Cancer Survivorship - Dr. Pozo-Kaderman


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Dr. Christina Pozo-Kaderman of Sylvester Comprehensive Cancer Center presented "Cancer Survivorship" at the 2011 WellBeingWell Conference in Miami.

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Cancer Survivorship - Dr. Pozo-Kaderman

  1. 1. Cancer Survivorship<br />Christina Pozo-Kaderman, Ph.D. <br />Administrative Director of the Courtelis Center for Psychosocial Oncology<br />
  2. 2. Cancer Survivorship<br />“Cancer Survivor” is the term used to include anyone who has been diagnosed with cancer, from the time of diagnosis through the rest of his/her life.<br />1 out of 3 will be diagnosed with cancer<br />Nearly 12 million cancer survivors in USA<br />
  3. 3. The feelings at the end of cancer treatment are as unique as each individual survivor, but there are some commonalities.<br />
  4. 4. How Survivors Often Feel<br />“I still worry about every lump or pain.”<br />“The days leading to my mammogram, my anxiety is off the chart.”<br />“Everyone in my family just wants things to go back to normal, but it’s different for me.”<br />“I feel like I’ve been walking on eggshells for 5 years. Now I’ve passed this mark and I still don’t feel safe.”<br />
  5. 5. What Survivors Often Hear<br />“It’s over. Now forget about it and go back to the way you were.”<br />“You are so lucky that it was caught early.”<br />“But you’re cured. What more do you want?”<br />“Don’t be negative. You must think positive. You’re going to be just fine.”<br />
  6. 6. Post-Treatment<br />Mixed Feelings<br />Access to oncology team decreases<br />Fear of Recurrence<br />Learning to decipher symptoms<br />Returning to “normal” life<br />Family, work, social, sexual<br />Social support diminishes<br />Insurance<br />Deal with feelings put on hold during treatment<br />
  7. 7. Post-Treatment <br />Possible Physical/Psychological Effects of Treatment<br />Fatigue<br />Weight Changes<br />“Chemo Brain”<br />Menopausal Symptoms<br />Sexual Changes<br />Feelings – Fear, anxiety<br />
  8. 8. Fatigue<br />Is an overwhelming sense of exhaustion that<br />Is unrelieved by sleep or rest<br />Is disproportionate to or unrelated to activity<br />Has a profound impact on quality of life<br />Doctors do not know the exact causes<br />Causes of fatigue during treatment are different than for post treatment<br />
  9. 9. Fatigue in Breast Cancer Survivors<br />34 % of women report symptoms of fatigue up to 10 years after diagnosis<br />Factors associated with fatigue<br />Depressive symptoms<br />Pain control problems<br />Heart disease & high blood pressure<br />Tx with Radiation & Chemotherapy Bower et al., 2006<br />
  10. 10. Fatigue Management<br />Fatigue<br />Check for physical causes and/or medications<br />Diet and drink plenty of fluids<br />Exercise<br />Pacing yourself<br />Relaxation/Imagery<br />Keep diary to see when most energetic<br />Music<br />Ask for help with tasks<br />
  11. 11. Weight Gain After Breast Cancer<br />Many women gain weight during and after chemotherapy<br />Not sure of causes? Decreased physical activity? Hormonal changes? Increased eating due to anxiety?<br />Average weight gain is 5-8 pounds<br />Journal of Clinical Oncology 2002: Increased risk of recurrence for overweight/obese survivors<br /> JAMA 2005: Women exercise 3-5 hrs a week less likely to die of breast cancer vs. women exercise < 1hr<br />
  12. 12. “Chemo Brain”<br />1 out 4 people with cancer report attention/memory problems after chemotherapy<br />Not sure of cause (s)<br />Some research has now documented actual changes in tests performance and PET scans among breast cancer patients who received chemo vs. those who did not<br />Silverman, et al., 2006.<br />
  13. 13. “Chemo Brain”<br />Memory difficulties may be related <br />Higher doses of chemotherapy<br />Chemotherapy and/or radiation to the head area<br />Medications<br />Anxiety and/or depression<br />Going through menopause<br />But in general not sure of causes<br />
  14. 14. “Chemo Brain”<br />May need a neuropsychological evaluation<br />Write notes to yourself<br />Repeat what you want to remember<br />Review information and talk yourself through it<br />Break information down into chunks, e.g., numbers<br />Leave reminders around the house<br />Manage stress<br />
  15. 15. Sexuality in General Population<br />1 out of 3 women report low sexual desire<br />40% of women report decreased libido during menopause<br />Levels of testosterone of women in their 40’s are half of the those of women in their 20’s<br />
  16. 16. How Is Your Sex Life Lately?<br />81% of breast cancer survivors never asked about sexual issues by healthcare providers<br />McCaughton, 1997<br />
  17. 17. Sexual Functioning: Breast Cancer<br />At 1 year 33% sexual problems compared to 8% of controls(Anderson & Lamb, 1995)<br />40% of sample of breast cancer survivors reported adverse effects to their sexual life(Meyerowitz, 1979)<br />Dyspareunia was reported in 57% of sample of breast cancer survivors having undergone chemotherapy(Schover et al., 1995)<br />60% of sample of breast cancer survivors reported decreased interest in sex<br />Painful intercourse reported at 11% before and 44% after tx (Lindley et al, 1998)<br />
  18. 18. Sexuality After Gynecologic Cancer<br />Ovarian Cancer Survivors<br />More than 50% cancer negative impact of sexual life<br />75% sex lives poor to adequate<br />Cervical and Endometrial Cancers<br />31% to 88% sexual problems especially if had radiation<br />
  19. 19. Prostate Cancer<br />Nerve Sparing less likely ED, may slowly return (up to 2 years)<br />Nerve Sparing depends on size and location of tumor<br />50% of men have ED before surgery<br />Seed Implants less likely ED than external beam and radical prostectomy<br />External Beam XRT gradual loss may occur<br />Younger (less than 60) and erectile function pre surgery better results<br />
  20. 20. Treatment Options for ED<br />Medications: Viagra, Levitra, Cialis<br />Injections: alprostadil or papaverine<br />Pellets of alprostadil<br />Vacuum Pumps<br />Penile Prosthesis<br />Better results with injections and penile implants, yet men less likely to try these<br />
  21. 21. Medications for ED<br />
  22. 22. Colon/Rectal and Bladder Cancer (Ostomies)<br />Careful how much you and eat and what you eat (or drink)<br />Change ostomy pouch even if not 1/3 full<br />Make sure pouch is empty and flat<br />If discomfort, change positions<br />Deodorant for pouch?<br />Special pouch covers<br />
  23. 23. Medications and Sexual Functioning<br />Anticancer Drugs: Chemotherapy<br />Endocrine Drugs<br />Antihypertensive<br />Diuretics<br />Neuroleptics<br />Allergy Meds<br />Antidepressants<br />Narcotics<br />Alcohol<br />
  24. 24. MENOPAUSE AFTER BREAST CANCER<br />Menopausal women diagnosed with breast cancer are asked to immediately discontinue hormone replacement…menopause symptoms may return<br />Zoladex : premature menopause<br />Aromatase Inhibitors: Joint/muscle pain, fatigue, decreased sexual desire<br />Tamoxifen:Possible side-effects vary by age<br />
  25. 25. MENOPAUSE AFTER BREAST CANCER<br />Chemotherapy: premature menopause<br />Higher doses: permanent menopause<br />Alkylating agents<br />The older you are, the more likely menopause will be permanent<br />Women under 40yo-------25 - 40% Premature Menopause<br />Women over 40yo---------76 - 90% Premature Menopause<br />
  26. 26. MENOPAUSE<br />Decrease in estrogen and testosterone levels<br />Hot Flashes <br />Vaginal Dryness/Pain/Tightness<br />Changes in Mood<br />Fatigue<br />Memory Changes<br />Sleep Difficulties<br />Decreased libido (sexual desire)<br />
  27. 27. ENHANCING YOUR SEXUALITYHOT FLASHES<br />Stay hydrated and carry water spray bottle<br />Antidepressants<br />Effexor, Celexa, Lexapro<br />May help with hot flashes (also with mood, sleep, fatigue)<br />Therapeutic doses may be lower than for depression (less likely to have sexual side-effects)<br />
  28. 28. ENHANCING YOUR SEXUALITYHOT FLASHES<br />Exercise<br />Relaxation Exercise (Meditation)<br />Diet<br />Herbal<br />Acupuncture<br />Neurotin<br />Avoid: Caffeine, Alcohol, Tobacco, Individual triggers (e.g., spicy foods, clothing)<br />
  29. 29. PREDICTORS OF SEXUAL DYSFUNCTION<br />Main predictor Vaginal dryness<br />Emotional Well-Being<br />Body-Image<br />Quality of Relationship<br />Ganz,1999<br />
  30. 30. ENHANCING YOUR SEXUALITY<br />If vaginal dryness/pain<br />Vaginal lubricants (water based)<br />Moisturizers (Replens, Silken)<br />Replens draws water out of cells into vaginal lining<br />Can be as effective as estrogen cream<br />Lubricants (Astroglide, K-Y Jelly)<br />Suppositories (Lubrin, Condom Mate)<br />
  31. 31. ENHANCING YOUR SEXUALITY<br />If vaginal dryness/pain:<br />Drink lots of water<br />Check Medications<br />Avoid douches<br />Avoid feminine hygiene sprays<br />Avoid perfumed soaps<br />Deodorant panty liners<br />
  32. 32. ENHANCING YOUR SEXUALITY<br />Marinol ?<br />Viagra, Levitra, Cialis ?<br />Wellbutrin (to deal with AD side-effects)<br />Herbal ?<br />
  33. 33. New Medications Being Researched<br />Flibanserin: sexual desire and arousal for premenopasualwomen, nonhormonal?<br />Ophena : vaginal atrophy, nonhormonal?<br />Bremelanotide: sexual desire/arousal, men and women, works via CNS?<br />LibiGel: gel formulation of testosterone, sexual desire for women?<br />Luramist:testosterone, transdermal spray?<br />Intrinsa:testosterone sexual desire women?<br />
  34. 34. Exercise<br />Several studies have shown that increased physical activity and/or exercise is beneficial in terms of sexual functioning for both men and women<br />Annals of Beh Medicine 1999, Urology 2005, Cancer 2004.<br />
  35. 35. ENHANCING YOUR SEXUALITY<br />COMMUNICATE WITH YOUR PARTNER<br />Get comfortable with yourself and changes<br />Give yourself time to get in the mood<br />Listen to relaxing music<br />Touch, hold hands, dance, kiss, tub bath<br />Watch a sexy/erotic movie <br />Gentle touching, extra time for foreplay<br />Sensual touching with massage, foot rub<br />
  36. 36. ENHANCING YOUR SEXUALITY<br />Try to keep an open mind about ways to feel sexual pleasure/positions/experiment<br />Self-stimulation/Vibrator<br />No matter what, most people enjoy being touched<br />Kegel exercises<br />Be patient with yourself<br />Limit touching, if painful (communicate)<br />Keep sex in perspective<br />
  37. 37. Feelings<br />Most early stage breast cancer patients adjust well after treatment. <br />Some studies show that 20-40% report feeling depressed, anxious or both 1 year post-treatment.<br />By the second, third and fourth year 25% report distress and by the fifth year 15%.<br />Moderate levels of distress reported by most on cancer specific concerns. *<br />Burgess et al., 2005<br />
  38. 38. Managing Cancer Anxiety<br />Acknowledging that it is normal to have some anxiety of cancer recurrence, especially on anniversary dates, when someone recurred.<br />Don’t neglect your healthcare. Have a plan.<br />Discuss your feelings and worries with friends, support group or other cancer survivors.<br />Learning to decipher physical symptoms<br />
  39. 39. Managing Cancer Anxiety<br />Stress is part of life. Even positive life events stressful, e.g. marriage, new job, new home, birth of child.<br />Stress management, e.g., exercise, meditation, humor, painting, whatever works for you.<br />Finding some meaning to cancer experience.<br />Know that anxiety gradually improves over time, cancer will not always be the center of your life…recedes to the background.<br />Use your anxiety as a reminder to appreciate life.<br />If your anxiety continues and interferes with quality of life seek professional help.<br />
  40. 40. Post-Treatment Adaptation to Breast Cancer<br />In comparison with women with benign breast disease, women with breast cancer report:<br />Improvement in their outlook on life<br />Enhanced interpersonal relationships<br />Deeper religious and spiritual satisfaction<br />Andrykowski et al, 1999<br />