Family Doctors in Driver’s Seat for Cancer Survivor Care

Jenni Laidman

August 18, 2014

General practitioners face a dilemma. In a recent survey (Ann Intern Med. 2014;160:11-17), most reported being unfamiliar with the guidelines and uncomfortable treating adult survivors of childhood cancer; however, they can expect to see more such patients each year as treatments for childhood cancer become increasingly successful.

Several measures can help internists when such patients come into their practice, according to Lisa Diller, MD, chief medical officer of the Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and founder and director of the David B. Perini Jr. Quality of Life Clinic.

"It's hard," Dr. Diller told Medscape Medical News. "The patient is worried about relapse, and sometimes relapse can present with very common symptoms, such as back pain." Internists can worry about missing an important development and overtest, or miss the red flags raised by the seeming pedestrian nature of some symptoms. Even then, not all back pain is a warning sign, she explained.

For instance, acute lymphocytic leukemia, the most common form of childhood leukemia, doesn't recur after 15 years. "It's extraordinarily rare for it to recur anyway, particularly as back pain. Knowing when a patient is cured of cancer is a good starting point, then you can start reassuring the patient," Dr. Diller said.

People treated with radiation to their back or chest can be at greater risk for a recurrence presenting as back pain, although radiation hasn't been used to treat leukemia in many years, Dr. Diller noted. In such cases, physicians should look at the kind of back pain the patient complains of. Further testing might be signaled "if it presents in an unusual way," she explained, such as if the "pain is constant, as opposed to occurring with activity or in certain positions, or is severe, waking them up at night."

She said a good question to ask is whether "there something out of the ordinary."

The first thing internists should do when treating a cancer survivor is to obtain a treatment summary, Dr. Diller said. Nowadays, patients often receive a summary when they complete their treatment. In absence of such a report, patients might be able to request one from their pediatric treatment center or ask an adult oncologist to put one together.

"It's really important knowing just what drugs the patient has received, whether they have received radiation and where, and what surgery they have undergone. The treatment can really inform your care," she explained.

Second, internists can refer to the Children's Oncology Group guidelines for monitoring survivors of pediatric cancers. The research-based guidelines list various cancer treatments common over the previous decades, the risks associated with each, and recommendations for screening.

It is critical to consider what types of treatment patients received as children. Radiation, for instance, is associated with several morbidity, depending on where it was aimed, Dr. Diller noted. From the 1970s to the 1990s, somewhere between 66% and 75% of children received radiation for the treatment of cancer.

Children who received chest radiation are at risk for pulmonary fibrosis, heart valve disease, and early coronary artery disease, and should undergo earlier mammography screening with the inclusion of breast MRI, Dr. Diller reported. Radiation to the brain is associated with learning issues, impaired vocational success, and impaired organizational skills, she added. It also can lead to neuro-endocrine disruption. In addition, neck radiation raises the risk for thyroid failure and requires screening for hypothyroidism, radiation to the pelvis increases the odds of ovarian failure and pregnancy complications, abdominal radiation should trigger early screening for colon cancer,

As well, each chemotherapy agent can have late-stage effects that clinicians should investigate, Dr. Diller said. Two of the most common forms of chemotherapy associated with late effects are anthracyclines, including doxorubicin (the most common anthracycline), and alkylating agents.

People treated with doxorubicin during childhood should receive cardiac screening and be prescribed beta-blockers and/or ACE inhibitors if they show early signs of asymptomatic left ventricular dysfunction.

Alkylating agents are associated with a low sperm count in men and early menopause in women. Physicians should encourage male patients ready to become fathers to obtain semen analysis, she advised. The ovaries of women treated with alkylating agents might have limited reserve, so after 6 unsuccessful months of trying to conceive, rather than the usual 12 months, these women should be referred to a fertility specialist.

Research shows that it is important to encourage a healthy lifestyle in these patients, Dr. Diller noted. In fact, when cancer survivors fail to adhere to healthy guidelines for diet and exercise, their risk for metabolic syndrome doubles, according to a recent study, as reported by Medscape Medical News.

Further, smoking presents an elevated cancer risk for anyone who had chest radiation as a child. Such patients are also at increased risk for coronary artery disease from high cholesterol and plaque. And being overweight places additional burdens on hearts weakened by cancer treatment, she explained.

"I envision the development of a subspecialty — either of doctors or nurse practitioners — who deal with cancer patients outside the care of an oncologist and who are trained in survivorship, know a lot about treatment, and know about supportive, palliative, and nutritional care in survivors," she said.

In the meantime, however, family practitioners are in the driver's seat.

Dr. Diller has disclosed no relevant financial relationships.

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