Mar 02, 2016
The inaugural Cancer Survivorship Symposium, held in January 2016, drew more than 800 attendees across the cancer-care spectrum—far exceeding the goal of 500 attendees. As a way to continue the discussion from the meeting, presenters responded to questions from General Sessions 5 and 6: Multidisciplinary Approaches to the Cancer Survivor with Complex Medical Needs—Parts I and II, including the following individuals:
- Co-Chair Belinda Vail, MD, of the University of Kansas Medical Center
- Co-Chair Tara O. Henderson, MD, MPH, of the University of Chicago
- Presenter Christopher J. Recklitis, PhD, MPH, of the Dana-Farber Cancer Institute
Smita Bhatia, MD, MPH, of the University of Alabama at Birmingham, who delivered the Keynote Lecture on “Long-Term and Late Effects: The Science of Survivorship,” also contributed.
In the following article, these individuals address some of the unanswered questions from attendees that did not get asked during the time set aside for discussion.
Q: Which diet do you recommend for survivorship? Do you advocate sugar restriction?
Dr. Vail: As a family medicine physician, I advise sugar restriction for everyone. The dietary approach for a cancer survivor is very similar to the approach that should be taken for someone with diabetes or any other chronic disease. That means fewer simple sugars, more complex carbohydrates, and more fruits and vegetables.
Most people, including cancer survivors, should be encouraged to adopt a healthy lifestyle and put themselves in the best position to stay healthy. The very best things people can do are not smoke, eat healthfully, and exercise.
Q: Are there antioxidants that can prevent chemobrain?
Dr. Vail: There are a lot of data out there on antioxidants. The problem is that much of it is contradictory. Often, when good positive data are identified in vitro, the positive findings do not always translate to real life. Alternatively, antioxidants may show promise in small observational studies, but no benefit emerges when larger studies are performed to validate the findings.
I think the best approach is to advocate a good diet. I tell my patients to eat well-balanced diets with lots of antioxidant-rich foods—that is, fruits and vegetables, as well as beans and nuts—and never much sugar.
Q: What options are there to detect treatment-induced subclinical cardiac damage? If detected early, what management options are there?
Dr. Henderson: The standard tools recommended for detection of subclinical cardiac damage are echocardiography or a multigated acquisition (i.e., MUGA) scan. Researchers are currently studying the utility of cardiac MRI.
In terms of management of subclinical disease, patients can be referred to cardiologists who specialize in caring for cancer survivors. Some drug options, such as angiotensin-converting enzyme inhibitors, are available to provide cardiac support to the patient. However, no data from clinical trials definitively support a specific therapeutic agent to reduce cardiac morbidity and mortality. This may change in the future, because ongoing clinical trials are addressing prevention. For example, Saro Armenian, DO, MPH, of City of Hope, was recently awarded a research grant from the National Institutes of Health to conduct a clinical trial evaluating a drug intervention to prevent anthracycline-induced cardiac damage.
Aside from these strategies, we must encourage patients to maintain their ideal body weights, exercise on a regular basis, ensure that diabetes is being managed appropriately in affected individuals, and reduce any other cardiovascular risk factors they may have, given the increased cardiac risk posed by certain cancer therapies.
Q: Given the declining cost of genetic testing, do you foresee genetic testing becoming standard practice for patients scheduled to receive anthracyclines to determine if they are at risk for cardiomyopathy?
Dr. Bhatia: That is indeed our goal—that is, to identify individuals at diagnosis such that treatments can be personalized and we can reduce potential harm to the patient while maximizing their chances of cure. Several single nucleotide polymorphisms (SNPs) have been linked to chemotherapy-induced cardiac complications. We plan to use these SNPs to develop a risk-prediction model, which would allow patients to be classified as at high or low risk for cardiac complications. This information will be used to decide the maximum dose of chemotherapy, the intensity of cardiac screening, and the pharmacologic interventions.
Q: What is the clinical experience to date with low-dose tamoxifen for breast cancer risk reduction?
Dr. Henderson: A study conducted in the late 1990s and early 2000s at the Dana-Farber Cancer Institute evaluated low-dose tamoxifen in female survivors of Hodgkin lymphoma who received chest radiation. Unfortunately, however, the trial had very poor accrual and was closed early. Subsequent to that, Dr. Bhatia received a research grant to conduct a randomized controlled trial of low-dose tamoxifen versus placebo in women exposed to chest radiation before the age of 30. That trial is ongoing. No data have been released yet, but we hope to see some data emerge in the near future.
Q: How do you clear a female cancer survivor for pregnancy in primary care? For example, if a young women survives breast cancer but is slated to receive hormone therapy for the next 5 to 10 years, how do you counsel her on the timing of pregnancy?
Dr. Vail: There are no easy answers to these questions. Clearing a cancer survivor for pregnancy is something that the primary care physician and oncologist need to discuss, because numerous factors must be taken into account.
For the specific example given of the young women who survived a diagnosis of breast cancer, you ideally do not want the individual, as with any woman, to be taking any type of medication during pregnancy. Tamoxifen use during pregnancy is discouraged, because it is a teratogen. In general, we would like the patient to finish all of the tamoxifen treatment before getting pregnant, but that might not be an option for a woman who is in her late 30s. There are some reasonable data to suggest that tamoxifen can be paused or delayed long enough for a successful pregnancy and then resumed or started, depending on a patient’s disease risk, without adversely influencing long-term outcomes.1-3 However, decisions like these should be made between the oncologist, general practitioner or obstetrician, and the patient, with full disclosure of the risks and benefits.
Q: What effects does radiation therapy to the chest wall have on the spine?
Dr. Henderson: The effects of radiation that involves the spine are very different for a youth versus an adult.
For a childhood cancer survivor who is still growing, radiation to the spine can impair growth, resulting in either diminished trunk growth or scoliosis. Radiation to any part of the body increases the risk of a second cancer. Radiation therapy to the chest wall specifically increases the risk of secondary spinal sarcoma or other cancers within the radiation field.
Adults do not face the risks associated with spinal growth, but they are still at risk of second malignancy.
Q: What interventions for fatigue are best for adolescent and young adult (AYA) survivors who are still in school?
Dr. Recklitis: In general, my recommended approach for addressing cancer-related fatigue (CRF) includes careful evaluation, identification, and treatment of any contributing medical issues and prescription of interventions, especially exercise and possibly other interventions, including cognitive behavioral therapy.
There are limited data on fatigue in young cancer survivors. However, data collected at Dana-Farber indicate that fatigue levels in AYA survivors appear similar to those in community samples, which suggests that CRF is uncommon in this age group. As a consequence, one should be vigilant in the patient work-up to carefully assess fatigue and look for possible medical or emotional problems that could be contributing (e.g., sleep disturbance, substance use, depression, and anxiety). Learning disabilities, especially those related to CNS-directed therapy, should also be carefully evaluated, because these can contribute to cognitive fatigue during school and homework, which can contribute to fatigue generally.
For school-aged survivors with CRF, the interventions are not much different than those for other survivors. Exercise has the best evidence to support it and can be worked into a school schedule. Cognitive behavioral therapy directed at fatigue also is likely to be helpful but may need to be altered on the basis of the needs of the student. Students who have very significant fatigue may need certain adaptations at school, such as additional time to complete assignments or rest periods during school, to accommodate their CRF, and the student or family may need to work with the school to put these in place.
Q: As a medical oncologist, I encourage patients who struggle with post-chemotherapy concentration issues while reading or who struggle with insomnia to limit their screen time with e-readers and other backlit devices and to use books and other paper items (i.e., magazine articles that are shorter) to help alleviate these issues. Do you have any commentary or recommendations regarding this practice?
Dr. Recklitis: There is growing evidence that light from tablets and e-readers can interfere with sleep, so it is reasonable to suggest to anyone with insomnia that they limit these activities, especially in the evening before going to bed. That said, the degree to which these devices affect sleep and the amount of exposure necessary to affect sleep are not well understood. These devices are not the only ways for people to develop habits that interfere with sleep. An animated telephone call, worry about the next day, watching television, or even reading in the bedroom may all negatively affect sleep for those with insomnia, so it is very important that recommendations about e-readers are only one component of education about sleep hygiene. Moreover, for individuals who have notable chronic insomnia, it is likely that many factors are contributing to their condition; therefore, changing their exposure to e-readers alone may not be enough to dramatically improve their sleep.
- Gradishar WJ, et al. Clin Breast Cancer. 2002;2:282-86.
- Arnon J, et al. Hum Reprod Update. 2001;7:394-403.
- Valachis A, et al. Obstet Gynecol Surv. 2010;65:786-93.