2008 updates in therapeutics: the pharmacotherapy ... · the largest relative increase of cancer...

Cancer Survivorship

Alex Chan, Pharm.D., FCCP, FISOPP, MPH, BCPS, BCOP

Deputy Head and Associate Professor

National University of Singapore and Duke-NUS Medical School

Specialist Pharmacist

National Cancer Centre Singapore

[email protected]

1

http://www.duke-nus.edu.sg/


Learning Objectives

Define cancer survivorship.

Elaborate common physical and mental health issues

surrounding cancer survivors.

Discuss a pharmacist’s role in cancer survivorship.

Understand the current developments of cancer

survivorship programs in Singapore.

2

Who are ‘cancer survivors’?

A. Individuals who had a life-threatening disease but have remained

disease free for a minimum of 5 years.

B. People who were diagnosed with cancer and are currently dealing

with the physical and psychological effects of diagnosis and

treatment.

C. Anyone between the time of cancer discovery and for the balance

of life.

D. Family members, friends, and care-givers of cancer patients.

E. All of the above.

Bell K, Ristovski-Slijepcevic S. J Clin Oncol 2013; 31(4):409-11.

6

Definitions

Survivorship, defined by the National Coalition for

Cancer Survivorship

From the time of diagnosis, through the balance of his

or her life

Family members, friends, and caregivers are also

impacted

Conventionally, after being ‘cured’

Late / long-term effects

Include life-threatening and life-altering effects

Subclinical in nature

Adopted from the National Coalition for Cancer Survivorship4

5http://healthland.time.com/2013/03/27/18-million-cancer-survivors-expected-by-2022/

de Moor JS et al. Cancer Epidemiol Biomarkers Prev 2013;22:561-570

http://healthland.time.com/2013/03/27/18-million-cancer-survivors-expected-by-2022/

Singapore Cancer Registry Interim Annual Registry Report : Trends in Cancer Incidence in Singapore 2009-2013 ; Last Accessed: March 27th 2018

Cancer Survivorship - Epidemiology

An estimated 15.5 million people in the United States had

been diagnosed with cancer in 2016.

A 3.5 fold increase compared to 1975

An estimated prevalence of cancer survivors will increase

from 15.5 million (2016) to 26.1 million (2040).

7

Age Group Estimated prevalence in 2040

<50 years old 8%

50 - 64 years old 18%

65- 74 years old 24%

75 – 84 years old 31%

85 years old 18%

de Moor JS, et al. Cancer Epidemiol Biomarkers Prev 2013;22:561-570

Bluethmann SM, et al. Cancer Epidemiol Biomarkers Prev 2016; 25;1029–36.

Distribution of Cancer Survivors

in the United States

de Moor JS, et al. Cancer Epidemiol Biomarkers Prev 2013;22:561-570

Breast, 22%

Prostate, 20%

Colorectal, 9%Melanoma, 7%

Corpus uterus, 5%

Bladder, 4%

Thyroid, 4%

Non-Hodgkin's Lymphoma, 4%

Lung, 3%

Leukemia, 2%

Others , 20%

8

DeSantis CE, et al. CA Cancer J Clin 2014;64:252-271.

0 10 20 30 40 50 60 70 80 90 100

Melanoma

Breast

Colon and rectum

Prostate

Proportion of survivors

0-39 40-49 50-59 60-69 70+

Age at prevalence Melanoma Breast Colon and rectum Prostate

0-39 79,410 43,260 14,830 590

40-49 136,410 240,100 52,290 23,910

50-59 232,640 596,870 159,980 259,850

60-69 259,900 849,920 265,720 841,770

70+ 337,080 1,401,290 752,950 1,849,850

All ages 1,045,430 3,131,400 1,245,770 2,975,970

Table: Age Distribution of Survivors for Selected Cancer Types, January 1, 2014

Figure: Proportion of cancer survivors in different age groups

The 2010 National Health Interview Survey contacted

1,882 cancer survivors and 24,804 adults without cancer

diagnosis.

Physical- and mental health-related quality of life were

assessed using PROMIS® Global Health Scale.

Majority of the survivors were 65-79 years old, white,

female and had at least 2 comorbidities.

Weaver KE, et al. Cancer Epidemiol Biomarkers Prev 2012; 21(11): 2108-17

PROMIS = Patient-Reported Outcomes Measurement Information System

Prevalence of health issues

among survivors

10

Prevalence of physical and mental

health issues

Weaver KE, et al. Cancer Epidemiol Biomarkers Prev 2012; 21(11): 2108-17

One standard

deviation below the

US population

mean

Prevalence

among cancer

survivors (%)

Prevalence among

adults without

cancer (%)

Population

estimate for cancer

survivors (n)

Physical health score 24.5% 10.9% 3,278,000

Mental health score 10.1% 5.9% 1,356,000

Both physical and

mental health scores7.2% 3.5% 973,000

Younger, unmarried, less-educated, and manifesting multiple non-cancer

co-morbidities were at greater risk for poor physical and mental

health-related quality of life among the cancer survivors

Maria H, Sheldon G, Ellen S. Institute of Medicine. 2006. Accessed February 26, 2015

Fallowfield L, Jenkins V. Journal of the National Cancer Institute. 2015;107(1):335.12

Psychological Distress

Cognitive Impairment

Physical effects

Adjustment back to normal life

Fatigue

Survivorship issues are

multidimensional

Feb 16th 2015

Straits Times

Today

Today, March 13 2012

Zaobao, March 13 2012

16December 7th 2015, Zaobao

December 4th 2015,

Today & Straits Times

17

June 1st 2013; Straits Times, Today and LianHe ZaoBao

18

LianHe ZaoBao

22 May 2018

The Impact of Silver Tsunami

on Cancer Survivors

The largest relative increase of cancer survivors by time

since diagnosis will be among people who are >15 years

post diagnosis.

The three most prevalent comorbid conditions are CHF,

COPD, and diabetes.

Lung cancer patients have the highest comorbidity burden before

diagnosis.

Conversely, breast and prostate cancer patients have the least.

19de Moor JS, et al. Cancer Epidemiol Biomarkers Prev 2013;22:561-570

Bluethmann SM, et al. Cancer Epidemiol Biomarkers Prev 2016; 25;1029–36.

20Loh KY,…., Chan A. Support Care Cancer 2016;24(4):1639-47.

Cancer Patient to Cancer Survivor:

‘Lost in Transition’

• Transition from active

treatment to post-treatment

care is critical to the long-term

health of cancer survivors

• Unfortunately, many patients

are “lost in transition” and do

not receive the care they

should

• Upon discharge from

treatment, every patient should

receive treatment summary

and survivorship care plan

Institute of Medicine and National Research Council21

What tends to be

‘Lost in Transition’?

Prevention of new and recurrent cancers and other late

effects.

Surveillance for cancer spread, recurrence, or second

cancers.

Assessment of late psychosocial and medical effects.

Coordination of care between primary care providers and

specialists to ensure that all of the survivor’s health

needs are met.

Institute of Medicine and National Research Council22

Components of

survivorship programme

Recommended by the United States Institute of Medicine

Maria H, Sheldon G, Ellen S. Institute of Medicine. 2006. 23

Intervention for consequences of cancer and its treatment

Discuss information on peer support groups

Conduct distress screening

Discuss sexuality issues

Discuss fertility issues

Discuss long term physical effects

Discuss exercise and physical activity

Discuss healthy diet recommendations

Discuss health behaviors

Discuss management at home

Discuss employment and financial issues

Challenges in Cancer Survivorship

Lack of evidence on effective management

strategies.

Community providers are unfamiliar with

survivorship health risks and are uncomfortable

in supervising care of survivors with complex

health issues.

Practice models vary around the world.

24

Role of a pharmacist

in cancer survivorship

Medication management and reconciliation

Maintenance therapies (e.g., hormonal therapies and targeted therapies)

Complementary alternative medicines

Medications for other chronic illnesses

Adherence to medications

Symptom management

Apply screening tools to monitor patients’ well-being

Manage cancer- or treatment-related symptoms

Counseling to reduce lifestyle risk factors

Smoking cessation and obesity

Involve in multidisciplinary survivorship care

25Chan A, Lee J. ACCP Ambulatory Care Self-Assessment Program 2017 Book 1 Oncologic/Hematologic Care

https://www.accp.com/store/product.aspx?pc=ACSAP17_1

Projects to improve survivorship

care – involving the pharmacist

Need assessments

Focus groups of patients and practitioners

Group-based intervention

Institution-based, to improve transition from

chemotherapy

Educational programs for practitioners

27



Need assessments

Focus groups of cancer survivors



chemotherapy


28

29Chan A, et al. J Glob Oncol 2016;3(2):98-104.

Specific Quotes

Understanding the terminology: Who is a Cancer Survivor?


Specific Quotes

Physical symptoms that affect our survivors


Specific Quotes

Emotional issues that affect them


Specific Quotes

How should we improve our follow-up care?


In summary..

A large void in the care of Asian cancer survivors.

Survivors are overwhelmed by their symptoms

(physical and psychological), and they receive

very little help with their oncologists.

There are a lot of cultural elements (Asian

specific) that need to be addressed in survivorship

care.

Family relationships, traditional medicines usage




Need assessments




chemotherapy


36

Strategies to deliver survivorship care

Osborn RL, et al. International journal of psychiatry in medicine 2006;36(1):13-34.

David N, et al. Psycho-social medicine 2011;8:Doc05.

Mehnert A, et al. Onkologie. 2011;34(5):248-253.37

Individual

Phone interview Web-based

Psychotherapy

Group

Rehabilitation

Education or cognitive

behavioral therapy

Psycho-Education Group (PEG) Study

for breast cancer survivors

38

Recruitment:

Stages 1-3 end of

(neo)adjuvant

Chemotherapy*

Intervention

Group

Control

Group

Three sessions of psycho-

education therapy

Randomization

Baseline assessment using

behavioral questionnaires

Reassessment using

behavioral questionnaires

and satisfaction surveys

“Usual Care”

All patients are given a NCC Chemotherapy Counseling Booklet at recruitment

*Some patients may receive trastuzumab and endocrine therapies after recruitment

Study is funded by NCCS Community Cancer Fund

1st run = Sept 2015

2nd run = Nov 2015

ClinicalTrials.gov, #NCT02600299

Chan A, et al. Psychooncology 2016; doi: 10.1002/pon.4357.

PEG Study - Inclusion/Exclusion Criteria

39

Female, 21 years or older

Diagnosed with early stage (stage 1-3) breast cancer by a medical oncologist Completing chemotherapy

Allow to receive adjuvant targeted therapy (e.g. adjuvant trastuzumab) and adjuvant endocrine therapy

Had no formal psychiatric diagnosis

Able to read and understand English


40

Week 1

Session 1: Enhancing Physical & Mental Functioning (Content duration: 4.5 hours)

Topic 1. Nutritional aspects of living well (1.5 hours) [Conducted by a dietitian]

Topic 2. Strengthening cognitive aspects (1.5 hours) [Conducted by a neuropsychologist]

Topic 3. Physical aspects of self-care (1.5 hours) [Conducted by a physiotherapist]

Week 2

Session 2: Enhancing Emotional & Social Well-being (Content duration: 4.5 hours)

Topic 1: Psychosocial and emotional issues in cancer care (2 hours) [Conducted by a health psychologist]

Topic 2: Journey towards personal and social well-being (1.5 hours) [Conducted by a medical social worker]

Topic 3: Motivational aspects of being a cancer survivor (1 hour) [Conducted by a cancer survivor]

Week 3

Session 3: Reassuring medical care in survivors (Content duration: 4.5 hours)

Topic 1: Medication issues and toxicities management (1.5 hours) [Conducted by an oncology pharmacist]

Topic 2: Continuation of care and referral (1.5 hour) [Conducted by an Advanced Oncology Nurse]

Topic 3: Improvement of survivorship (1.5 hours) [Focus group session among participants]

PEG study – Intervention Arm


PEG Study - Usual care

41Chan A, et al. Psychooncology 2016; doi: 10.1002/pon.4357.

Study Tools

De Haes JC, et al. British Journal of Cancer. 1990;62(6):1034.

Aaronson NK, et al. Journal of the National Cancer Institute. 1993;85(5):365-376.

Luo N, et al. Quality of life research. 2005;14(4):1181-1186.

Beck AT, et al. Journal of consulting and clinical psychology. 1988;56(6):893.

Larsen DL, et al. Evaluation and Program Planning. 1979;2(3):197-207. 42

Rotterdam Symptom Checklist (RSCL)

European Organization for Research and Treatment of

Cancer Quality of Life Questionnaire (EORTC-QLQ-C30)

Beck Anxiety Inventory (BAI)

Satisfaction questionnaire

PEG Study - Patient Characteristics

44

Patient Characteristics

Number of patients (%)

Usual Care

(N=38)

Intervention (N=34)

AgeMean age (years) ± standard

deviation52.6 ± 8.6 53.4 ± 9.4

Race

Chinese 32 (84.2) 29 (85.3)

Malay 3 (7.9) 2 (5.9)

Indian 1 (2.6) 2 (5.9)

Others 2 (5.3) 1 (2.9)

Cancer Stage

Stage I 7 (18.4) 6 (17.6)

Stage II 21 (55.3) 21 (61.8)

Stage III 10 (26.3) 7 (20.6)

Level of

Education

Secondary (Junior high) or lower15 (39.5) 11 (32.4)

Pre-university (Senior high) or

higher25 (60.5) 23 (67.6)


45Chan A, et al. Psychooncology 2016; doi: 10.1002/pon.4357.

Items from Satisfaction

Questionnaire (n=28)

Strongly

disagree, n

(%)

Disagree, n

(%)

Neutral, n

(%)

Agree, n

(%)

Strongly

agree, n (%)

The content taught in the program

has addressed your needs.0 (0) 0 (0) 0 (0) 9 (32.1) 19 (67.9)

You are satisfied with the amount

of help you are receiving. 0 (0) 0 (0) 0 (0) 11 (39.3) 17 (60.7)



Need assessments




chemotherapy


48

49https://www.accp.com/store/product.aspx?pc=W_ONC2_16R

50ACCP Ambulatory Care Self-Assessment Program 2017 Book 1 Oncologic/Hematologic Care

https://www.accp.com/store/product.aspx?pc=ACSAP17_1

51Loh K,..Chan A, Soo KC et al. Journal of Global Oncology 2018; DOI: https://doi.org/10.1200/JGO.17.00117

Our Vision on Cancer Survivorship

52Loh K,..Chan A, Soo KC et al. Journal of Global Oncology 2018; DOI: https://doi.org/10.1200/JGO.17.00117

Scholarships to study in Singapore – SINGA!

54

https://www.a-star.edu.sg/singa-award/

55

ISOPP/BOPA

Joint Meeting 2019

Cancer Survivorship

Alex Chan, Pharm.D., FCCP, FISOPP, MPH, BCPS, BCOP

Deputy Head and Associate Professor

National University of Singapore and Duke-NUS Medical School

Specialist Pharmacist

National Cancer Centre Singapore

[email protected]

56



2008 updates in therapeutics: the pharmacotherapy ... · the largest relative increase of cancer...

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