Slide 1Carrie Thompson, MD Lymphoma Research Foundation October 18, 2019
©2011 MFMER | slide-2
Living with Cancer or a History of Cancer
• Growing number of cancer survivors • 15.5 million in USA now (3 million 1971)
SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesda, MD, /based on November 2010 SEER data submission, posted to the SEER web site, 2011
Doc, what can I do to stay healthy… …now that I’m in remission? …if my lymphoma comes back? …so that I don’t develop long term health complications?
Outline
• Diet • Loss of Immunity • Exercise • Emotional Aspects
Late Effects of Chemotherapy and Radiation Therapy
• Cardiovascular disease • Secondary cancer • Fertility • Thyroid disease • Psychosocial issues
Factors to Consider
• Radiation therapy • Causes fibrosis (scar tissue) • Fibrosis can affect pericardium, myocardium,
conduction system, coronary arteries, valves • Chemotherapy (anthracyclines)
• Leads to myocyte loss and damage
Who is at risk?
• Incidence for all types of CVD: 1% incidence per year in NHL1
• CAD 10-20 years after treatment • Treatment factors
• Radiation to chest, anthracycline chemo • Patient factors
• Tobacco use, lack of exercise, family history, high blood pressure, high cholesterol, diabetes
1Thompson Blood; 2011
Recommendations for those at risk
• Annual physical exam • BP check • Lipids every 3-5 years • Glucose annually
• Particularly if hx paraaortic LN xrt • Treat cardiac risk factors • Lifestyle modifications
JCO 2009; 27:5383-89
JCO 2014; 32:3257-63
Screening Recommendations: CVD
• Post-radiation therapy • If >30 Gy to mediastinum
• Stress test (exercise stress echo) starting 5-10 years post therapy then q 5 years
• Post anthracycline chemotherapy • If >240 mg/m2 doxorubicin
• Echo starting 5 years after treatment then q 5 years
Secondary Cancers
• Chemotherapy and radiation therapy are carcinogenic
• 16% of all new cancer cases are in patients who previously had a cancer • Late sequelae of treatment • Genetics • Lifestyle factors • Environmental exposures
JNCI 2006;98:15-25
• Due to radiation • Breast cancer
• In those treated for childhood HL, estimated incidence of breast cancer 20% at age 45
• Thyroid cancer • Lung cancer
• Risk significantly increases in those who smoke after radiation therapy
JCO 2003; 21:4386-94
• Due to radiation • Gastric/colorectal cancers • Sarcoma • Skin cancers
• Due to chemotherapy • AML/MDS
• ~5% lifetime risk in those treated for HL
Recommendations for those at risk
• Annual skin exam in irradiated field • Annual mammogram (+/- MRI) 8 years after
radiation or at age 40, whichever is earlier • Colonoscopy 15 years after pelvic, abdominal,
spinal irradiation or at age 35 • Tobacco cessation • Life-long surveillance
• Very important issue for younger patients • ABVD does not affect fertility • Fertility preservation pre-treatment • Wait 2-5 years post-treatment to have children
• No increase in birth defects, miscarriage, cancer in offspring compared to general population
www.fertilehope.org
Thyroid Disease
• Caused by radiation therapy • Radiation doses >15 Gy to the neck leads to
hypothyroidism in ~50% • Hyperthyroidism rare • Thyroid nodules are common in those who have
received radiation • Majority benign
Metzger Ped Blood Ca 2006;46:314-9 Crom Med Pediatr Oncol 1997;28:15-21
Recommendations for those at risk
• Annual TSH (blood test) if received radiation to neck
• Physical exam of thyroid • If abnormality, thyroid ultrasound
PSYCHOSOCIAL SURVIVORSHIP
What is quality of life?
QOL
Physical
Functional
Emotional
Social
Depression and Anxiety in Cancer Survivors
• Depression higher than general population in 1st 2 years after diagnosis, then no different
• Anxiety levels higher than general population and tend to persist
Mitchell et al; Lancet Oncology 2013; 14:721-32
Anxiety
Anxiety Among 459 NHL Survivors in Norway vs. General Population
3.3%
14.5%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Chart1
Anxiety Among 459 NHL Survivors in Norway vs. General Population
3.3%
14.5%
0.033
0.145
Sheet1
Anxiety
15%
To resize chart data range, drag lower right corner of range.
Anxiety in Lymphoma Survivors and Spouses
Mitchell et al; Lancet Oncology 2013; 14:721-32
Employment and Insurance
• Insurance and loans • 15% of 221 NHL survivor2
• 31% of patients had trouble getting insurance because of cancer3
• Financial toxicity
1Mols et al.; Cancer; 2007; 7(6):791-6 2van Tudler et al.; Annals of Oncology; 1994: 5:153-158
3Kornblith et al.; Cancer; 1992;70(10):2508-16
PSYCHOSOCIAL SURVIVORSHIP
Positive Sequelae
Positive Sequelae • Positive and negative may exist concurrently • Study of 133 hem malignancy pts vs. 60
controls3
• Comparing life before/after cancer • Hem pts had higher percentage of “better”
responses • Religion • Relationships with family • Outlook on life • Friendships
1Andrykowski et al.;JCO;23(3):599-608;2Fromm et al.;Journ of Beh Med;19(3):221-240; 3Andrykowski et al.;Psycho-Oncology;1993;2:261-6; 4Somerfield et al.;Journ of Beh
Med;19(2):163-184
QOL in 3-year lymphoma survivors is better than the general population
Thompson JCO 2015
Diet: Prevention of lymphoma
• Decreased risk of developing NHL: • More total fruits & veggies • More yellow/orange and cruciferous veggies • More broccoli • More apple cider/juice
The Mediterranean Diet
• Randomized trial of Mediterranean diet vs. usual showed reduction in cardiovascular disease and overall death
NEJM 2018;378:e34(1)- e34(14)
The Mediterranean Diet
• Avoid added sugar • Read food labels
• Drink water
Do I still need to worry about being more susceptible to illnesses?
Loss of Immunity: Vaccines
• NO live vaccines • Influenza vaccine annually (No FluMist) • Shingrix (2 doses) • Tdap/Td every 10 years • HPV vaccine if <age 26 • Pneumococcal vaccine
• PCV-13 and PPV26
• Families and close contacts need to get their flu shot!!
JCO 2019; 37(30):2795-2804
Loss of Immunity: Vaccines Special Situations
• If splenectomy or splenic RT • Meningococcus, HIB, PCV13 at time of
treatment • PPV23 8 weeks later then 5 years later • Meningococcus every 5 years
• If hematopoietic stem cell recipient • More complicated revaccination schedule
Is it possible that I still have “chemo brain”?
Cancer and Treatment-related Neurocognitive Dysfunction
• Deficits in attention and memory, executive functioning, information-processing speed
• Common side effect • No validated screening tool • Few randomized studies on management
Handb Clin Neurol 2016;138:297-309
Post-allo transplant neurocognitive testing
• Only 3% moderate impairments
JCO 2000; 18:2695-2701
• Severe symptoms • Get evaluated! • Cognitive rehab
• Repetitive exercises to train brain
What else can I do?
Benefits of exercise Improves fatigue Improves depression/anxiety Helps you sleep better Improves physical function Improves your immune system Decreases risk of developing heart disease
Decreases risk of lymphoma coming back!
Higher physical activity 3-years after lymphoma
diagnosis is associated with better survival
outcomes
INCREASING physical activity
Risk of CVD in HL survivors
JCO 2014; 32: 3643-50
How to Get Started
• LIVESTRONG at the YMCA
• Healthy lifestyle choices • Exercise • Diet rich in fruits and vegetables
• Continue to see your health care providers at least annually
• Be the expert on your health • Communication • Coordinated care
THANK YOU!
Living with Cancer or a History of Cancer
Slide Number 3
Factors to Consider
Screening Recommendations: CVD
Fertility Issues
Thyroid Disease
PSYCHOSOCIAL SURVIVORSHIP
Cancer and QOL
Anxiety
Employment and Insurance
Positive Sequelae
QOL in 3-year lymphoma survivors is better than the general population
Slide Number 28
Slide Number 38
Post-allo transplant neurocognitive testing
Management
Higher physical activity 3-years after lymphoma diagnosis is associated with better survival outcomes
INCREASING physical activity AFTER lymphoma diagnosis is associated with longer survival
Risk of CVD in HL survivors
Recommendations for physical activity: Aerobic activity
Recommendations for physical activity: Strength training
Recommendations for physical activity: Other activities
How to Get Started