COMMENTARY

The Cancer Survivor in Primary Care

Charles P. Vega, MD; Lidia Schapira, MD

Disclosures

September 30, 2016

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Charles P. Vega, MD: Hello, and welcome to Critical Issues in Oncology. I'm Chuck Vega, and I'm a clinical professor of family medicine at the University of California at Irvine. Today I'm delighted to be joined by Dr Lidia Schapira. She is an associate professor of medicine at the Stanford School of Medicine and is also director of cancer survivorship at the Stanford Cancer Institute. Lidia, welcome.

Lidia Schapira, MD: Thank you. It's great to be here.

Caring for the Breast Cancer Survivor

Dr Vega: Today we're going to be talking about caring for survivors of cancer. This is a growing population in the United States. It is now estimated that there are 14 million cancer survivors living in the United States, and two thirds of these individuals will live more than 5 years.

They come to your clinical practice and mine with a host of needs. They have, of course, acute issues. They've got chronic health conditions to manage, mental health issues, and preventive care. But foremost among one of my concerns for these patients is recurrence of cancer, the prevention of cancer recurrence, and early detection, if there is to be a recurrence of cancer.

Today we will focus on some of the most common types of cancer that we may see among cancer survivors and the most effective means to take care of these patients.

We are going to start with breast cancer. Lidia, this is something that you have a lot of experience and expertise in. My question to you, as a primary care physician, is the follow-up of these patients. On a routine basis we monitor with mammography. Yet, I know there are limitations in the accuracy of mammography. For the routine survivor of breast cancer, what role do other imaging modalities play—say, MRI and PET scan? I'd like your thoughts.

Dr Schapira: The first point that you addressed so well is the fear of recurrence, and that fear is something I think all of us need to be very sensitive to, both primary care clinicians and the specialists. In fact, that fear of recurrence can look very much like a generalized anxiety disorder.

Some patients are distressed even months to years after their diagnosis, almost as if they've been traumatized. So the first point for primary care clinicians is to be aware of that and to screen for that, and to ask some questions. It's normal to be afraid of recurrence, but if people are having intrusive thoughts every day or are crying every day, they need to be referred.

Dr Vega: Absolutely.

Dr Schapira: One of the important points is to reassure patients that mammography is still our gold standard for screening. Mammograms are getting better and better. Many institutions are doing tomosynthesis, which basically gives you a three-dimensional mammogram. The quality of the mammogram is important, and it still is the test that we all refer to for screening.

The role of ultrasound is very important if you're working up a problem. So whether you feel something or your patient feels something, if there is an abnormality, something that needs to be worked up, then ultrasound in combination with mammogram can give you a lot more information.

MRI is supersensitive, so the problem with MRI is that it may pick up more than we want. Often, for instance, after surgery there are some architectural changes that will show up as abnormalities. Every time you do a biopsy, every time you have surgery, the breast changes. So it requires very good interpretation. And sometimes it makes us worry and may even lead to more biopsies than are necessary.

We don't recommend that for everybody. For very young women, for instance, women who had cancer, women who are at high risk for cancer, who carry a BRCA mutation, MRI may be a very good screening tool. But for the general population, for everybody who has had breast cancer, not so much.

The part that I wanted us to chat a little bit about is the role of PET or systemic scans. Many women feel that somehow we're not doing enough if we don't order a CT scan of the abdomen or a bone scan. And that's something that medical oncologists spend a lot of time talking to patients about. There is no role for these scans on a regular basis. We'd have to do them indefinitely, expose women probably to more radiation than they need, and cause a lot of worry. So those scans are discouraged. In fact, none of the guidelines promote use of any systemic staging studies, unless you're working up a symptom or it's clinically indicated.

Dr Vega: All of that extra testing comes with extra radiation. And the cost of that is an increased risk for another type of cancer, which could grow de novo in these patients who are living for many years after their original tumor is treated.

The Prostate Cancer Survivor

Dr Vega: I'm going to move on to prostate cancer. The follow-up for prostate cancer is based on prostate-specific antigen (PSA) testing. It makes sense, checking a PSA post-treatment every 6-12 months for 5 years and then annually thereafter.

I think it's important for primary care physicians to understand that after a radical prostatectomy, the goal is for PSA levels to be undetectable,[1] and any level that's detectable should merit referral back to urology for a possible workup. In addition, after radiation treatment for prostate cancer, the PSA level should be less than 1 mg/dL, so even a modest elevation in PSA should prompt a referral for further evaluation if necessary.

One thing I think is really interesting about prostate cancer screening among prostate cancer survivors is the recommendation for an annual digital rectal examination (DRE). There's not a ton of literature on it, but there was one study that demonstrated that among men with a recurrence of prostate cancer, 25% of tumors were undetectable by DRE but they were detectable by PSA.[2] The average lag time between a positive PSA and a positive DRE was 14 months.

If the goal is an expeditious and exact finding for a recurrent cancer, and the timing is important, then PSA testing is the most important part. I'm not sure, particularly in a patient who has undergone radiation therapy and surgery, whether DRE has a strong role in the primary care office because of the failure and sensitivity, and also it's just very uncomfortable for patients and is associated with a rare risk for serious complications. I wanted to mention that.

The Colorectal Cancer Survivor

Dr Vega: I want to make sure we leave time for our last subject, which is colorectal cancer. In this situation, the guidelines for follow-up aren't necessarily as straightforward. It depends on the type of tumor, the stage, the type of treatment the patient received, and then all of the things that may be encountered during follow-up, including carcinoembryonic antigen (CEA) levels, routine CT scans, and routine colonoscopy.

Communication is important. The triad of practitioners who are going to be taking care of these patients includes the primary care clinician, a gastroenterologist, and most likely an oncologist.

I've never seen a care plan for a colorectal cancer patient that states: "I will follow this patient for the next 2 years and check CEA levels every 6 months with a colonoscopy at the end, and then I will hand over care to the oncology team, who will follow the patient for the next 3 years." I've never seen that once in my practice, yet it seems like that would be really valuable, just to know who has which responsibility at which time.

I'd like to hear your thoughts on that as an oncologist. What can we be doing better, because it seems like there's a chance for some significant gaps in communication, which could cost some patients in terms of morbidity and mortality.

Dr Schapira: I think that's a phenomenal point that the patients and the primary care clinicians lament—that we often don't work as a team. Guidelines from professional societies like the American Society of Clinical Oncology, for instance, which endorsed a statement from Cancer Care Ontario, form the structure for our recommendations for colorectal cancer survivorship. One of the main points is to have a team and a discussion with a primary care clinician so that everything that you point out actually is spelled out.

Ideally, the patient should have a survivor care plan that details all of this. Who's going to do what and when? The important point here is that the oncologist needs to look out for signs of early recurrence because in the case of colorectal cancer, finding the recurrence early could be lifesaving and could lead to surgery and a complete change in management. Unlike in some of the other cancers, I think the reason for these misunderstandings is that the care plan needs to be individualized. Patients who have colorectal cancer need somebody to think about when they ought to have their colonoscopies. If they presented urgently, perhaps they need the follow-up colonoscopy sooner than if they didn't. So I think that it needs to be spelled out.

Because you need somebody to do a colonoscopy, you need the gastroenterologist involved as well. It is not just between the cancer clinician and the primary care clinician; you need to involve somebody who has that procedural ability.

And as you've pointed out, sometimes information is lost or not transmitted. You need all of that information to individualize a care plan. If a patient has an adenoma, for instance, they may need to have their next colonoscopy sooner than if their 1-year colonoscopy is completely clean.

So the interplay between the different cancer clinicians, the primary care and GI person, plus the schedule for testing of CEA, and for doing physical exams, needs to be spelled out in every patient. Perhaps what our message to the general population should be is that the primary care clinician can be an advocate and can help the patient get that plan, and then figure out who's going to do what and when.

Dr Vega: Because I see with colorectal cancer—and this is certainly pertinent to prostate, breast, and every other type of cancer as well when we're thinking about a care plan—it is jointly owned by the oncologist, the primary care physician, any other specialist treating the patient, and the patient. The patient needs to be involved in the care plan. I understand sharing that plan. And I understand that everybody should have the right to edit that plan, which seems to be the most efficient way to keep it updated. In your opinion, who should really own it? Where should it be housed? Should it be in the primary care office?

Dr Schapira: I love that question. My personal feeling is that the patient needs to own it. What we all need to do, and perhaps the cancer community needs to do better, is to help patients really understand what's happening and what is going to happen. I think every patient should have the plan written or in a thumb drive, and hopefully have the ability to share it, and then also be a stakeholder in implementing it. But in the absence of that, or perhaps as an additional safeguard, the primary care clinician needs to have it. That needs to be the home for the patient.

Dr Vega: That is an outstanding ideal. It's a very patient-centered approach, particularly when, at some stage, the patient cannot have a say in getting follow-up. For example, the 93-year-old who had his prostate cancer treated 25 years ago—he should have the right to decide that maybe it is time to rethink his care plan. Patients' lives may have changed significantly such that they want to rethink the way they go about doing it.

It will take a lot of advocacy and education. I certainly want primary care and oncology to be very involved. Working on the communication is the key part. Later on, we could work toward a system where it has just become expected that using technology—things like patient portals and access to electronic records—that patients will be more involved, with access to easily understandable plans of care that they can own and talk to their clinicians about.

Dr Schapira: I completely agree.

Dr Vega: This has been really helpful for me and hopefully for our audience too. Thank you so much for joining us today. We'll see you next time on the Critical Issues series.

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