. More doses or higher doses (transplant)
are always more toxic both acute and long term.
Most drugs are given in combinations, and
concurrent exposure can worsen late toxicities.
Late Effects of Chemotherapy
30
Adriamycin
Late Effects of Chemotherapy
31

• Adriamycin
• Uses NHL, HD, leukemia, sarcomas, breast cancer
• Late toxicity cardiomyopathy
• Worsened by radiation to the mediastinum,
  cyclophosphamide exposure, and the usual cardiac
  risk factors
• Practical points
• Bright red in color (AKA Red Devil)
• Toxicity increases after approx eight doses
  (400-450 mg/m2)

Late Effects of Chemotherapy
32
Cisplatin (CDDP, cis dichlorodiamino
platinum) Uses Testicular cancer, small cell
lung cancer, NHL, NSCCL, bladder cancer, ovarian
cancer, head and neck cancer, esophageal cancer,
many others Toxicity renal failure and renal
magnesium wasting Practical point often
presents as fatigue and chronic energy
loss
Late Effects of Chemotherapy
33
Bleomycin Uses Testicular cancer,
Hodgkins Late Toxicity Pulmonary
fibrosis Worsened by radiation,
cyclophosphamide, adriamycin, renal
insufficiency
Late Effects of Chemotherapy
34
Aromatase inhibitors Arimidex, Femora,
Aromasin A class of drug widely used in breast
cancer for early stage (curable) disease Oral
and hormonal Toxicity Osteoporosis
Late Effects of Chemotherapy
35
Infertility Frequent in men with minor
chemotherapy exposure Age dependant in women
with early menopause a more identifiable event
(uncommon before age 30, then steadily
increases) Babies that are conceived are
normal
Late Effects of Chemotherapy
36
Late Effects of Chemotherapy
Second malignancy AML Non-Hodgkin's
lymphoma
37
New agents Imatinib (Gleevec) Rituximab
(Rituxin) Traztusumab (Herceptin) Bevasizamab
(Avastin) Sunitinib (Sutent) Lenolidamide
(Revlamid) Many others Too early to know (less
than 20 years)
Late Effects of Chemotherapy
38
Emotional Sequelae After Cancer Therapy A 72
year old woman comes to see you for breast cancer
follow up. She had a modified radical mastectomy
in 1982 for stage IIA (node negative) ER cancer.
She took tamoxifen for five years, had no
radiation, and is faithful about breast self exam
and annual mammograms. She saw her prior doctor
twice a year for breast exams. She tells you that
the only time she ever sleeps at night is the
night after seeing her doctor, as she is
terrified of recurrent cancer.
Late Effects of Diagnosis
39
Emotional Sequelae After Cancer
Therapy Causes 1. Uncertainty Will it come
back? When?
Late Effects of Diagnosis
40
Emotional Sequelae After Cancer
Therapy Causes 1. Uncertainty 2. Life
interruption My family treats me
differently My boss/job/coworkers treat me
differently Im behind everyone else
Late Effects of Diagnosis
41
Emotional Sequelae After Cancer
Therapy Causes 1. Uncertainty 2. Life
interruption 3. Altered appearance Alopecia M
astectomy Head and neck surgery Amputation W
eight gain and loss
Late Effects of Diagnosis
42
Emotional Sequelae After Cancer
Therapy Causes 1. Uncertainty 2. Life
interruption 3. Altered appearance 4. Sexual
dysfunction Premature menopause Lubrication
loss Climactic dysfunction Therapy induced
impotence Surgical alteration Mastectomy C
olostomy/ Ileostomy Urostomy Tracheotomy

Late Effects of Diagnosis
43
Emotional Sequelae After Cancer
Therapy Causes 1. Uncertainty 2. Life
interruption 3. Altered appearance 4. Sexual
dysfunction 5. Spiritual turmoil Why did God
let this happen? Does God love me? Am I
worthy?
Late Effects of Diagnosis
44
Emotional Sequelae After Cancer
Therapy Therapy 1. Counseling 2. Support
groups 3. Avoid/limit BMW chat rooms 4. Consult
other professionals Ministers Psychiatrists
Career coaches Gynecologist Urologists Socia
l Workers
Late Effects of Diagnosis
45
Emotional Sequelae After Cancer Therapy A 72
year old woman comes to see you for breast cancer
follow up. She had a modified radical mastectomy
in 1982 for stage IIA (node negative) ER cancer.
She took tamoxifen for five years, had no
radiation, and is faithful about breast self exam
and annual mammograms. She saw her prior doctor
twice a year for breast exams. She tells you that
the only time she ever sleeps at night is the
night after seeing her doctor, as she is
terrified of recurrent cancer.
Late Effects of Diagnosis
46
Emotional Sequelae After Cancer
Therapy Management 1. See her every week for
exam and reassurance for first six weeks 2.
Psychiatric consult Hypnosis Counseling

Late Effects of Diagnosis
47
Following the Patient with Rare Cancer
48
David Friess Metastatic paraganglioma of the
cauda equina, 1992 Treated with surgery
(L3-L4-L5 laminectomy) and radiation from coccyx
to T10 Post treatment urinary incontinence
(resolved) Chronic back pain controlled with
ibuprofen
Patients with Rare Cancer
49
What do you do?
Patients with Rare Cancer
50
What do you do? NOBODY KNOWS!
Patients with Rare Cancer
51

• What do you do?
• Get old records

Patients with Rare Cancer
52

• What do you do?
• Get old records
• Ask the original doctor what the plan was

Patients with Rare Cancer
53

• What do you do?
• Get old records
• Ask the original doctor what the plan was
• Ask your regional experts (MD Anderson/NCI/Memoria
  l Sloan Kettering)

Patients with Rare Cancer
54

• What do you do?
• Get old records
• Ask the original doctor what the plan was
• Ask your regional experts (MD Anderson)
• Screen for recurrence? Probably not after ten
  years

Patients with Rare Cancer
55

• What do you do?
• Get old records
• Ask the original doctor what the plan was
• Ask your regional experts (MD Anderson)
• Screen for recurrence? Probably not
• Monitor for late radiation effects? Probably so
  (bladder, rectum, skin, neurologic)

Patients with Rare Cancer
56

• What do you do?
• Get old records
• Ask the original doctor what the plan was
• Ask your regional experts (MD Anderson)
• Screen for recurrence? Probably not
• Monitor for late radiation effects? Probably so
  (bladder, rectum, skin, neurologic)
• Expect the unexpected
• Vitiligo
• Hyperparathyroidism (Is this now MEN 2?)

Patients with Rare Cancer
57
Remember Nobody knows what to do, so you
cant be wrong!
Patients with Rare Cancer
58

59

• A growing group of cancer survivors will be
  coming to see you
• Follow up will include
• Recurrence screening
• Late effects of therapy
• New malignancy at the previous organ
• New malignancy elsewhere
• 3. Expect new developments

Conclusions