Am 11.30 grunfeld

668 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
668
On SlideShare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
4
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Like the Institute of Medicine in its report From Cancer Patient to Cancer Survivor this discussion will focus on the more narrow definition principally in order to allow for a more focused discussion
  • From IOM report From Cancer Patient to Cancer Survivor, 2006
  • From IOM report From Cancer Patient to Cancer Survivor, 2006
  • Late effects – eg cardiovascular, fatigue, cognitive functioning
  • Compared to 5 years of tamoxifen alone, addition of an AI improves DFS and reduces the risk of breast cancer events, including distant recurrence, loco-regional recurrence and contralateral breast cancer. In absolute terms, the reduction in risk of recurrence associated with AI compared with tax is modest, typically <5%.. Tam and AIs are equivalent in terms of OS. Two of six trials of sequential treatment strategies yielded statistically significant improvements in OS compared with Tam alone, although absolute difference is modest.
  • The surveillance recommendations for breast cancer survivors are relatively minimal. The ASCO guidelines suggest a history and physical 2 to 4 times a year for the first few years then 1-2 times a year. Other than mammograms, imaging and lab tests are NOT recommended for asymptomatic patients.
  • Breast cancer survivors in the Nurses Health Study according to their levels of physical activity (MET=metabolic equivalents per week). The sedentary referent group is represented by the far left-hand set of bars. These sedentary women had significantly higher rates of recurrence, breast cancer mortality and all-cause mortality compared with women who had increased physical activity. The cut point of 9 hrs per week is approx 30 minutes a session, 5 session per week. This is based on a longitudinal observational study. More definitive work is needed. Slide taken from Demark-Wahnefried’s chapter in Implementing Cancer Survivorship Care Planning.
  • Data from breast cancer survivors enrolled in the Nurses Health Study. Women who increased their body mass index from 0.5 to 2 units were at significantly higher risk for breast cancer recurrence, breast cancer mortality and overall mortality when compared with women who maintained their weight (represented by the second set of bars from the left. This unit increase in weight is not large and can be anywhere from 3 to 13 lbs, depending on the women’s height. This is based on a longitudinal observational study. More definitive work is needed. Slide taken from Demark-Wahnefried’s chapter in Implementing cancer survivorship care planning.
  • CEA- tumour marker update says q3 for at least 3 years; ASCO 2000update says q 2 to 3 months for at least 2 years Apply to patients who with stage IIb or III and fit and willing to have resection. Clinical series have shown that resection of liver met can cure up to 60%. Similarly, resention of lung met, local and new primary CEA is elevanted in approximately 60% of patients with recurrence.
  • From IOM report From Cancer Patient to Cancer Survivor, 2006 Over 80% are over age 65
  • From IOM report From Cancer Patient to Cancer Survivor, 2006 For those over 65, 80% have two or more comorbidities
  • From IOM report From Cancer Patient to Cancer Survivor, 2006 Severity of comorbidities varies by cancer site but roughly over 50% have comorbidities that are moderate or severe
  • Yancik R et al JAMA 2001;285:885-892
  • Risk of contralateral breast primary approximately 0.5 to 1% per year Risk increases with early age, genetic predisposition, or lobular carcinoma
  • All results at 18 months of follow-up Total of 26 recurrences: 10 in GP group; 16 in hospital group Study was powered to detect a 3month difference in delay at 90% and alpha=0.05 needed 30 recurrences Time with patient” 3.39 visits in GP group; 2.8 visits in hospital group Costs per patient = average cost over 18 months of follow-up per patient (includes costs of visits and costs of tests Time for the patient per appointment = to and from appointment, waiting to see the doctor, with the doctor, does not include costs for the accompanying person. NO difference in deterioration in HRQOL GP patients more satisfied
  • The trial rationale and objectives were developed in response to one of the chief recommendations made in the seminal IOM report “From Cancer Patient to Cancer Survivor: Lost in Transition.” The recommendation was that “All patients completing primary treatment should be provided with a comprehensive care summary and follow-up plan described as a survivorship care plan. The recommendation that all patients should receive a SCP was made because it was considered to have face validity, although it was acknowledged that to date there has never been a rigorous evaluation.
  • All patients were on active follow-up through tertiary cancer centres at the time of enrollment
  • After randomization all patients in both groups were transferred to the primary care physician for exclusive follow-up. If there were multiple providers such as medical, surgical and radiation oncologists, all agreed to transfer follow-up to the PCP. All patients received a final discharge visit with their oncologist according to usual practice at that centre. The oncologist was asked to recommend to the patients and to the PCP via the dictation note that the first visit be in 3 months, and a clear statement that follow-up was now the responsibility of the PCP.
  • In addition, patients in the experimental group received the SCP The patient’s PCP received, by mail, a copy of the SCP, a copy of the Canadian published guideline on follow-up, a user friendly abbreviated version of the guidelines and a reminder table of visits and tests.
  • SCP contained a personalized record of care, a summary of what to expect, patient version of the guideline, identification of providers, and supportive care resources. These documents were completed and compiled in a binder by a nurse and reviewed with the patient during a 30 minute educational session.
  • As shown here there were also no differences in change scores between groups. Once again, as there were no differences when each stratum was analyzed separately, we show here the results for the total sample.
  • Am 11.30 grunfeld

    1. 1. Care of the Cancer Survivor Eva Grunfeld, MD, DPhil, FCFPOntario Institute for Cancer Research, andDept of Family and Community Medicine, University of Toronto
    2. 2. No conflicts of interest
    3. 3. Objectives of the Presentation1. Definition and epidemiology of cancer survivors2. Overview of cancer-related healthcare needs of cancer survivors3. Overview of general medical and preventive healthcare needs of cancer survivors.4. Review the role of PCPs and survivorship care plans5. Conclusions
    4. 4. Objectives of the Presentation1. Definition and epidemiology of cancer survivors2. Overview of cancer-related care needs of cancer survivors3. Overview of general medical and preventive care needs of cancer survivors.4. Review the role of PCP and survivorship care plans5. Conclusions
    5. 5. Definitions of Survivorship From the time of diagnosis through the remaining years of life. National Action Plan for Cancer Survivorship, Centers for Disease Control and Lance Armstrong Foundation, USA, 2004 versus The period following first diagnosis and treatment and prior to the development of a recurrence of cancer or death. Source: From Cancer Patient to Cancer Survivor, Institute of Medicine, USA, 2006
    6. 6. Cancer Care Trajectory Source: IOM, 2006
    7. 7. Source: J. Natl. Cancer Inst. 2008 100:236; doi:10.1093/jnci/djn018
    8. 8. Breast Cancer:Conditional relative survival Source: IOM Report, 2006
    9. 9. Colorectal Cancer:Conditional relative survival Source: IOM Report, 2006
    10. 10. Summary 50% of cancer patients will be long-term survivors Breast and colorectal are among the most prevalent cancers ⇒Between 60 to 80% are long-term survivors approximately 3% of the population are cancer survivors most are elderly and most have multiple comorbidities
    11. 11. Objectives of the Presentation1. Definition and epidemiology of cancer survivors2. Overview of cancer-related healthcare needs of cancer survivors (focus on breast and colorectal cancers)3. Overview of general medical and preventive healthcare needs of cancer survivors.4. Review the role of PCP and survivorship care plans5. Conclusions
    12. 12. Case : Breast CancerYour patient is a 48 y.o. with T2N1M0 carcinoma of the left breast. Primary treatment consisted of lumpectomy, chemotherapy, and radiotherapy. She is on extended adjuvant treatment with an aromatase inhibitor. ⇒ Now what? Her oncologist recommends the following protocol for follow-up:  Visits every 3-4 months for 10 years  Annual CT and bone scan  CBC, LFTs each visit  Tumour markers (CA-15, CA-27, CEA) each visit  Bilateral mammogram biennially (as per screening recommendations) ⇒ Do you agree?
    13. 13. Survivorship IssuesRoutine follow-up care Surveillance for recurrence Surveillance for late effects of treatment Surveillance for new primary cancer Psychosocial issues Special concerns (social/economic/occupational)General medical and preventive care
    14. 14. Special Issues Ongoing adjuvant hormonal therapy Weight control Lymphoedema Menopausal Symptoms Osteoporosis Cognitive functioning Psychosocial functioning
    15. 15. Breast Cancer: surveillance for recurrence Distant recurrences  occur within 5 years  can occur ≥ 10 years Most frequent sites of recurrence:  breast, bone, liver, lungs 69% of recurrences are interval events and present with signs or symptoms, not routine tests Source: Grunfeld et al., BMJ, 1996
    16. 16. Diagnosis of Recurrence Interval or symptomatic (%) Tomlin 1987 64 Zwaveling 1987 73 Rutgers 1989 77 (distant) Ciatto 1985 58 Ormistan 1985 78 Valagussa 1981 78 Stierer 1989 40 (distant) Pandya 1985 54 Scanton 1980 73 Winchester 1979 91 Grunfeld 1997 69* Woster 1995 77* Donnelly 2002 74* te Boekhorst 2001 63* Identified as interval event Source: Tomiak, Ann Oncol, 1993
    17. 17. Adjuvant hormonal treatment Extended adjuvant treatment with Aromatase Inhibitors (AI) and/or Tamoxifen (for hormone receptor +ve) Several scenarios:  immediate Tam (maximum of 5 years)  immediate AI (maximum of 5 years)  AI after 2 to 3 years, or after 5 years of Tamoxifen  AI followed by 2nd AI  AI for postmenopausal only  s/e = loss of BMD, fracture (2-4%), bone/joint pain Tam for pre, peri, or postmenopausal  s/e = uterine cancer (1%), hot flashes, DVTs (1-2%) Source: Burstein, J Clin Oncol, 2010
    18. 18. Breast Cancer: ASCO Guidelines for Follow-Up History and physical, including breast exam Every 3 to 6 months for Years 1-3 Every 6-12 months for Years 4-5 Annually thereafter Annual mammogram, unless otherwise indicated Other lab tests and scans NOT recommended in asymptomatic patients Source: Khatcheressian et al., JCO, 2006
    19. 19. Surveillance Mammography Purpose  Detection of ipsilateral recurrence  Detection of contralateral new primary RCTs of follow-up regimens control for mammography Guidelines recommend annual Source: Grunfeld, Noorani et al., The Breast, 2002
    20. 20. Prevalence of Late ToxicitiesCommon Less CommonPremature Depends on age Cardiovascular CHF 1-5%menopause and regimen; 70% of Disease women over 40 CMFHot flashes 40-50% Second Primaries Leukemia 1-2%Weight gain 50% gain 6-11 lbs; Endometrial cancer <1%Fatigue 30% 1-5 yrs Sarcoma <1%Cognitive 30% Bone health 2% fractureImpairment on AILymphedema 12-35% Blood clots 1-3% From Cancer Patient to Cancer Survivor, IOM Report 2006
    21. 21. Outcomes related to exercise in breast cancer survivors Level of Exercise (MET hours/week) Source: Adapted from Holmes et al., 2005
    22. 22. Outcomes related to weight gain in breast cancer survivors Change in Body Mass Index (BMI) Source: Adapted from Kroenke et al., 2005
    23. 23. Case: Colon CancerYour patient is a 65 year old otherwise healthy woman whohas just completed adjuvant chemotherapy for Duke’s Ccolon cancer.⇒She wants to know what happens now. She asks you: - how often do I need to see the doctor? - do I not to go to the oncologist or my PCP? - what kind of regular tests do I need? - what problems should concern me? ⇒ What do you tell her?
    24. 24. Colorectal Cancer: surveillance for recurrence early stage – 90% 5 year survival Stage III – 65% 90% of recurrences in first 5 years most common sites ⇒liver, lung, local, abdomen Metachronous new primary 3 to 5% in first five years Meta-analysis of RCTs show that intensive follow-up results in improved survival
    25. 25. Colorectal Cancer: ASCO Guidelines for Follow-up ASCO 2005 update History and physical: - q 3 to 6 months x3 years; q 6 months years 4+5 CEA - q 3 months ≥ 3years; if stage II or III, eligible for Sx or CTx LFTS, FOBT, CBC - no CT chest and abdo; CT pelvis for rectal cancer - annual if eligible for Sx or CTx Colonoscopy - perioperative; year 3; year 5; more frequently if polyps
    26. 26. Objectives of the Presentation1. Definition and epidemiology of cancer survivors2. Overview of cancer-related care needs of cancer survivors3. Overview of general medical and preventive care needs of cancer survivors.4. Review the role of PCP and survivorship care plans5. Conclusions
    27. 27. Cancer prevalence by age 25.0% 19.3% 20.0% 18.0% 17.8% 14.8% 15.0% 11.3% 10.0% 8.0%Percentage 5.4% 5.0% 3.5% 2.2% 0.6% 0.9% 1.4% 0.0% 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age
    28. 28. Number of comorbidities by age 12.8 24.3 12.5 38.6 18.4 16.4 16.1 20.1 22.5Percentage 16.9 19.2 21.1 15 13.6 12.7 8.8 6.4 4.6 55-64 65-74 75+ Age 0 1 2 3 4 5
    29. 29. Severity of comorbidity by cancer site 2.9 5.5 4.4 7.4 6.8 9 10.3 14.2 14.1 13.3 16.1 17.3 17.3 20 25.4 28.8 31.6 27.6 27.3 29.8 29.8 None 32.9 Mild 29.3 Mode rate 28.6 Se ve rePercentage 55.3 53.6 52.2 45.5 46 38 31.2 30.6 Lung Breast Prostate All Patients Gynecological and Neck Head Urinary System Digestive System
    30. 30. Competing Causes of DeathYancik, R. et al. JAMA 2001;285:885-892. Source: Yancik et al., JAMA, 2001p 30 mon
    31. 31. General Medical and Preventive Care Management of comorbid conditions  heart disease, diabetes Early diagnosis of chronic diseases Preventive health care Screening for other primary cancers new breast primary, colorectal cancer, ovarian cancer Screening for other chronic diseases osteoporosis, hypertension, hyperlipedemia
    32. 32. Never screened over 4 years Index Cancer 4 % HodgkinÕ s Breast Lymphoma Endometrial Colorectal (n=11,219 ) (n=2,322 ) (n=3,473 ) (n=1,833 ) Screening 1 Mammogram - 36.6 24 .4 38 .4 Pap 2 50.7 37 .0 - 63 .2 Colorectal 65.3 76 .1 65 .6 - cancer 31. Females age 50-692. Females age 20+3. Age 50 to 74; FOBT, Barium enema, sigmoidoscopy or colonoscopy4. Size of sample varies based on age/sex eligibility for screening modality Source: Grunfeld et al., Can Fam Phys In Press
    33. 33. Summary Cancer survivors are at risk for late complications Complex interactions between late effects of treatment, other medical conditions, and cancer Focus on medical care for conditions other than the index cancer is crucial, particularly for older cancer survivors
    34. 34. Objectives of the Presentation1. Definition and epidemiology of cancer survivors2. Overview of cancer-related care needs of cancer survivors3. Overview of general medical and preventive care needs of cancer survivors.4. Review the role of PCP and survivorship care plans5. Conclusions
    35. 35. Breast cancer patients: mix of physician visits Follow -up Year % of patients with at least one visit Physician Specialty Year 2 Year 3 Year 4 Year 5 (n=11,219) (n=10,026) (n=9,297) (n=8,624)Primary Care Only * 8.0 12.3 17.3 23.0Oncology Only* 8.8 7.7 7.5 6.4 Multiple 4.9 3.6 3.0 2.2PCP and Onc ology* 81.1 77.0 71.8 66.6 PCP and Medical 11.3 16.5 18.4 17.6 PCP and Radiation 7.5 8.2 9.2 9.3 PCP and Surgical 13.1 13.9 14.7 15.9 PCP and Multiple 49.2 38.4 29.5 23.8 * P < 0.001 Source: Grunfeld, J Oncol Pract, 2010
    36. 36. Mix of Physician Specialties Visited: Breast Cancer Survivors706050 Year 140 Year 2 Year 330 Year 420 Year 510 0 Both PCP Only Oncologist Neither Only *p<0.0001 for change over time Source: Snyder et al., JGIM, 2009
    37. 37. Testing a Primary Care Model of Breast Cancer Follow-up Care STUDY YEARS METHODS SUBJECTS 1991-1992 Focus Groups Patients (England) 1992-1993 Focus Groups Patients (England)Phase I 1992-1993 Survey FPs (England) 1992-1993 Survey Specialists (England)Phase II 1993-1994 RCT (n=296) English PatientsPhase III 1997-2003 RCT (n=968) Canadian PatientsPhase IV 2007-2011 RCT (n=400) Canadian Patients
    38. 38. Testing a Primary Care Model of Breast Cancer Follow-up Care STUDY YEARS METHODS SUBJECTS 1991-1992 Focus Groups Patients (England) 1992-1993 Focus Groups Patients (England)Phase I 1992-1993 Survey PCPs (England) 1992-1993 Survey Specialists (England)Phase II 1993-1994 RCT (n=296) English PatientsPhase III 1997-2003 RCT (n=968) Canadian PatientsPhase IV 2007-2011 RCT (n=400) Canadian Patients
    39. 39. Results – Phase IIRandomized Trial Difference(18 months follow-up) Trial Group (95%CI) PCP Specialist n = 148 n = 141Time to diagnosis of recurrence 22 days 21 days 1.5 (-13 to 22)(days)Total time with the patient (min) 35.6 20.7 14.9* (11.3 to18.4)Cost per patient (£s) 65 195 - 130 * (-149 to -112)Time cost to the patient (min) 53 82 - 29 * (-37 to -23) No difference in health-related quality of life over time No difference in anxiety or depression over time PCP patients more satisfied *p<0.001 Source: Grunfeld et al., BMJ, 1996
    40. 40. Testing a Primary Care Model of Breast Cancer Follow-up Care STUDY YEARS METHODS SUBJECTS 1991-1992 Focus Groups Patients (England) 1992-1993 Focus Groups Patients (England)Phase I 1992-1993 Survey PCPs (England) 1992-1993 Survey Specialists (England)Phase II 1993-1994 RCT (n=296) English PatientsPhase III 1997-2003 RCT (n=968) Canadian PatientsPhase IV 2007-2011 RCT (n=400) Canadian Patients
    41. 41. Follow-Up Guideline Sentto Primary Care Physicians
    42. 42. Family Physician Cancer Centre Risk Difference (FP) Group (CC) Group CC – FPOutcome Event (n=483) (n=485) (95% CI) Number of Patients (%)Recurrence 54 (11.2%) 64 (13.2%) 2.02%Distanta 36 38 (-2.13, 6.16)Locala 10 12Contralaterala 11 15Death (All Causes) 29 (6.0%) 30 (6.2%) 0.18% (-2.90, 3.26)Serious Clinical Events 17 (3.5%) 18 (3.7%) 0.19% (-2.26, 2.65)Spinal Cord compressionb 0 1Pathological fractureb 3 8Uncontrolled local recurrenceb 2 0KPS ≤ 70b 14 18Brachial plexopathyb 0 0Hypercalcemiab 2 2
    43. 43. Testing a Primary Care Model of Breast Cancer Follow-up Care STUDY YEARS METHODS SUBJECTS 1991-1992 Focus Groups Patients (England) 1992-1993 Focus Groups Patients (England)Phase I 1992-1993 Survey FPs (England) 1992-1993 Survey Specialists (England)Phase II 1993-1994 RCT (n=296) English PatientsPhase III 1997-2003 RCT (n=968) Canadian PatientsPhase IV 2007-2011 RCT (n=400) Canadian Patients
    44. 44. Evaluating a survivorship care planOverall Objective:  To determine if a survivorship care plan and educational intervention for breast cancer survivors ready for transition from specialist care to primary care improves patient and health service outcomes
    45. 45. From Cancer Patient to Cancer Survivor: Lost in Transition Institute of Medicine, 2006 Recommendation 2: Patients completing primary treatment should be provided with a comprehensive care summary and follow-up plan that is clearly and effectively explained. This “Survivorship Care Plan” should be written by the principal provider who coordinated oncology treatment.
    46. 46. What is a care plan Identifying information (patient and provider) Cancer treatment summary Diagnostic tests completed Risk of recurrence Signs and symptoms Recommended surveillance guidelines Potential late effects Preventive care recommendations
    47. 47. Design and SettingDesign: Multicenter randomized controlled trialSetting: 400 breast cancer patients on active follow- up through tertiary cancer centers throughout Canada
    48. 48. Study Intervention All Patients Received:Transfer to patients’ own FP for exclusive follow-up (i.e., alloncology providers agree to transfer)Discharge visit with oncologist according to usual practicePatients and FPs instructed to schedule the first follow-up visit inapproximately 3 monthsStatement that follow-up now provided by FP
    49. 49. Study Intervention Intervention Group Only Received:Patient received:30 minute educational session with nurseSurvivorship care planPatient’s FP received:Survivorship care planGuideline on follow-upUser friendly abbreviated versionReminder table of visits and tests
    50. 50. Survivorship Care Plan
    51. 51. Patient-reported Outcomes: Change Scores over Time Red dashed line = SCP, Black solid line = No SCP Source:Grunfeld, J Clin Oncol, 2011
    52. 52. Who should provide long-term care?ASCO guideline - 2005 update Based on two RCTs .. follow-up by a PCP appears to lead to the same health outcomes as specialist follow-up with good patient satisfaction. There is no reason to think that US patients will be any different.Canadian guideline - 2005 “responsibility for follow-up should be formally allocated to a single physician, with the patient participating as much as possible”
    53. 53. Percent willing to provide exclusive cancer follow-up: results from a Canadian national survey of FPs1Cancer ≤2yrs 3 to 5 yrs 10+ or neverProstate 55.3 35.4 8.1Colorectal 49.8 33.4 15.4Breast 50.0 40.5 7.7Lymphoma 42.0 41.6 15.41. Current experience providing exclusive follow-up most significant predictor ofwillingness. Source: Del Giudice, Grunfeld, et al,, J Clin Oncol, 2009
    54. 54. Usefulness of various modalities to help PCPs provide exclusive cancer follow-upRank Modality % 1 Patient-specific standardized letter with guidelines 95.4 2 Printed guidelines 91.8 3 Expedited rates of re-referral 92.7 4 Expedited access to test for suspected recurrence 91.1 5 Ability to telephoneemail specialist for advice 86.1 Source: Del Giudice, Grunfeld, et al J Clin Oncol, 2009
    55. 55. Objectives of the Presentation1. Definition and epidemiology of cancer survivors2. Overview of cancer-related care needs of cancer survivors3. Overview of general medical and preventive care needs of cancer survivors.4. Review the role of PCP and survivorship care plans5. Conclusions
    56. 56. Conclusions Growing prevalence of cancer survivors Change in perspective from acute life threatening disease to chronic disease Growing body of research shows that PCPs can, are, & wish to play a key role in post-treatment cancer care For breast cancer patients, a standard discharge visit with the oncologist achieved similar results as a survivorship care plan and educational session Quality of general preventive care is a concern Involvement of PCPs in post-treatment cancer care is essential but need guidelines, access, and education
    57. 57. Niagara Falls, Canada

    ×