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Cancer Survivorship Management
for Primary Care Physicians
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Cancer Survivorship Management for Primary Care
Physicians Video Transcript
Transcripción del video sobre gestión de
sobrevivientes del cáncer para médicos de cuidado
primario
Professional Oncology Education
Cancer Survivorship Management for Primary Care
Physicians
Time: 38:38
Educación Oncológica Profesional
Gestión de sobrevivientes del cáncer para médicos
de cuidado primario
Duración: 38:38
Lewis E. Foxhall, M.D.
Vice President
Health Policy, Office of the Executive Vice President,
Physician-in-Chief
The University of Texas MD Anderson Cancer Center
Dr. Lewis E. Foxhall
Vicepresidente
Políticas de Salud, Oficina del Vicepresidente
Ejecutivo y Jefe Médico
MD Anderson Cancer Center, Universidad de Texas
Hello, I’m Lewis Foxhall, VP for Health Policy at MD
Anderson and I appreciate your attention for this
presentation: Cancer Survivorship Management for
Primary Care Physicians.
Hola, soy Lewis Foxhall, Vicepresidente de Políticas
de Salud en el MD Anderson Cancer Center y
describiré la gestión de sobrevivientes del cáncer
para médicos de cuidado primario.
Cancer Survivorship
Management for Primary
Care Physicians
Lewis E. Foxhall , M.D.
Vice President
Health Policy, Office of the Executive
Vice President, Physician-in-Chief
M. D. Anderson Cancer Center • Houston, Texas
1
Cancer Survivorship Management
for Primary Care Physicians
US Cancer Survivor Prevalence
12,000,000
10,000,000
Number
8,000,000
Cancer survivorship is an issue that has become more
prevalent over the last several years. As you can see
from this first slide, the number of cancer survivors
has increased dramatically over the last several years.
And there are almost 12 million cancer survivors in the
United States today. So this is a very prevalent
problem and something that you will certainly see in
your practices.
La supervivencia al cáncer se ha vuelto más
prevalente en los últimos años. Esta diapositiva
muestra que el número de sobrevivientes del
cáncer ha aumentado drásticamente en los últimos
años. Actualmente, existen en los Estados Unidos
casi 12 millones de sobrevivientes, por lo cual este
es un problema prevalente en nuestra práctica
profesional.
Cancer survivors are of many different sorts, as you
can see here in this breakdown of cancer survivors by
site. Female breast cancer survivors and prostate
cancer survivors in men are the most common,
followed by colorectal cancer, gynecologic cancers,
hematologic and urinary tract; melanoma, and thyroid
making up smaller proportions, and then a number of
other cancers contributing another 11 percent. So as
you can see, this is an issue that’s predominated by
several very common cancer types and these you will
certainly encounter frequently.
Como vemos en este gráfico, hay muchas clases de
sobrevivientes, según el órgano afectado. Los
sobrevivientes más comunes son mujeres con
cáncer de mama y hombres con cáncer de próstata,
seguidos por pacientes con cáncer colorrectal,
ginecológico, hematológico y del tracto urinario;
melanoma y tiroides en menor proporción; mientras
que otros cánceres representan el 11%.
Es evidente la prevalencia de varios tipos de cáncer
muy comunes que ocurren con más frecuencia.
6,000,000
4,000,000
2,000,000
0
Year
Cancer Survivorship Management
for Primary Care Physicians
Cancer Survivors by Type
Thyroid
4%
Melanoma
7%
Other
11%
Female Breast
23%
Urinary Tract
(Bladder, Kidney,
Renal Pelvis)
7%
Hematologic (HD, NHL,
Leukemia, ALL, Myeloma)
8%
Prostate
20%
Colorectal
10%
Gynecologi
c
9%
2
Cancer Survivorship Management
for Primary Care Physicians
Female Survivors - n=6.2M
Thyroid
5%
Ovary
3%
As we look at it from the female gender, breast cancer
is the much more prevalent condition that we will
encounter, followed by colorectal, hematologic,
bladder, melanoma, then cervix, lung and bronchus,
ovary, and thyroid.
Si consideramos a los pacientes de sexo femenino,
el cáncer de mama es la condición prevalente,
seguido por el cáncer colorrectal, hematológico,
vesical y melanoma; luego el cáncer cervical, de
pulmón y bronquios, ovario y tiroides.
On the male side, prostate cancer again contributing a
very large proportion of the number of cancer
survivors, followed by colorectal, then hematologic,
urinary bladder, melanoma, lung and bronchus,
oropharyngeal, and testicular, and then the others
making up 10 percent.
En pacientes masculinos, el cáncer de próstata
contribuye a una gran proporción de sobrevivientes,
seguido por el cáncer colorrectal, hematológico,
vesical, melanoma, de pulmón y bronquios,
orofaríngeo, testicular, y otros que conforman el
10%.
Other
8%
Lung & Bronchus
3%
Cervix
4%
Female Breast
43%
Melanoma
7%
Urinary Bladder
8%
Hematologic
7%
Colorectal
11%
Cancer Survivorship Management
for Primary Care Physicians
Male Survivors - n=5.2M
Testis
4%
Oropharyngeal
3%
Other
10%
Lung & Bronchus
3%
Melanoma
7%
Prostate
44%
Urinary Bladder
8%
Hematologic
10%
Colorectal
11%
3
Cancer Survivorship Management
for Primary Care Physicians
Cancer Survivors by Age
< 19 Years of Age
1%
65+ Years of Age
60%
20-39 Years of Age
4%
Survivors by Duration
People in millions
Males
Females
2.0
En cuanto a la edad de los sobrevivientes,
predominan las personas de mayor edad, de
65 años en adelante, que en los Estados Unidos
constituyen un 60% de los sobrevivientes. Sin
embargo, hay un número sorprendentemente alto
de sobrevivientes en el grupo etario de 40 a
64 años, que es el 35%. Hay sobrevivientes del
cáncer más jóvenes, pero son una minoría.
If we consider the distribution of cancer survivors from
the time of diagnosis to current, then there are of
course a larger number of survivors in the time period
from diagnosis to 5 years and then from 5 years on
out it tapers down. But then begins to increase slightly
in females as we get into the longer time periods. As
you can see, the makeup of males and females in the
younger, rather in the age groups that are closer to
diagnosis is fairly even, but as time goes by the
females predominate in the survivor population.
Si consideramos la distribución de los
sobrevivientes desde el momento del diagnóstico
hasta el presente, naturalmente hay un mayor
número de sobrevivientes en el período del
diagnóstico hasta los 5 años, que luego se reduce.
A medida que avanzamos en el tiempo, el número
de mujeres aumenta ligeramente. La composición
de hombres y mujeres en el grupo etario más
cercano al diagnóstico es bastante uniforme, pero,
a medida que transcurre el tiempo, las mujeres
predominan en la población sobreviviente.
40-64 Years of Age
35%
Cancer Survivorship Management
for Primary Care Physicians
2.5
If we look at the age breakdown of cancer survivors it
would be expected predominated by individuals in
older age groups, 65 years and above, contributing
about 60 percent of the cancer survivors in this
country. But there is a surprisingly large number of
survivors in the 40 to 64 year old age group
contributing 35 percent. Certainly a number of
younger cancer survivors but they are the minority.
1.5
1.0
0.5
0.0
0 to <5
5 to <10 10 to <15 15 to <20 20 to <25
Years from Diagnosis
>25
4
Cancer Survivorship Management
for Primary Care Physicians
Goals of Survivorship Management
• Maximize benefits of treatment
• Maximize quality and duration of survivorship
Cancer Survivorship Management
for Primary Care Physicians
Goals of Cancer Survivorship Management
• Detection of recurrent disease at
earliest opportunity
• Prevention and detection of second primaries
So what are our goals for cancer survivorship
management? What are we trying to achieve?
Certainly the first thing is to maximize the benefits of
the treatments that the individuals have received.
These cancer patients have gone through often
difficult treatments and have been successful in
making that transition into survivorship. And we want
to be sure we can maximize that for their benefit.
Certainly the next, and also very important goal, is to
maximize the quality of life for individuals surviving
cancer and be sure that we can maximize the duration
of that survivorship. So there are a number of things
that we can do especially in the primary care arena to
be sure that we work toward those goals.
¿Cuáles son nuestros objetivos para el control de
los sobrevivientes del cáncer? ¿Qué tratamos de
lograr? Sin duda, lo primero es maximizar los
beneficios de sus tratamientos. Han recibido
terapias a menudo dificultosas y han logrado
franquear la transición a la supervivencia.
Queremos maximizar esa circunstancia para su
beneficio. El siguiente objetivo, también muy
importante, es maximizar la calidad de vida de los
sobrevivientes del cáncer y prolongar su
supervivencia en la medida de lo posible. Existen
diversas alternativas, sobre todo en el ámbito del
cuidado primario, para la consecución de esos
objetivos.
As we look at the primary areas of focus for cancer
survivorship management, our goals are first to detect
a recurrent disease at the earliest opportunity. We
want to prevent and detect any second primaries that
may occur. And we want to monitor post- treatment
side effects. These can be fairly common and quite
significant. We want to provide, of course, support for
our patients and their family and caregivers as they
continue the journey through cancer survivorship.
Con respecto a las áreas primarias de enfoque para
controlar la supervivencia al cáncer, el primer
objetivo es detectar lo antes posible una
enfermedad recurrente. Queremos prevenir y
detectar cualquier segundo tumor primario, y
también monitorizar los efectos secundarios
posteriores al tratamiento, que suelen ser usuales y
considerables. Debemos brindar a pacientes,
familiares y cuidadores el apoyo que necesitan
durante la sobrevida.
• Monitor post-treatment side effects
• Provide support to patient and family
5
Cancer Survivorship Management
for Primary Care Physicians
Cancer Survivor Health Risks
• Recurrence
• Second primary tumor
• Side effects of chemotherapy, radiation
and surgical interventions
– Long term and late occurrence
• Co-morbid conditions - 70% prevalence
There are certainly a number of risks that all of our
patients face, but in particular, cancer survivors face a
number that are more challenging. Obviously, the
chance of recurrence is a big challenge for most
survivors. This is something that many survivors have
a lot of concern and anxiety about, and something that
we need to pay attention to and to monitor very
closely to surveil for any evidence of that recurrence.
Second primaries may occur. Cancer survivors are at
increased risk for a number of primaries outside their
original cancer. So we want to be sure that we’re
following the appropriate screening and prevention
guidelines for these individuals and providing
additional screening if that’s indicated. Management
of the side effects of chemotherapy, radiation and
surgical interventions can be a challenge, both during
the treatment phase, but in particular, after the
treatment phase. So there are a number of conditions
which may persist after treatment and others that may
occur significantly later after the treatment is
completed. So these are things that we need to pay
particular attention to and to monitor and treat as we
find them. It is important to remember that many of
our cancer patients have co-morbid conditions. There
is a prevalence of about 70 percent of co-morbid
conditions in the cancer survivorship population, and
this is significantly higher than the general population.
So we must be alert to this and manage these in
conjunction with the other important priorities of
surveillance for recurrence, application of preventative
strategies, screening for second primaries and the
management of long-term and late complications.
Hay varios riesgos que todo paciente enfrenta, pero
los sobrevivientes del cáncer deben superar los
más difíciles. Obviamente, para la mayoría de ellos,
la probabilidad de recurrencia es un problema
importante que provoca gran preocupación y
ansiedad, y que debe vigilarse y monitorizarse
atentamente para no omitir ninguna evidencia de
recurrencia. Pueden aparecer segundos cánceres
primarios, pues los sobrevivientes del cáncer tienen
un riesgo mayor de contraer una serie de cánceres
primarios externos al cáncer original. Por eso,
debemos seguir pautas de detección y prevención
adecuadas y, si corresponde, hacer exámenes
preventivos adicionales. La gestión de los efectos
secundarios de la quimioterapia, la radiación y las
intervenciones quirúrgicas puede ser compleja
durante el tratamiento y, en particular, después de
esa fase. Hay una serie de condiciones que pueden
persistir después del tratamiento, y otras que
pueden ocurrir bastante después de completarlo.
Debemos atender estos factores, monitorizarlos y
tratarlos. Muchos pacientes de cáncer tienen
condiciones comórbidas. En la población
superviviente hay una prevalencia del 70% de
condiciones comórbidas, un índice
considerablemente más alto que el de la población
general. Es preciso estar atento a estas condiciones
y gestionarlas en conjunto con las otras prioridades:
vigilar la recurrencia, aplicar estrategias
preventivas, hacer exámenes para detectar
segundos cánceres primarios, y gestionar las
complicaciones tardías y a largo plazo.
6
Cancer Survivorship Management
for Primary Care Physicians
Under Use of Care by Survivors
• Prevention and health promotion is important
– Cancer survivors are at risk for other diseases
• Cancer survivors are significantly less likely
to receive recommended screening and other
preventive services
• Cancer diagnosis may shift attention away from
important non-cancer problems
(Earle CC et al, Cancer 2004:101:1712-1719)
Prevention and health promotion is a very important
thing. I think as primary care physicians, we all
recognize this and try best we can to apply those
principles in our practices for all of our patients. But in
particular, we need to pay attention to our cancer
survivors. It’s a shock to some cancer survivors I
think, but they are -- actually are at risk for other
diseases. Many of them feel that they’ve managed to
be able to get around a very serious problem and
have, in fact, done that and have been successful. But
there is a tendency to ignore the other things that we
need to pay attention to in prevention, screening and
early detection. It has been found that cancer
survivors actually are significantly less likely to receive
recommended screenings and other preventive
services. It’s unclear exactly why this occurs but it has
been clearly documented. It’s perhaps related to the
confusion or the distraction of the cancer diagnosis
and paying attention to that, to the detriment of paying
attention to the more common everyday things that we
can do to help prevent cancer, as well as other
problems, and to help maintain the patient’s state of
wellness and well being.
La prevención y la promoción de la salud son muy
importantes. Como médicos de cuidado primario,
creo que todos lo reconocemos y tratamos de
aplicar esos principios a nuestra práctica con todos
los pacientes. En particular, es necesario prestar
atención a los sobrevivientes del cáncer, que suelen
sorprenderse al recordarles que también pueden
sufrir otras enfermedades. Consideran que han
superado un grave problema —de hecho, han
tenido éxito—, pero tienden a ignorar otros
componentes de la prevención: los exámenes
preventivos y la detección precoz. Se ha
determinado que los sobrevivientes del cáncer
tienen una probabilidad considerablemente menor
de recibir los exámenes y servicios preventivos
recomendados. Desconocemos la causa, pero esto
ha sido claramente documentado. Tal vez tenga
relación con la confusión o la distracción generadas
por el diagnóstico de cáncer, al que se presta toda
la atención en desmedro de cosas cotidianas y
comunes que ayudan a prevenir esta y otras
enfermedades, y contribuyen a mantener el
bienestar del paciente.
7
Cancer Survivorship Management
for Primary Care Physicians
Late and LongLong-term Effects
• Long-term effects: develop in active treatment and persist
> 5 years
–
–
–
–
–
Neuropathy with weakness, numbness or pain
Fatigue, cognitive difficulties, sexual dysfunction
Functional difficulty with returning to work
Restricted physical and social activities
Depression, Anxiety
• Late-effects: not present or identified at treatment
–
–
–
–
–
–
Musculoskeletal complication
Late onset fatigue
Cardiovascular complications
Hypothyroidism
PTSD
Depression, Anxiety
Stein, Cancer Supplement, 2008
Let’s talk a little bit about delayed and long-term
effects. This is a situation that, I think, is perhaps new
to many and one that deserves a little more attention.
Long-term effects as we’ve described them, are those
that develop during active treatment and persist. That
is they’ve continued through, and often during, as well
as immediately after, treatment. And they may last for
some time. The ones that we’re concerned about are
those that last for several years, particularly over 5
years. These are a list of common long-term effects
that have been documented and these occur across
many different cancer sites. But the common ones are
neuropathy, this particularly manifests by weakness,
numbness or pain particularly in extremities. Fatigue,
cognitive difficulties, sexual dysfunction are also
reported fairly commonly. Functional difficulties may
result and these may impact the individual’s ability to
return to work or to resume their usual activities so
they can be quite debilitating at times. There are often
restricted physical or social activities, particularly with
some of our more intense treatments that need to be
managed. Depression and anxiety is a problem that
may occur both in the long term effects and also in the
late effects. That is, they may be present during or in
the first few years after treatment, but they may be
resolved and then appear later in time. So this is one
that actually is on both lists as you see. Late effects of
cancer treatment are those that are clearly not
present, or at least, not identified, during the initial
treatment. These can include musculo-skeletal
complications, late onset fatigue, cardiovascular
complications in particular are common,
hypothyroidism. Some patients encounter a posttraumatic stress disorder and this is something that
would occur significantly after treatment. Again as I
mentioned, depression and anxiety are challenges
Hablemos de los efectos demorados y a largo
plazo. Es una situación que, a mi parecer, es nueva
para muchos y merece más atención. Los efectos a
largo plazo, tal como hemos descrito, se desarrollan
durante el tratamiento activo y persisten. Continúan
a lo largo del tratamiento y, con frecuencia,
inmediatamente después de este, y pueden
prolongarse durante un tiempo. Nos preocupan los
que duran varios años, en particular más de 5. Esta
es una lista de los efectos a largo plazo más
documentados de diversos tipos de cáncer. Los
más comunes son la neuropatía —que se
manifiesta en debilidad, entumecimiento o dolor de
las extremidades— y la fatiga, las dificultades
cognitivas y la disfunción sexual. Pueden aparecer
dificultades funcionales en la capacidad del
paciente para volver a trabajar o reanudar sus
actividades habituales, ya que suelen ser bastante
debilitantes. A menudo hay restricciones a las
actividades físicas y sociales, en especial con
algunos de los tratamientos más intensos.
La depresión y la ansiedad pueden ocurrir a largo
plazo y también como efecto tardío. Pueden estar
presentes durante el tratamiento, o en los primeros
años después de este, y pueden resolverse y
reaparecer. La depresión y la ansiedad son efectos
tardíos y a la vez a largo plazo. Los efectos tardíos
son los que claramente no están presentes o no se
identifican en el tratamiento inicial. Pueden incluir
complicaciones musculoesqueléticas, fatiga tardía,
complicaciones cardiovasculares —que son
particularmente comunes— e hipotiroidismo.
Algunos pacientes experimentan un trastorno de
estrés postraumático tiempo después del
tratamiento. La depresión y la ansiedad pueden
ocurrir en la mayoría de las situaciones.
8
that may occur in most situations.
Cancer Survivorship Management
for Primary Care Physicians
Conceptual Model of Physical Performance
Ness,Ann Epidemiol. 2006
This is a conceptual model of the challenges that we
face and perhaps gives you a way to think about how
these problems impact our patients. If you consider
the result of cancer diagnosis, and a subsequent
treatment as impacting on our patients, those are
obviously translated through the patient’s personal
characteristics. Their physical and mental condition at
the time of diagnosis has a significant impact on the
level to which the treatment may impact their wellbeing. These treatments and the interactions with the
individuals’ genetic and personal conditions may
result in some organ system impairments. So these
are the ones that then lead to physical performance
limitations and then eventually to what we see in the
office of participation restrictions. That is, the
individual is not able to do the things that they used to
do. They’re not able to do the things that they want to
do to resume their everyday life. The indications from
the boxes on the side are simply saying that this flow
of problems from treatment through the individual’s
personal situation, through organ impairment, and
their limitations and restrictions are clearly impacted
by their social and environmental factors. So the
patient’s living conditions, their ability to seek care,
their ability to have support, and provide additional
treatments for the early stages of complications can
play a big role in the ultimate condition of the patient.
On the other side of the chart, of course, age of the
patient and the time from diagnosis also can make a
big difference. So patients who are younger who
perhaps were in better health or have fewer co-morbid
conditions at the time of treatment, may well have, a
lesser impact than those patients who are older or if
they have other medical problems.
Este es un modelo conceptual de los desafíos que
enfrentamos, y tal vez le permita pensar en cómo
estos problemas afectan a nuestros pacientes. Los
pacientes son afectados por el resultado del
diagnóstico de cáncer y el tratamiento posterior, y
estos factores obviamente se manifiestan a través
de las características personales del paciente.
Su condición física y mental en el momento del
diagnóstico influye considerablemente en el grado
en que el tratamiento afecta su bienestar. Estos
tratamientos y las interacciones con las condiciones
genéticas y personales del paciente pueden causar
cierto deterioro en el organismo. Son factores que
luego generan limitaciones en el rendimiento físico
y, con el tiempo, las restricciones en la participación
que comprobamos en el consultorio. El paciente no
puede realizar ciertas actividades que
acostumbraba hacer. Tampoco puede hacer lo que
desea para reanudar su vida cotidiana. Las flechas
de los recuadros laterales indican la secuencia de
los problemas, desde el tratamiento hasta la
situación personal del paciente, así como el
deterioro del organismo, y sus limitaciones y
restricciones, claramente afectadas por los factores
sociales y ambientales. Por lo tanto, las condiciones
de vida del paciente, su capacidad para buscar
atención y recibir apoyo, y los tratamientos
adicionales en las primeras etapas de las
complicaciones pueden desempeñar un papel
importante en su condición final. A la derecha, la
edad del paciente y el tiempo desde el diagnóstico
pueden establecer una gran diferencia. Los
pacientes más jóvenes, tal vez con mejor salud o
menos condiciones comórbidas en el momento del
tratamiento, pueden sufrir un impacto menor que los
9
pacientes mayores o los que tienen otros problemas
médicos.
Cancer Survivorship Management
for Primary Care Physicians
Psychological Late Effects in Cancer Survivors
Ness,Ann Epidemiol. 2006
The other area of concern, as we mentioned, is in the
psychological effects. Just as well as the physical
effects, these can occur as long-term challenges or
late effects. And in this diagram, we see a description
of how there is a very complex interaction amongst
the various components of this problem. So as we
think about the stress created by the cancer treatment
or the cancer itself, as we… some people consider the
cancer burden. It’s made up of several different
components: physical, psychological, interpersonal,
financial or existential or spiritual challenges. And
these are managed through the resources that are
available. The individual has some resources
hopefully to call upon; those interpersonal
relationships that they have, interpersonal
relationships. The idea that information or knowledge
is important if they have access to that. And there may
be some tangible issues, such as finances or other
resources that they can call upon. So you see the
arrows go both ways here. So the cancer burden, may
in fact, draw down on the resources of the person that
has fewer resources in their personal situation, as well
as if the cancer stress and burden decreases, their
resources may be more abundant. So those have a
way of interplaying together. Also involved in this
interchange are the patient’s coping mechanisms. So
how we deal with problems varies from person to
person and each individual has to apply their own
skills and their own ability to cope with problems to try
to achieve the best outcome. So at the end of this
whole process, we see what we note in the office, of
the psychological effects that are impacting the patient
and what we observe how they’re dealing with the
cancer problem short-term and long-term. And as
La otra área de preocupación mencionada son los
efectos psicológicos. Tal como los efectos físicos,
pueden ocurrir como problemas a largo plazo o
efectos tardíos. En este diagrama vemos una
descripción de la compleja interacción entre los
componentes de este problema. El estrés que crea
el tratamiento del cáncer, o el propio cáncer —o la
“carga del cáncer”, como lo definen algunas
personas—, tiene varios componentes: físicos,
psicológicos, interpersonales, financieros y
existenciales o espirituales, que se gestionan a
través de los recursos disponibles. Es de esperar
que la persona los tenga y pueda recurrir a ellos,
como las relaciones interpersonales y la idea de
que la información o el conocimiento son
importantes. También puede haber cuestiones
tangibles, como las finanzas y otros recursos. Las
flechas apuntan en ambos sentidos. Por lo tanto, la
carga del cáncer puede consumir los recursos de la
persona que menos tiene y, si el estrés y la carga
del cáncer disminuyen, sus recursos pueden ser
más cuantiosos. Estos factores interactúan y en
este intercambio también intervienen los
mecanismos del paciente para enfrentar la
situación. La forma de hacer frente a los problemas
varía para cada persona, y cada uno debe aplicar
sus propias habilidades y su propia capacidad para
lograr el mejor resultado. Al final del proceso vemos
lo que se comprueba en el consultorio: los efectos
psicológicos que afectan al paciente y cómo
enfrenta el problema del cáncer a corto y a largo
plazo. Como muchos habrán observado, esto no
siempre es negativo. Algunos pacientes
experimentan un efecto muy positivo por haber
10
Cancer Survivorship Management
for Primary Care Physicians
Guidelines for Management
many of you have observed, this is not always
negative. Some patients experience a very positive
effect from having dealt with cancer and lived through
cancer so that it builds and personally strengthens
them and helps them to manage other challenges in
life. So it’s not always a negative situation.
enfrentado al cáncer y haber sobrevivido; se
fortalecen a nivel personal y eso les ayuda a
manejar otros problemas de la vida. Entonces, no
siempre es una situación negativa.
Now we turn to some discussion of guidelines for
management of a few of the common cancer areas.
So we’ll talk a bit about the ways that we’re trying to
approach breast cancer, colorectal cancer, and
prostate cancer.
Hablemos ahora de las pautas para gestionar
algunas áreas comunes del cáncer, y de cómo
abordamos el cáncer de mama, colorrectal y de
próstata.
• Breast
• Colon and Rectal
• Prostate
Kattlove H et al, CA Cancer J Clin 2003;53:172-196
11
Cancer Survivorship Management
for Primary Care Physicians
Breast Cancer
• Over 2 million female breast cancer survivors
in US (85% alive at 5 years)
• Recommendations:
– BSE monthly
– Mammography of remaining breast tissue annually
– Clinical exam and history q 3-6 mos x3 yrs then 6-12
mos x2 yrs then annually
Burstein, New Engl J Med 2000;343:1086-1094 NCCN guidelines
In breast cancer, there are over 2 million female
breast cancer survivors today. About 85 percent of
women diagnosed are alive at 5 years so this is a
great success story. We are extremely pleased that so
many women with breast cancer can be successfully
treated. It is a challenge, though, for us managing
cancer survivors, in that there are many more of them.
So these, I think, will be situations that we see very
commonly in practice. The recommendations that are
available are the ones that I have described here are
from the NCCN Guidelines and these include breast
self examination on a monthly basis, mammography
of any remaining breast tissue annually as more
women are treated with lumpectomy and do not have
a complete mastectomy. Then there is certainly a
need to examine the remaining breast tissue for any
metachronous lesions or new lesions which may
develop after the initial treatment. A clinical exam, and
of course, a history is very important here as we want
to pick up any evidence of symptoms of recurrence as
early as possible. So it’s recommended that we do
this every 3 to 6 months for the first 3 years, then 6 to
12 months for the next 2 years, and then return to an
annual schedule which would be similar to what we
recommend for women in general.
En la actualidad, existen más de 2 millones de
mujeres sobrevivientes al cáncer de mama.
Alrededor del 85% tienen una sobrevida de al
menos 5 años, lo cual es alentador. Estamos muy
complacidos de que se pueda tratar con éxito a
tantas mujeres con cáncer de mama. Para nosotros
es un desafío gestionar a las sobrevivientes del
cáncer, ya que son mayoría. Estas situaciones son
muy comunes en la práctica. Las recomendaciones
aquí descritas son pautas del Instituto Nacional del
Cáncer: autoexamen mensual de mamas y
mamografía anual del tejido mamario remanente, ya
que son más las mujeres tratadas con lumpectomía
que con mastectomía completa. Es necesario
examinar el tejido mamario remanente para
descartar lesiones metacrónicas y nuevas lesiones
posteriores al tratamiento inicial. También es muy
importante hacer un examen clínico y, por
supuesto, una historia clínica, ya que debemos
recopilar cualquier evidencia de síntomas de
recurrencia tan pronto como sea posible.
Se recomienda hacerlo cada 3 a 6 meses durante
los primeros 3 años, cada 6 a 12 meses durante los
siguientes 2 años, y posteriormente volver a un
programa anual similar al que se recomienda para
las mujeres en general.
12
Cancer Survivorship Management
for Primary Care Physicians
Breast Cancer
• Intensive screening--bone scan, CT, MRI, PET,
CXR, lab tests for tumor markers etc. have not
shown survival advantage
Intensive screening has been tried. Various
combinations of bone scan, CT, MRI, PET scanning,
chest x-rays and multiple lab tests and various
tumorous markers have really not been shown to have
any significant survival advantage. So these or the
sort of intensive methods of surveillance is not
recommended.
Con respecto a los exámenes preventivos
intensivos, las diversas combinaciones de
exploraciones óseas, tomografía computada,
resonancia magnética, PET, radiografías de tórax,
pruebas de laboratorio y marcadores tumorales no
han demostrado mayores ventajas para la
supervivencia. Por lo tanto, no se recomienda
utilizar estos métodos intensivos de vigilancia.
It’s important to thoroughly evaluate any symptoms
and it’s a good idea to direct specific questions to our
patients when they come in to determine if they are
having any problems that might be related to their
previous disease. Even things that are fairly
nonspecific like weight-loss or cough are important to
examine very completely. Obviously any abnormalities
on the examination should be considered, changes in
the chest wall, adenopathy, may be due to recurrence.
So we have to be especially careful in these women,
even though they may have been disease free for
quite some time, to pay attention to these changes
and to evaluate them. This, of course, is related to the
stage of disease at which they were treated. Of
course those with later stage would be more likely to
have a recurrence. Many of the recurrences that do
occur are within the first 5 years so it is a good
prognostic sign when we see patients that have
managed to reach that milestone, but we’re never out
of the woods with this disease. It’s something that we
Es importante evaluar exhaustivamente cualquier
síntoma, y también es conveniente hacer preguntas
específicas a las pacientes para determinar
problemas relacionados con su enfermedad
anterior. Debemos examinar por completo los
factores relativamente inespecíficos, como pérdida
de peso y tos. Asimismo, debe tenerse en cuenta
cualquier anomalía que surja del examen, como
cambios en la pared torácica o adenopatía tal vez
causados por una recurrencia. Estas pacientes
requieren una dedicación especial, aunque hayan
estado libres de la enfermedad por cierto tiempo,
para prestar atención a estos cambios y evaluarlos.
Esto tiene relación con la etapa de la enfermedad
en la que fueron tratadas, ya que los casos de
etapas más avanzadas tienen mayor probabilidad
de recurrencia. Muchas recurrencias ocurren dentro
de los primeros 5 años. Si una paciente supera ese
plazo, es una señal de buen pronóstico, aunque con
esta enfermedad nunca se está fuera de peligro.
• Not recommended
Rojas, Follow up strategies for women treated for early breast cancer.
Cochrane database. Syst Rev 2000; (4):CD001768 (Level A evidence)
Cancer Survivorship Management
for Primary Care Physicians
Breast Cancer
• Thorough evaluation of symptoms and directed
questions are important
• Even non-specific symptoms, i.e., weight loss,
persistent cough and abnormalities on exam,
changes in chest wall or adenopathy, may be
due to recurrence
• Related to stage of disease
• Most recurrences within 5 years
13
Cancer Survivorship Management
for Primary Care Physicians
Breast Cancer Symptoms of Metastatic Disease by Site
• Liver
– e.g., anorexia, N/V, abd pain
• Lung
– e.g., cough, SOB, hemoptysis
• Bone
– e.g., bone pain, esp at night
• Brain
always want to pay careful attention to.
Es algo a lo que siempre debemos estar atentos.
There are certainly areas where metastatic disease
occurs that are more common with breast cancer
patients and symptoms related to those sites of
metastasis are ones that we want to pay particular
attention to. So disease in the liver, of course, may
manifest itself as anorexia, nausea and vomiting or
abdominal pain. Lung lesions produce cough,
shortness of breath and hemoptysis at times. Bone
lesions are frequently associated with some bone
pain, especially nocturnal pain, seems to be more
prevalent in our cancer survivors. Lesions in the
central nervous system and the brain may be related
to increased headache and neurological symptoms.
Hay zonas de enfermedad metastásica que son
más comunes en las pacientes con cáncer de
mama, y tenemos que concentrarnos en los
síntomas relacionados con esos sitios de
metástasis. La enfermedad en el hígado puede
manifestarse como anorexia, náuseas y vómitos, o
dolor abdominal. Las lesiones pulmonares producen
tos, dificultad para respirar y, a veces, hemoptisis.
Las lesiones óseas son frecuentemente asociadas
con algún dolor en los huesos, especialmente el
dolor nocturno, que parece ser más frecuente en los
sobrevivientes del cáncer. Las lesiones del sistema
nervioso central y el cerebro pueden estar
relacionadas con mayor dolor de cabeza y síntomas
neurológicos.
Second primaries, as we mentioned, are a problem in
everyone. But in particular in cancer survivors, and in
breast cancer survivors, we want to pay particular
attention to disease that may occur in the same breast
as the original lesion if there’s remaining tissue, or in
the opposite breast. Colon and rectal cancer are more
common as is ovarian cancer. So these particular
sites deserve some particular attention and we need
to be sure that our patients receive the appropriate
screenings that are indicated for breast and colorectal
cancer and that we pay careful attention to any
symptoms that may be related to ovarian cancer.
There are some protocols for screening for ovarian
cancer that are being tested experimentally, but none
of these have been approved so far by the major
authorities.
Los segundos cánceres primarios son un problema
generalizado. En las sobrevivientes al cáncer de
mama, es preciso prestar especial atención a la
enfermedad que puede ocurrir en la misma mama
que la lesión original, si existe tejido remanente, o
en la mama opuesta. El cáncer de colon y el cáncer
rectal son más comunes, al igual que el cáncer de
ovario. Estos sitios merecen atención especial y
necesitamos estar seguros de que nuestras
pacientes se hagan los exámenes preventivos de
cáncer de mama y rectal, y prestar mucha atención
a cualquier síntoma relacionado con el cáncer de
ovario. Algunos protocolos para la detección del
cáncer de ovario se están ensayando
experimentalmente, pero ninguno ha sido aprobado
por las principales autoridades.
– e.g., increasing headache, neuro sxs
Cancer Survivorship Management
for Primary Care Physicians
Breast Cancer
• Second primary locations
– Same or other breast
– Colon and rectal cancer
– Ovarian cancer
14
Cancer Survivorship Management
for Primary Care Physicians
Breast Cancer
• Adjuvant tamoxifen
– Gynecologic eval q 6-12 mos
– Be alert for abnormal bleeding - EMB +/-ultrasound
– Risk of DVT and PE
• Aromatase inhibitors
– increasingly use (anastrozole, letrozole, exemestane)
– Better tolerated but risk of bone loss
– Bisphosphanates 2+ years
ATAC Trialists Group, Lancet 2005;365(9453):60-2.
Women after breast cancer treatment may be on
tamoxifen. This requires some additional follow-up. If
you happen to have a patient in your office who’s
receiving this and not receiving follow-up elsewhere,
then it’s important to be sure that we follow the
appropriate procedures. This would include a
gynecologic exam every 6 to 12 months, and whether
you’re following the patient primarily or not, we want to
be particularly alert to any abnormal bleeding. And
that needs to be evaluated with an endometrial biopsy
and possibly an ultrasound. There’s always a risk of
deep vein thrombosis and pulmonary embolisms, so
symptoms related to those conditions are ones that
we need to be alert to and address properly.
Aromatase inhibitors are used increasingly and these
are listed on your slide. They are generally better
tolerated than tamoxifen - fewer side effects - but
there is some increased risk of bone loss. So it is
recommended that the patients also receive
bisphosphonate for the first couple of years that
they’re using these medications.
Después del tratamiento del cáncer de mama, es
posible que la paciente deba tomar tamoxifeno, lo
que requiere un seguimiento adicional. Si una
paciente toma este medicamento y no ha recibido
ningún seguimiento, es importante implementar los
procedimientos apropiados. Esto incluye un examen
ginecológico cada 6 a 12 meses, y el médico que
realice el seguimiento primario debe estar atento a
cualquier sangrado anormal, que debe evaluarse
con una biopsia endometrial y, posiblemente, con
una ecografía. Siempre hay riesgo de trombosis
venosa profunda y embolia pulmonar, por lo cual los
síntomas relacionados con esas condiciones son
los que debemos vigilar y abordar correctamente.
Los inhibidores de la aromatasa se utilizan cada vez
más y se detallan en la diapositiva. Generalmente
son mejor tolerados que el tamoxifeno porque
tienen menos efectos secundarios, pero hay mayor
riesgo de pérdida ósea. Por eso, se recomienda
administrar bifosfonato concomitante durante los
dos primeros años de tratamiento.
15
Cancer Survivorship Management
for Primary Care Physicians
Breast Cancer
• Management of tamoxifen side effects
• Symptoms of estrogen deprivation, hot
flashes, night sweats and vaginal discharge
• Soy products should be avoided
• Selective serotonin reuptake inhibitor
antidepressants may be problematic
Cancer Survivorship Management
for Primary Care Physicians
Breast Cancer
• Enzyme CYP2D6 is essential for the breakdown
of tamoxifen to the active metabolite endoxifen
• Commonly used CYP2D6 inhibitors - SSRI
antidepressants fluoxetine (Prozac) and paroxetine
(Paxil), frequently used to prevent hot flashes while
on tamoxifen.
• Two recent studies show conflicting results
– 2x risk of recurrence - Aubert, RE et al "Risk of breast cancer
recurrence in women initiating tamoxifen with CYP2D6 inhibitors"
J Clin Oncol 2009; 27(15S)
– No difference in risk - Dezentje V, et al "Concomitant CYP2D6
inhibitor use and tamoxifen adherence in early-stage breast cancer"
J Clin Oncol 2009;
27(15S):http://www.breastcancer.org/treatment/hormonal/new_resea
rch/20090530b.jsp September 27,2009
Management of tamoxifen side effects is something
that you may be called upon to deal with. These are
related to, primarily to symptoms of estrogen
deprivation: hot flashes, night sweats, discharge at
times may occur. Some have recommended using soy
products but due to the phyto-estrogens involved in
those, it’s not recommended that we approach things
with that method. Selective serotonin re-uptake
inhibitors- these anti-depressants also have been tried
but there appear to be perhaps some problems
related to that.
Es posible que debamos tratar los efectos
secundarios del tamoxifeno. Estos síntomas se
relacionan, principalmente, con la privación de
estrógeno: sofocos, sudores nocturnos y a veces
descargas vaginales. Algunos recomiendan los
productos de soja, pero dado que contienen
fitoestrógenos, no son recomendables. También se
han probado los inhibidores selectivos de la
recaptación de la serotonina, pero al parecer estos
antidepresivos presentan algunos problemas.
It is unfortunate but the enzyme that’s essential for the
breakdown of tamoxifen to its active metabolite is also
one that is involved in the mechanism of action of the
SSRI drugs. So there is an overlap and there may be
interactions which occur. There are a couple of
studies which show conflicting results. One is a bit
concerning, which reported an increased risk of
recurrence of patients taking SSRIs for treatment of
these side effects. So that is something that we
should carefully discuss with our patients and let them
know what the potential risks are. Another study didn’t
hold up and there was no evidence. So here is a
situation in which we don’t really have the final answer
and perhaps in the near future we will, but right now
it’s still a challenge for us. So the best thing in that
situation is if you’re going to use those sorts of
products, is to be sure to thoroughly discuss that with
the patients and, of course, document the challenges
involved.
Desafortunadamente, la enzima esencial para la
descomposición del tamoxifeno a su metabolito
activo también interviene en el mecanismo de
acción de los inhibidores selectivos. Por lo tanto,
hay una superposición de efectos y pueden ocurrir
interacciones. Dos estudios han mostrado
resultados contradictorios. Uno de ellos es algo
inquietante, ya que informó un mayor riesgo de
recurrencia en las pacientes que tomaban
inhibidores selectivos para tratar los efectos
secundarios. Debemos hablar atentamente con
nuestras pacientes e informarles cuáles son los
riesgos. El otro estudio no fue coincidente y no
indicó evidencias de riesgo. En esta situación no
tenemos una respuesta definitiva, y aunque tal vez
la tengamos en un futuro próximo, por el momento
continúa siendo un dilema. Si se decide utilizar
estos fármacos, conviene analizar el tema
detalladamente con las pacientes y, por supuesto,
documentar cualquier problema.
16
Cancer Survivorship Management
for Primary Care Physicians
Complications of Treatment
• Monitor for physical, psychological and
social complications
– Arm lymphedema, induced menopause,
osteoporosis, neurological-cognitive changes
– Sexuality, fatigue, depression, and
– Social issues (impact on family and
work life, insurance)
Cancer Survivorship Management
for Primary Care Physicians
Induced Menopause
• May occur after chemotherapy as well
as oophorectomy
• HRT in breast cancer patients –
Not Recommended
• WHI data shows combined HRT associated
with increased risk of BC also increased risk
of lung cancer
RT Chleboski MD The Lancet, Early Online Publication, 20
September 2009 doi:10.1016/S0140-6736(09)61526-9
Complications of treatment as we mentioned, the late
and long-term effects are listed here. Issues related to
surgical interventions with lymphedema, induced
menopause, either due to surgery or due to the drugs
used, are fairly common. Osteoporosis, neurological
and cognitive changes may be present although these
appear to diminish; the neurological cognitive changes
appear to diminish somewhat over time. Sexuality,
fatigue, depression and social issues that we
mentioned earlier are certainly a common problem in
this group of patients so we need to address those as
we identify them.
Aquí se enumeran las complicaciones del
tratamiento como efectos tardíos y a largo plazo.
Son bastante comunes los problemas relacionados
con las intervenciones quirúrgicas: linfedema y
menopausia inducida, ya sea debido a la cirugía o a
los medicamentos utilizados. Es posible que haya
osteoporosis y cambios neurológicos y cognitivos,
aunque estos últimos parecen disminuir en cierta
medida con el tiempo. En este grupo de pacientes
es común encontrar problemas de sexualidad,
fatiga, depresión y las dificultades sociales ya
mencionadas, todo lo cual debe abordarse a
medida que se identifique.
Induced menopause may occur after chemotherapy
but also may be related to oophorectomy which may
be performed at the time of the initial treatment.
Hormone replacement therapy for breast cancer
patients is a tempting alternative to deal with this, but
it’s really not recommended. Again, there have been
some conflicting results earlier, but it’s generally
accepted that this is not a good idea to use in these
patients due to risk of recurrence. The data from
several very large studies have been discussed in
many settings, and the increased risk of hormonal
replacement therapy, and -- has been related to our
challenges in breast cancer. So individuals using
these products are at increased risk of breast cancer,
in general, whether or not they’ve been diagnosed.
Certainly, this is additional information that would
warn us against using these products. Interestingly,
there is also some increased risk of lung cancer in
individuals who use these products so that’s another
reason to be very cautious.
Después de la quimioterapia puede ocurrir
menopausia inducida, aunque también está
relacionada con una ooforectomía realizada junto
con el tratamiento inicial. En pacientes con cáncer
de mama, la terapia de reemplazo hormonal es una
alternativa tentadora para enfrentar esta situación,
pero en realidad no es recomendable. Una vez
más, los resultados han sido contradictorios, pero
generalmente se acepta que no es conveniente
utilizarla en estas pacientes debido al riesgo de
recurrencia. Los datos de los grandes estudios han
sido analizados ampliamente, y el mayor riesgo de
la terapia de reemplazo hormonal se ha relacionado
con los desafíos que presenta el cáncer de mama.
En general, el uso de estos productos conlleva un
mayor riesgo de cáncer de mama, con o sin
diagnóstico previo. Debemos considerar que esta
información es una advertencia contra el uso de
esos fármacos. Curiosamente, también existe un
mayor riesgo de contraer cáncer de pulmón, que es
17
otra razón para ser muy cautelosos.
Cancer Survivorship Management
for Primary Care Physicians
Genetic Risk Assessment for Patient and Family
• Up to 10%of breast cancers may be genetic
Genetic risk assessment is something we need to
think about and talk about with our patients. About 10
percent of breast cancers are likely to be genetic and
these are linked to the common mutations of the
BRCA1 and 2. And this accounts for the vast majority
of the hereditary breast cancers that are seen.
La evaluación del riesgo genético debe ser
considerada y analizada con la paciente. Alrededor
del 10% de los cánceres de mama son genéticos y
están vinculados con mutaciones comunes de los
genes BRCA1 y 2. Esto explica la gran mayoría de
los cánceres de mama hereditarios.
Screening for these individuals is much more intense
than what we provide for patients at average risk. And
for individuals with a known BRCA genetic mutation,
or a history that would indicate a very high likelihood
of those genetic changes, should receive intensive
screening. This information that you see is being done
by -- information you see is being used by a number
of centers around the country to screen women with
these mutations. But it is still based on expert opinion
and is not backed up by randomized control trials.
However, it is a proposal and one that’s being tested.
So this involves doing the monthly BSE, especially on
younger women, clinical breast examination starting a
bit earlier than average, mammograms every 6 to 12
months, pelvic exams every 6 months, ultrasounds
and CA125 as well. Some centers are also using
alternating the mammography with MRI on an every 6
month basis as well.
En estas pacientes, los exámenes preventivos son
mucho más intensos que los indicados para
pacientes con riesgo promedio. Las pacientes que
tienen una mutación genética BRCA conocida, o
bien antecedentes que indiquen una probabilidad
muy alta de cambios genéticos, deben hacerse
exámenes preventivos intensos. Esta información
es utilizada por varios centros de todo el país para
evaluar preventivamente a las mujeres con estas
mutaciones; sin embargo, se basa en la opinión de
los expertos y no está respaldada por ensayos
aleatorios controlados. Es aún una propuesta que
se está probando. Implica un autoexamen de
mamas mensual, especialmente en las mujeres
jóvenes; un examen clínico de mamas un poco
antes que lo usual; mamografías cada 6 a
12 meses; exámenes pélvicos cada 6 meses;
pruebas de ultrasonido; y también la prueba CA125.
Algunos centros alternan una mamografía con una
• Linked to BRCA1 and BRCA2 in 80-90% of
these cases
Loman N et al, J Natl Cancer Inst 2001;93:1215-1223
Sifri R et al, CA Cancer J Clin 2004;54:309-326
Cancer Survivorship Management
for Primary Care Physicians
Screening for BRCA Carriers
• Monthly BSE starting ~ age 18-21
• Clinical breast exam ~ age 25-35
• Mammogram q 6-12 mos ~ age 25-35
• Pelvic exam q 6 mos
• Transvaginal US q6-12 mos ~ age 25-35
• CA-125 q6-12 mos ~ age 25-35
• Start screening 5 yrs before age of youngest
afflicted family member
CAVEAT: based on expert opinion
Sifri R et al, CA Cancer J Clin 2004;54:309-326
18
resonancia magnética cada 6 meses.
Cancer Survivorship Management
for Primary Care Physicians
Interventions for BRCA Carriers
• Prophylactic oophorectomy
Individuals who are known to have BRCA mutations
can intervene before they’re diagnosed with breast
cancer. These interventions can involve prophylactic
oophorectomy or prophylactic mastectomy, or the
individuals may consider using tamoxifen for a period
of 5 years.
Las personas con mutaciones BRCA conocidas
pueden ser intervenidas antes de recibir un
diagnóstico de cáncer de mama. Estas
intervenciones pueden incluir ooforectomías o
mastectomías profilácticas, y la administración de
tamoxifeno durante un plazo de 5 años.
This Slide points out an issue of some concern, and
that is as we mentioned earlier, that cancer survivors,
and breast cancer survivors in particular, as depicted
on this slide, may not receive the appropriate followup. This shows the rates of mammography usage for
breast cancer survivors as opposed to the years after
diagnosis. And you would think that breast cancer
survivors would be the most interested in getting
mammography if it’s indicated, but as you can see
here, the rates decline over time. So that is something
we need to pay attention to and we want to be sure to
follow-up with our patients.
Esta diapositiva señala un tema de preocupación,
que ya mencionamos, y es que los sobrevivientes
del cáncer —en particular las pacientes con cáncer
de mama— posiblemente no reciban un
seguimiento adecuado. Vemos aquí las tasas de
uso de mamografías en las sobrevivientes al cáncer
de mama en función de los años posteriores al
diagnóstico. Cabría pensar que serían las más
interesadas en hacerse una mamografía, pero las
tasas indican una franca disminución. Esto es
importante al hacer el seguimiento de nuestras
pacientes.
– Reduces risk of breast as
well as ovarian cancer
• Prophylactic mastectomy
• Tamoxifen for 5 years
Sifri R et al, CA Cancer J Clin 2004;54:309-326
Cancer Survivorship Management
for Primary Care Physicians
Mammography Use Post Treatment
100
90
80
70
60
50
40
30
20
10
0
79.8
76.8
74.0
70.7
62.6
1
(797)
2
(732)
3
(668)
4
(604)
5
(262)
Years of follow-up (n)
Doubeni, Cancer 2006, April 24
19
Cancer Survivorship Management
for Primary Care Physicians
Colon and Rectal Cancer
• Over 1 million male and female colon and rectal
cancer survivors in US
• Recommendations:
– Clinical exam and history q 3 months for 2 years,
then q 6 months for 3-5 years
– CEA q 3 mos for 2 years, then q 6 months
for 3-5 years
– CT abdomen and pelvis annually for 3 years
– Optical colonoscopy after 1 year (at 6 months if not
done pre-treatment), then at 3 years then q 5 years
Cancer Survivorship Management
for Primary Care Physicians
Colon and Rectal Cancer
• Role of intensive surveillance unclear
• Use of frequent visits, liver panels, CXR, CEA,
CT, MRI and ultrasound may improve survival
• BUT, which tests and which schedule not well
defined
Next is colorectal cancer. Over 1 million male and
female colon and rectal cancer survivors in our
country. The recommendations to follow these
individuals are listed. Clinical exam and history every
3 months for 2 years, then every 6 months for the next
3 to 5 years, CEA every 3 months for 2 years, and 6
months for the next 3 to 5 years. CEA, as you
remember, is not useful in screening but it is very
helpful in monitoring for recurrence. CT of the
abdomen and pelvis annually for the first 3 years, and
an optical colonoscopy after the first year after
treatment. It can be done and should be done sooner
if it was not done prior to treatment. If the operation
was done, or the treatment was done in an
emergency setting, or perhaps there was not an
opportunity to do it ahead of time, then that should be
done sooner rather then waiting the full year. After
that at 3 years it should be repeated and then at 5
years if everything is clean.
Luego tenemos el cáncer colorrectal. En los
Estados Unidos hay más de un millón de
sobrevivientes al cáncer de colon y rectal, tanto
hombres como mujeres. Aquí se enumeran las
recomendaciones a seguir: examen clínico e
historia clínica cada 3 meses durante 2 años, y
cada 6 meses en los siguientes 3 a 5 años; prueba
de antígeno carcinoembrionario cada 3 meses
durante 2 años, y cada 6 meses durante los 3 a
5 años siguientes. Esta prueba no es útil como
prevención, pero sí para detectar recurrencias.
Tomografía computada de abdomen y pelvis
anualmente durante los 3 primeros años, y una
colonoscopia óptica luego del primer año siguiente
al tratamiento. Si no se hizo antes del tratamiento,
debe hacerse antes del año. Si la operación o el
tratamiento fueron de emergencia, o si aún no se ha
realizado, es mejor hacerla antes del año. Debe
repetirse a los 3 años y, si no hay novedades, a los
5 años.
The role of intensive surveillance is unclear as we
mentioned with breast cancer. The use of frequent
interventions, follow-ups, liver panels, chest x-rays,
CEA, etcetera, may possibly improve survival, but is
not as clear as in the situation with breast cancer.
Which tests are better than others? Which ones
should be used when? It’s still not clearly defined but
you may see follow-up protocols that do involve more
intensive surveillance. However, the
recommendations still need some further refinement.
Tal como para el cáncer de mama, no está clara la
función de la vigilancia intensiva. Es posible que
frecuentes intervenciones, seguimientos,
hepatogramas, radiografías de tórax, pruebas de
antígeno carcinoembrionario, etc., mejoren la
supervivencia, pero es aún menos evidente que en
el cáncer de mama. ¿Qué pruebas son las
mejores? ¿Cuáles hay que utilizar y cuándo? Esto
tampoco está bien definido, pero existen protocolos
de seguimiento que incluyen una vigilancia más
intensa. Sin embargo, las recomendaciones aún
deben perfeccionarse.
Jeffery, Follow up strategies for patients treated for non metastasis colorectal
cancer. Cochrane Database Syst Rev 20043):CD002200
Renehan AG et al BMJ 2002:324:1-8
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Cancer Survivorship Management
for Primary Care Physicians
Colon and Rectal Cancer
CEA elevations, when they occur, should be
evaluated as soon as possible using CT or PET if
that’s available and possibly optical colonoscopy if it’s
indicated. So again, as with breast cancer we want to
thoroughly evaluate any symptoms.
Los niveles elevados en la prueba de antígeno
carcinoembrionario deben evaluarse cuanto antes
mediante tomografía computada o PET y, si se
indica, por colonoscopia óptica. Al igual que en el
cáncer de mama, debemos evaluar los síntomas en
detalle.
And in a similar vein, symptoms related to the sites of
metastatic disease are the ones we want to pay very
close attention to. Similar to breast cancer and liver
and lung mets, bone mets presenting again with pain,
in this situation more commonly in the back and hips,
and perhaps pelvis and again nocturnal pain is an
indication that we may have a problem.
Del mismo modo, hay que prestar atención a los
síntomas relacionados con los sitios de metástasis.
Similarmente a las metástasis del cáncer de mama,
hígado y pulmón, una posible indicación de
complicaciones es la presentación de metástasis en
hueso, con dolor, en este caso más comúnmente
en la espalda y las caderas, y tal vez la pelvis, y
también dolor nocturno.
• CEA elevations evaluated with CT, PET
and or optical colonoscopy
• Thoroughly evaluate any symptoms
Cancer Survivorship Management
for Primary Care Physicians
Colon Cancer Symptoms of Metastatic Disease by Site
• Liver
– e.g., anorexia, N/V, abd pain
• Lung
– e.g., cough, SOB, hemoptysis
• Bone
– e.g., bone pain, commonly back, hips,
pelvis esp at night
• Brain
– e.g., increasing headache, neuro sxs
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Cancer Survivorship Management
for Primary Care Physicians
Colon and Rectal Cancer
• Second primary locations
Second primary locations for colon and rectal cancer
patients include the colon itself, of course, for
metachronous lesions that may not have been present
or detectable at the time of the initial treatment.
Breast, ovarian and prostate lesions may also be
present. So screening as indicated for those is
certainly a good idea.
Los lugares de segundos tumores primarios en
pacientes de cáncer de colon y rectal incluyen el
propio colon, con lesiones metacrónicas que
pueden no haber estado presentes o no haber sido
detectables en el tratamiento inicial. También puede
haber lesiones de mama, ovarios y próstata, por lo
cual es recomendable indicar exámenes
preventivos.
Monitoring again for the physical, psychological and
social challenges that our cancer patients face and
referring them to appropriate treatment is, of course,
indicated for these patients as well. Individuals who
receive treatment with radiation or surgery may
encounter problems related to that, including radiation
proctitis, diarrhea, incontinence or adhesions.
Certainly ostomy- related problems can be a
challenge and body image or sexuality issues should
be addressed as well with appropriate counseling and
interventions.
También se indica monitorizar los problemas
físicos, psicológicos y sociales de los pacientes con
cáncer, y referirlos al tratamiento adecuado.
Quienes reciben tratamiento con radiación o cirugía
pueden tener complicaciones consecuentes, como
proctitis de radiación, diarrea, incontinencia o
adherencias. Sin duda, los problemas relacionados
con la ostomía pueden ser complejos, y las
cuestiones de imagen corporal o sexualidad deben
abordarse con el asesoramiento y las
intervenciones correspondientes.
– Colon metachronous lesions
– Breast
– Ovarian
– Prostate
Cancer Survivorship Management
for Primary Care Physicians
Colon and Rectal Cancer
• Monitor for physical, psychological and
social complications
• Radiation and surgical complications
– Radiation proctitis, diarrhea,
incontinence, adhesions
– Ostomy-related problems
– Body image, sexuality
22
Cancer Survivorship Management
for Primary Care Physicians
Genetic Risk Assessment for Patient and Family
• 20% of cases have a family member with CRC history:
– One afflicted relative < age 60 or ≥ 2 afflicted relatives at
any age
– Start screening earlier, at age 40 or 10 yrs earlier than the
age of youngest afflicted relative
• Up to 5% of colon and rectal cancers genetic
• FAP, HNPCC (associated with ureteral, renal pelvis,
endometrial and small intestinal cancer), role
of NSAID’s ?
Sifri R et al, CA Cancer J Clin 2004;54:309-326
Genetic risk for these patients: it’s thought that about
20 percent of cases have a family history or a family
member with a colorectal cancer history. It’s important
to assess a good family history with any of these
patients. If there is one patient in the family who had
colon cancer below the age of 60, or two, at any age,
we have to exercise more caution. And screening is
initiated earlier than the usual 50 years of age if those
patients are identified as being at higher risk. About 5
percent of colon and rectal cancers have a clear
genetic cause that can be identified. Two conditions
that are at times related to colon cancer that we need
to be alert to are FAP and HNPCC, familial
adenomatous polyposis and hereditary non-polyposis
colon cancer are ones that we need to be alert to.
These are not very common but they are certainly
associated with very high risk so we want to try to
identify those families that may have additional family
members who are at risk. These are also associated
with other cancer sites in the ureter, renal pelvis, the
endometrium and small intestine. So we need to be
alert to those possibilities. There is some role in the
use of NSAIDS in the prevention and management of
these conditions. However, that is still being
evaluated.
Con respecto al riesgo genético de estos pacientes,
se considera que un 20% tienen antecedentes
familiares o un familiar con cáncer colorrectal.
En todos ellos, es importante realizar una adecuada
evaluación familiar. Si un pariente ha tenido cáncer
de colon antes de los 60 años, o dos lo tuvieron a
cualquier edad, debe actuarse con más precaución.
Si se comprueba que hay un riesgo mayor, los
exámenes preventivos deben iniciarse antes de la
edad habitual de 50 años. Alrededor del 5% de los
cánceres de colon y rectales tienen una clara causa
genética que puede ser identificada. Dos
condiciones que a veces se relacionan con el
cáncer de colon y a las que tenemos que estar
atentos son la poliposis adenomatosa familiar y el
cáncer de colon hereditario sin poliposis. No son
muy comunes, pero ciertamente se asocian con un
muy alto riesgo, y debemos identificar a los
familiares en riesgo. También se asocian con
cáncer de uréter, pelvis renal, endometrio e
intestino delgado. Los antiinflamatorios no
esteroideos cumplen una función en la prevención y
gestión de estas condiciones; sin embargo, son
todavía objeto de evaluación.
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Cancer Survivorship Management
for Primary Care Physicians
HNPCC
• DNA mismatch repair genes
• 3 relatives with HNPCC-related cancer
– Endometrial, stomach and ovarian
HNPCC is associated with a mismatch repair gene in
the DNA. There are a set of criteria which can be used
to diagnose this which are listed here: related to the
number of relatives, the number of generations that
have been affected, and whether or not a first degree
relative is present, and assuming that FAP has been
excluded. So these patients require intensive
surveillance and often times surgical intervention at a
fairly early age.
El cáncer de colon hereditario sin poliposis está
asociado con un gen de reparación de
desapareamiento en el ADN. Aquí se enumeran
varios criterios para este diagnóstico: el número de
familiares afectados, el número de generaciones
afectadas, y si hay o no un pariente de primer
grado, suponiendo que se haya excluido la poliposis
adenomatosa familiar. Estos pacientes requieren
una vigilancia intensiva y a menudo una
intervención quirúrgica a una edad muy temprana.
FAP is another genetic abnormality in the APC gene,
less common than HNPCC, but can be more
problematic. Prophylactic surgery is often indicated
with complete colectomy frequently at an early age to
manage this condition. Again the role of NSAIDS is
currently being evaluated. There’s also some
increased risk for upper GI adenoma and
adenocarcinoma in these patients as well. And they
are usually followed with early onset endoscopy that is
much more intense than with our regular patients.
La poliposis adenomatosa familiar es otra anomalía
genética del gen APC, menos común que el cáncer
sin poliposis, pero que puede ser más problemática.
La cirugía profiláctica suele indicarse con
colectomía completa y a una edad temprana.
También en este caso, la función de los
antiinflamatorios no esteroideos está siendo
evaluada. Hay un riesgo algo mayor de adenoma y
adenocarcinoma del tracto gastrointestinal superior,
y generalmente se hace un seguimiento con
endoscopia temprana, mucho más intensa que lo
usual.
• 2 consecutive generations
• 1 relative is first degree or diagnosed under age 50
– FAP excluded
• Intensive surveillance or surgery
Cancer Survivorship Management
for Primary Care Physicians
FAP
• APC gene
• Less common than HNPCC
• Prophylactic proctocolectomy
• +/- COX-2
• Risk for upper GI adenoma and adenocarcinoma
– Periodic upper GI endoscopy starting at age 25
24
Cancer Survivorship Management
for Primary Care Physicians
Prostate Cancer
• Over 1.7 million prostate cancer survivors
Finally is prostate cancer. There are over 1.7 million
prostate cancer survivors in the U.S. The
recommendations for following these patients after
definitive therapy include PSA done every 6 months
for 5 years, and then on an annual basis, and a
regular DRE on an annual basis.
Por último, tenemos el cáncer de próstata. En los
Estados Unidos hay más de 1.7 millones de
sobrevivientes. Las recomendaciones de
seguimiento después de la terapia definitiva
incluyen una prueba de PSA cada 6 meses durante
5 años, y una prueba anual, más un examen rectal
digital por año.
It’s expected that the PSA levels would be
undetectable after a prostatectomy, so anything that
appears, that goes up above zero requires a prompt
and thorough evaluation. These sorts of levels are of
a concern, certainly if there is any after surgery, and
any elevation after treatment with radiation from the
post- treatment levels, also warrants investigation.
Bone scan certainly can be used for evaluation of
symptoms related to rising PSA or bone pain
symptoms, and those symptoms frequently are related
to metastatic disease.
Los niveles de PSA deben ser indetectables tras
una prostatectomía, por lo que cualquier valor
mayor que cero requiere una evaluación inmediata
y exhaustiva. Desde luego, estos niveles son
preocupantes si aparecen después de la cirugía, y
cualquier elevación posterior al tratamiento con
radiación también justifica una investigación.
La exploración ósea puede utilizarse para evaluar
los síntomas relacionados con un valor elevado o
con dolor de huesos, síntomas que a menudo se
relacionan con la metástasis.
• Recommendation:
– Following definitive therapy
• PSA q 6 months for 5 years then
annually
• DRE annually
Scardino, Clinical practice guidelines in oncology, prostate cancer.
NCCN at www.nccn.org
Cancer Survivorship Management
for Primary Care Physicians
Prostate Cancer
• Undetectable levels expected after prostatectomy
• Any detectable level after surgery or any elevations
elevation from lowest level after radiation indicates
recurrence
• Bone scan for evaluation of rising PSA or symptoms
• Metastatic disease symptoms due to bone lesions
25
Cancer Survivorship Management
for Primary Care Physicians
Prostate Cancer
• Treatment may be hormonal, further radiation,
surgery or watchful waiting
• Post operative PSA velocity, Gleason score
and staging may predict recurrence
Amling CL et al, J Urol 2000;164:101-105
Cancer Survivorship Management
for Primary Care Physicians
Prostate Cancer
• Second primary location
So treatment for these patients may be required or is
required if, of course, a recurrence is identified and
these would be done using hormonal therapies,
additional radiation surgery, or at times watchful
waiting, following the patient to determine if significant
problems develop. Prostate cancer is a challenge in
that it is, at times, a very indolent disease which may
not progress rapidly or require any immediate
intervention. However, some patients do have much
more aggressive disease. It’s unfortunately difficult to
determine which sort of prostate cancer trajectory an
individual patient will have. Post- operative PSA
velocity, that is the rate of change of PSA over time.
There are pathological scores called the Gleason
Score, and, of course, they’re changing... their staging
may be opportunities for us to get a better idea of the
prognostic situation for any given patient.
Si se detecta recurrencia, estos pacientes requieren
tratamiento con terapia hormonal, radiación
adicional, cirugía o a veces un control atento para
determinar si se desarrollan problemas
significativos. El cáncer de próstata es una
enfermedad a veces indolente que no progresa
rápidamente ni requiere una intervención inmediata,
aunque en algunos pacientes puede ser mucho
más agresiva. Lamentablemente, es difícil
determinar la trayectoria del cáncer de próstata de
un paciente particular. La recurrencia puede
predecirse con el índice de cambio de PSA
postoperatorio a lo largo del tiempo; con puntajes
patológicos, llamados Clasificación de Gleason; y,
por supuesto, la estadificación puede ofrecernos la
oportunidad de definir mejor el pronóstico de un
paciente determinado.
Second primaries can occur in the bladder,
particularly those who’ve had radiation therapy.
Lymphoma, kidney and possibly rectal cancers may
be more common.
Pueden aparecer segundos tumores primarios en la
vejiga, especialmente en las personas que
recibieron radioterapia. Pueden ser comunes el
linfoma, el cáncer de riñón y, posiblemente, el
cáncer rectal.
– Bladder cancer with radiation therapy
– Lymphoma, kidney, rectal?
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Cancer Survivorship Management
for Primary Care Physicians
Genetic Risk Assessment for Patient and Family
• Prostate cancer risk related to number of
relatives involved, family members with
breast and ovarian cancer have increased
risk for BRCA1 and 2
Prostate cancer is linked also genetically, but in a less
clear fashion, with other conditions. And family
members of relatives of patients with prostate cancer
may have some increased likelihood of having a
breast or ovarian cancer and possibly of carrying the
BRCA mutations.
El cáncer de próstata también está vinculado
genéticamente, aunque de manera no tan clara, con
otras condiciones. Las parientas de pacientes con
cáncer de próstata pueden tener mayor
probabilidad de cáncer de mama u ovario y,
posiblemente, de portar mutaciones en los genes
BRCA.
The gene that has been identified related to prostate
cancer is on Chromosome 1 and the X chromosome.
There’s an increased likelihood of carriers being
diagnosed at a younger age. It is more likely if there is
a stronger family history. Any patient who has such a
history should be counseled and consider screening
starting at an earlier age.
El gen asociado con el cáncer de próstata está en
el cromosoma 1 y en el cromosoma X. Existe una
alta probabilidad de que estos portadores sean
diagnosticados a una edad temprana, sobre todo si
tienen sólidos antecedentes familiares. Todo
paciente con tales antecedentes debe ser
asesorado, y se deben considerar los exámenes
preventivos desde una edad más temprana.
Steinberg GD et al, Prostate 1990:17:337-47
Cancer Survivorship Management
for Primary Care Physicians
Genetic Risk Assessment for Patient and Family
• Gene found on chromosome 1 and X
chromosome
• Increased likelihood if diagnosed before age 55
• More likely if
– 3 first degree relatives diagnosed
– 2 under age 55
• Suspect family history screen starting at age 40
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Cancer Survivorship Management
for Primary Care Physicians
Prostate Cancer
• Monitor for physical, psychological and social
complications
• Radiation and surgical complications
– Urinary incontinence
– With RP 30% use pads
– 10% totally or almost totally incontinent
• Hormonal treatment: osteoporosis
Cancer Survivorship Management
for Primary Care Physicians
Prostate Cancer
• ED 80% with RP 61 % with RTX
– Patients with nerve-sparing procedure
respond to Phosphodiesterase inhibitors
• GI complications with radiation
– Pain with BM or diarrhea 21% with RP
and 37% with RTX
• But, major study found 81% with RP and 90%
with RTX delighted , satisfied, or pleased with
treatment decision
Again monitoring for physical, psychological, and
social complications is always indicated and
particularly if there are significant challenges or
symptoms that the patient’s facing. Radiation and
surgical complications are not uncommon. Urinary
incontinence occurs in about 30 percent of patients
with radical prostatectomy. Ten percent totally are
almost totally incontinent. And these vary depending
on the individual situation and the procedures that are
done. Hormonal treatment is associated with
osteoporosis so that needs to be followed and treated
as needed.
Siempre está indicado monitorizar las
complicaciones físicas, psicológicas y sociales,
particularmente si el paciente enfrenta problemas o
síntomas importantes. Las complicaciones de la
radiación y la cirugía no son infrecuentes. Un 30%
de los pacientes con prostatectomía radical sufre
incontinencia urinaria, mientras que un 10%
padecen incontinencia casi total. Esto varía según
la situación particular y los procedimientos
realizados. El tratamiento hormonal está asociado
con osteoporosis, la cual debe seguirse y tratarse.
Erectile dysfunction is another common problem in
many patients. This can occur with patients receiving
radical prostatectomy as well as radiation. Those that
have had a nerve sparing procedure may respond to
medication so it’s always worth a trial to see if that
might be successful. GI complications, particularly
with radiation may be problematic. Pain with bowel
movements or diarrhea are not unusual and, but
generally can be managed. Interestingly, it’s been
found that the majority of patients with radical
prostatectomy and radiation therapy are quite happy
with their situation. So they’re pleased with the
outcome and despite the problems that they face, feel
like they made the best decision.
Otro problema común es la disfunción eréctil, que
puede ocurrir en los pacientes que reciben
prostatectomía radical y radiación. Si se les realiza
una cirugía con conservación de nervios, pueden
responder a los medicamentos, por lo cual siempre
es mejor probar si esta alternativa tiene éxito. Las
complicaciones gastrointestinales, en particular con
la radiación, pueden ser problemáticas. No es
inusual que ocurran diarrea o dolor al evacuar, pero
generalmente esto puede manejarse. Resulta
interesante que la mayoría de los pacientes
sometidos a prostatectomía radical y radioterapia
estén bastante satisfechos con su situación y el
resultado. Pese a los problemas que enfrentan,
consideran haber tomado la mejor decisión.
Potosky AL et al, J Natl Cancer Inst 2000;92:1582-1592
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Cancer Survivorship Management
for Primary Care Physicians
Summary
• More than 12 million Americans are
currently cancer survivors
• Cancer is increasingly a chronic condition
• Survivors at risk for not receiving
recommended care
So in summary, more than 12 million Americans are
currently cancer survivors. Cancer is an increasingly
common chronic condition and we must remember
that our survivors are at risk for not receiving the
recommended care that they need. And we have to
ask ourselves, “What can we do to help survivors live
longer and better?” Thank you very much for your
attention and we appreciate your participation in our
series.
En resumen, más de 12 millones de
estadounidenses son actualmente sobrevivientes
del cáncer. El cáncer es una enfermedad crónica
cada vez más común, y debemos recordar que los
sobrevivientes están en riesgo si no reciben el
cuidado recomendado que necesitan. Debemos
preguntarnos qué podemos hacer para ayudar a los
supervivientes a vivir más y mejor. Muchas gracias
por su atención y le agradecemos su participación
en nuestra serie.
• What can we do to help survivors live
better longer?
29