lymphoma survivors: late and long-term effects carrie thompson, md nccs cancer policy advocate...
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Lymphoma Survivors: Late and Long-Term Effects
Carrie Thompson, MD
NCCS Cancer Policy Advocate Training
June 25, 2015
Outline
• What is lymphoma survivorship
• Medical survivorship issues
• Psychosocial survivorship issues• Negative sequelae • Positive sequelae
Lymphoma Survivors
• 14.5 million cancer survivors in the US• 761,659 people living with or in remission
from lymphoma in US
SEER Cancer Statistics Review 2014ACS Cancer Facts and Figures 2015
Non-Hodgkin Lymphoma in US
60% aggressive
40% indolent
Medical Sequelae of Treatment
• Thyroid
• Heart
• Secondary cancers
Thyroid Disease
• Caused by radiation therapy
• Radiation doses >15 Gy to the neck leads to hypothyroidism in ~50%
• Hyperthyroidism rare
• Thyroid nodules found in 30-40% of Hodgkins survivors who have received radiation• Majority benign
Metzger Ped Blood Ca 2006;46:314-9Crom Med Pediatr Oncol 1997;28:15-21
Cardiovascular Disease
• Radiation therapy• Causes fibrosis (scar tissue)• Fibrosis can affect pericardium, myocardium,
conduction system, coronary arteries, valves
• Chemotherapy (anthracyclines)• Leads to myocyte loss and damage
Congestive heart failure
• Subclinical (asymptomatic, echo abnormal)• 27.6% in lymphoma survivors1
• Do not know if this will lead to clinical CHF
• Clinical CHF• 7.2% incidence with 6 year followup2
• May become evident during times of increased cardiac workload• Pregnancy, anesthesia, BMT, illness
1JCO 1998; 16:3502-8 2Ryberg 1998
Coronary artery disease
• Prospective study in 294 asymptomatic survivors of Hodgkin lymphoma • ≥35 Gy to mediastinum• Excluded patients with known CVD• Nuclear study and stress test
• 40 patients (14%) underwent coronary angiography
• Coronary artery stenosis >50% in 22 patients• 7.4% of those screened
JCO 2007; 25:43-9 Blood 2007; 109:1878-86
Other cardiac diseases
• Valvular disease• Predominantly mitral and aortic valves
affected
• Pericardial disease• Historically most commonly affected cardiac
structure• Now <10% of patients
• Conduction system• Arrhythmias and QT prolongation
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
Benefits of exercise
JCO 2014; 32: 3643-50
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
Types of secondary cancers
• 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
Types of secondary cancers, continued
• Due to radiation• Gastric/colorectal cancers• Sarcoma• Skin cancers
• Due to chemotherapy• AML/MDS
• Mostly due to chemotherapy (alkylators)
• NHL• ~5% lifetime risk in those treated for HL
PSYCHOSOCIAL SURVIVORSHIP
• Quality of Life (QOL)• Depression• Anxiety• PTSD•
What is quality of life?
QOL
Physical
Functional
Emotional
Social
Impact of Lymphoma on QOL and Functioning
76 CLL pts.vs.
152 HC1
459 NHL pts.vs.
Gen. Pop of Norway2
93 NHL pts.vs.
186 HC France3
46 HL pts.vs.
46 HCSpain4
81 NHL116 HC5
Physical x x x x x
Role x x x
Cognitive x x
Emotional x
Social x x x
General Health
x
Perceived Health
x
1Holzner et al.; Eur J Hematol;2004;72:381-389 2Loge et al.; Annals of Onc; 10:71-77 3Joly et al.; JCO; 1996:14(9):2444-2453 4Gil-Fern et al.; Ann Hematol;2003;82:14-18 5van Tulder et al.; Annals of Onc;1994;5:153-158
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
• 70 survivors of aggressive lymphoma• 37% reported clinically significant anxiety• Associations of higher anxiety levels with
• Worse doctor-patient relationship• History of relapse
• Qualitative• Fear of recurrence
• “Scan-itis”• Anxiety worst in 1st year after treatment
Thompson et al.; Annals of Oncology; 2010
Anxiety in Lymphoma Survivors and Spouses
Mitchell et al; Lancet Oncology 2013; 14:721-32
Post Traumatic Stress Disorder
CancerFeelings of loss
and crisis
PTSD symptoms
• 886 NHL survivors1
• 8%- Full PTSD criteria• 9.1%- Partial criteria• 39%- Met at least one
criteria
• 44 lymphoma survivors2 vs. 44 other trauma
• 18%- Full PTSD • 14%- Partial PTSD
• Prevalence of PTSD in general population- 2.4%1
1Smith et al., JCO; 2008; 26(6): 934-412Geffen et al.; Leukemia and Lymphoma;
2003;44(11):1925-1929
Employment and Insurance
• Changing jobs, reducing hours, stopping work, interference with career1
• Insurance and loans• 15% of 221 NHL survivor2
• 31% of patients had trouble getting insurance because of cancer3
1Mols et al.; Cancer; 2007; 7(6):791-62van 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
ASCO 2015
Survivorship Care Models
• Primary care providers not trained in care of long-term cancer survivors
• Communication and coordination of care is key• Survivorship care plan
• Treatment summary• Follow-up care plan
JOP 2014; Epub 10/14/14www.asco.org
Improvements in lymphoma survivors who attended clinic vs. those who did not:
Receipt of SCP
Education needs met-Late & long term effects, habits/lifestyle, decreasing risk of cancer, managing anxiety, staying fit, nutrition, sexuality, insurance
Confidence in getting more information if needed
Distress/PTSD (Impact of Events scale)
Thompson Unpublished data
Summary
• Lymphoma diagnosis and treatment may have long-term effects• Heart disease, secondary malignancies,
fatigue, fertility, loss of immunity• QOL, anxiety, psychosocial issues• Positive effects
• Coordinated survivorship care is key
