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Cancer survival doesn't end health challenges (ASCO annual meeting)

Earlier detection and better treatments are increasing the success rates for cancer battles. But those treatments have been linked to later varied and often severe medical problems.

By Susan J. Landers, amednews staff. June 20, 2005.

Reports from conferences important to physicians

Expanding ranks of cancer survivors have upped the odds that primary care physicians will encounter at least one or two such patients in an average-size practice.

To illustrate: In 1971, an estimated 3 million people made up the group of patients who had combated the deadly disease and lived to tell about it. By 2001, that number swelled to 10 million -- about the same as the population of Los Angeles. And this tally shows every sign of continuing to grow.

Who are they?
Meeting details
Survivor gap
Finding melanoma early is key, but not easy
Treatment tips
Research findings
See related content

The cadre of childhood cancer survivors, for example, long has been recognized as a medical success story. But this group is being joined by more patients whose cancers were diagnosed when they were adults. Most of them are older than 65. Most had breast, prostate, colorectal or gynecologic cancers. And predictions are for 64% of those newly diagnosed to survive for at least five years.

Earlier diagnoses, more effective treatments and the prevention of secondary diseases are all part of this success story, said researchers at the annual meeting of the American Society of Clinical Oncology, held last month in Orlando, Fla.

But the well-recognized health risks of cancer treatments pose follow-up concerns for patients and physicians, said Patricia Ganz, MD, PhD, professor of health services at the University of California-Los Angeles Schools of Medicine and Public Health.

For instance, adults who were treated for childhood cancers in the 1970s and 1980s are five times more likely to have a moderate to severe health problem than their siblings, say new data from the Childhood Cancer Survivor Study. "Most survivors will have future health problems related to their previous cancer therapy, which are likely to increase as they reach their 30s and 40s," said Kevin C. Oeffinger, MD, professor of family medicine at the University of Texas Southwestern Medical Center in Dallas and the study's lead author.

60,000 new melanoma cases are expected in the U.S. this year.

The health problems faced by all survivors are varied and depend on the type of treatment and the person's age when treated, noted Lois Travis, MD, ScD, a researcher at the National Cancer Institute.

Attention also must be paid to the tissue that was treated, Dr. Ganz said. "We know that certain tissues, for example the gonads, are more susceptible to injury, particularly in youths."

But nearly all tissue can be affected, and there is a broad range of health concerns that include lymphedema, premature menopause, infertility, osteoporosis and fractures, she said.

Second cancers are among the most serious consequences for long-term survivors of childhood cancers, accounting for 10% to 15% of newly diagnosed cancers as adults. Cardiorespiratory complications, while rare, also can also be very serious, Dr. Ganz said.

Treatment summaries, which should accompany all patients who leave an oncologist's office, can guide follow-up care, Dr. Ganz said. Such summaries should include the nature and expected toxicity of treatment. Necessary care does not end when the patient completes cancer therapy, she added.

"Doctors should take into account a survivor's previous cancer and cancer therapy, personal and family medical history, lifestyle habits and other health conditions to develop a life plan to periodically screen for health problems and educate survivors on ways they can reduce risk and maximize their health," Dr. Oeffinger said.

Melanomas detected after they are 4 mm thick are likely to be fatal.

Despite this advice, many patients with childhood cancers are lost to follow-up, said Leslie L. Robison, PhD, associate chair of the Children's Oncology Group, a network of institutions and investigators who identify and treat about 90% of children with cancer.

Despite the best efforts of this group to track 20,720 eligible members, 3,017 fell through the cracks. The important message is "we shouldn't lose them in the first place. We must maintain contact," Dr. Robison said.

Cancer survivors don't have just medical needs. The majority of more than 1,000 two-year survivors surveyed by the Lance Armstrong Foundation said they also had psychosocial needs that were largely unmet by physicians. The findings were presented at the ASCO meeting.

Seventy percent said they were depressed because of their cancer, and 53% said the emotional issues surrounding their disease were more difficult to handle than its physical effects or its treatment.

"Patients who experience the psychosocial or other nonmedical problems need to discuss these issues with their physicians and ask for a referral to the appropriate resources," said Steven N. Wolff, MD, professor of medicine at Meharry Medical College in Nashville, Tenn., and the study's lead author.

Forty-three percent said their income had decreased, and one-quarter said they had gone into debt because of the illness' consequences, with 24% reporting that they had incurred debt of $10,000 to $24,000. Fifteen percent set this amount from $25,000 to $49,000.

But the survey also revealed that respondents were optimistic about life. Nearly half said that, as a result of their experience, they are leading a better life. "Dealing with cancer is an experience that changes people's lives forever," said Doug Ulman, director of survivorship at the Lance Armstrong Foundation and a cancer survivor.

ASCO has taken steps to address cancer survivors' needs by forming a task force to coordinate activities within the organization.

The task force, which is co-chaired by Dr. Ganz and ASCO President Sandra J. Horning, MD, professor of medicine at Stanford University and a cancer survivor, will direct a revision of the society's training curriculum and develop clinical practice guidelines on long-term care and the proper monitoring of these patients.

ASCO's already updated core curriculum includes follow-up care at the end of treatment, surveillance, screening for second cancers, and monitoring for short-term and long-term toxicity.

The society operates People Living with Cancer, a patient-oriented Web site (www.plwc.org).

ADDITIONAL INFORMATION:

Who are they?

Nearly 10 million people in the United States have survived cancer.

70% are between ages 50 and 85.
Approximately 14% were diagnosed more than 20 years ago.
60% are survivors of breast, prostate, colorectal and gynecologic cancers.
24% of adults with cancer are parents who have a child 18 or younger.

Source: National Cancer Institute Office of Cancer Survivorship

Meeting details

More information about lectures, presentations and other developments at the American Society of Clinical Oncology annual meeting can be found online (www.asco.org/ac/1,1003,_12-002092,00.asp).

Survivor gap

Increasing survival rates among young children and older adults with cancer are not, unfortunately, reflected among older adolescents and young adults, those between the ages of 15 and 30, said Archie Bleyer, MD, professor of pediatrics at the University of Texas M.D. Anderson Cancer Center in Houston.

Among the explanations for this gap are lack of health insurance coverage as children age out of parents' policies and less access to clinical trials because a majority of young adults receive care at community-based centers rather than academic centers where trials are often conducted.

In addition, poorer understanding of the biology of adolescent and young adult cancers and, perhaps, more advanced disease at the time of diagnosis, have caused this group to lag behind younger and older counterparts, said Dr. Bleyer.

To improve this situation he recommends that physicians:

Recognize that cancer does occur during early adulthood and that everyone is at risk.
Be aware that young adults often deny symptoms and are too embarrassed to report them.
Realize that young adults are the least likely to have adequate health insurance and should be encouraged to maintain coverage.
Urge young adults with cancer to enroll in clinical trials.

During a poster session at last month's American Society of Clinical Oncology annual meeting in Orlando, Fla., Dr. Bleyer presented findings showing that those ages 15 to 30 comprise the group least likely to be evaluated promptly for a symptom of cancer and most likely to have a delay in diagnosis.

There is a dearth of specialists trained in treating cancer in this age group, said Dr. Bleyer. And the diseases in this group are unique, he added. "Biologically, the disease is different."

Finding melanoma early is key, but not easy

Looking and seeing are key to reducing the current high level of mortality from melanoma.

Prevention has not been successful, tanning parlors continue to proliferate and physicians are not making full body scans a high priority, said Martin Weinstock, MD, PhD, professor of dermatology at Brown University in Rhode Island. Predictions are for 60,000 more melanoma cases in the United States this year, which, following trends of past years, is a new high, said Dr. Weinstock, during an education session presentation at last month's American Society of Clinical Oncology annual meeting in Orlando, Fla.

And treatment is abysmal, he added. Either the melanoma is surgically excised and the patient is cured or it is surgically excised and the patient is not cured and dies.

Thus, discovering problem spots before they reach a crisis point is critical. "Early detection has been key to making whatever progress we've made so far," said Dr. Weinstock.

Melanomas that are detected when less than a millimeter thick are 90% curable while those detected when more than 4 mm thick are likely to be fatal.

The challenge is to get both physicians and patients to look and see early-stage melanomas, said Dr. Weinstock. And the well-recognized A,B,C,Ds of skin exams -- asymmetry, border irregularity, color variation and diameter larger than a pencil eraser -- aren't always the best way to detect the presence of dangerous growths, said other presenters. They showed numerous slides illustrating malignant skin lesions that lacked the usual signs of melanoma.

Since such detection difficulties are likely to shake the confidence of primary care physicians intent upon careful skin inspections, Dr. Weinstock and colleagues will begin field testing next month a curriculum intended to help.

Preliminary trials indicate that the curriculum, based on an algorithm for detecting melanoma that Dr. Weinstock and colleagues developed in 1996, increased the likelihood that primary care doctors would check their patients more closely, particularly their backs and the backs of their legs -- the sites of most melanomas. Studies also reveal that melanoma deaths are increasing among white men older than 50, making that group a cost-effective target for scrutiny, said Alan Geller, MPH, RN, research associate professor in the dermatology department of Boston University. He also was a presenter at the meeting.

As the A,B,C,Ds yield less-than-perfect results, physicians and patients should be alert to any changes in a growth's appearance. To this end, photos of suspicious moles can play a vital role. Teledermatology is also emerging as an important diagnostic tool, with images being forwarded to distant sites for expert analysis, Dr. Weinstock said.

Treatment tips

Here are some treatment tips from the meeting:

The challenge of cognitive impairments and cancer treatment. Patients who have cancer and are cognitively impaired, either as a result of treatment or because of an unrelated dementia, are a quandary for physicians -- whether the goal is gaining informed consent for a procedure or making certain that important instructions are understood.

Although effective treatments are available for the nausea and vomiting that can accompany cancer treatment as well as the pain associated with the disease, fatigue and cognitive problems have not been as well recognized, said Lynne I. Wagner, PhD, a clinical research scientist at Northwestern University in Chicago. She advised that physicians first rule out anemia and then counsel stress management, the use of memory tricks and mind-stimulating activities such as crossword puzzles.

Patients also might undergo relatively subtle changes after chemotherapy that affect their memories and abilities to concentrate, said Timothy Ahles, PhD, professor of psychiatry at Dartmouth College in Hanover, N.H. They can be distracted easily, have difficulty learning new material and seem less likely to trust themselves not to make mistakes, he said.

To ensure that patients understand treatment instructions, Martine Extermann, MD, assistant professor of oncology and medicine at the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla., recommended asking patients to repeat information and to provide the same information to a patient's health care proxy.

Health disparities and clinical delays. African-American women are more likely to experience delays in the diagnosis and treatment of their breast cancer than other women, according to a new Columbia University study.

"While this study confirms results of other smaller studies, we were very surprised by the degree of clinical delay experienced by black breast cancer patients when compared to other women," said Sherri N. Sheinfeld Gorin, PhD, associate professor of clinical sociomedical sciences and epidemiology at Columbia University in New York City and the study's lead author.

Researchers analyzed the time between initial screening, diagnosis and treatment in 49,865 women ages 64 and older who were diagnosed with breast cancer between 1992 and 1999. Of that number, 2,982 were black.

In addition, researchers encouraged physicians to be more assertive in guiding women, especially minority women, to necessary follow-up care.

Differences in dose not linked to outcome disparities. A second study suggests that racial disparities in breast cancer mortality cannot be explained by chemotherapy doses that differ between black and white women. Since black patients tend to have lower baseline white blood cell counts than whites, physicians have speculated that black women with breast cancer may receive lower doses of chemotherapy to avoid dangerous drops in white blood cell counts. But researchers from the National Surgical Adjuvant Breast and Bowel Project determined that dosing differences are not the likely cause of the higher mortality, said Charles R. Thomas Jr., MD, vice chair of the University of Texas Health Science Center's Dept. of Radiation Oncology.

The study retrospectively compared white blood cell counts and doses of chemotherapy drugs for 1,041 black women and 9,639 white women with breast cancer. Baseline white blood cell counts were slightly lower in black women, but the total chemotherapy dose did not differ between the two groups.

Research findings: Breast cancer recurrence risk; impact of low-fat diets, statin use

Adhering to a low-fat diet lowered the risk of relapse among postmenopausal women with early-stage breast cancer compared with women who followed a standard diet, said the Women's Intervention Nutrition Study. The women had undergone surgery to remove tumors and were receiving standard follow-up care.

Results from this study were among the new research findings presented last month during the American Society of Clinical Oncology annual meeting in Orlando, Fla.

Researchers compared the incidence of breast cancer recurrence between 975 women who consumed an average of 33 grams of fat daily and 1,462 women who consumed about 51 grams of fat a day.

After five years, 96 of the women on the low-fat diet had a recurrence of their cancer compared with 181 of the women on the higher-fat diet.

These findings also suggested that the effect of the low-fat diet was more pronounced among women with estrogen receptor-negative cancers, which is considered a marker for a poorer prognosis. This result will need additional trials to confirm, said Rowan T. Chlebowski, MD, PhD, a medical oncologist at the Los Angeles Biomedical Research Institute and the study's lead author.

Meanwhile, other research presented during the meeting indicated a breast cancer risk reduction benefit for women who took statins.

After controlling for age, smoking, alcohol use and diabetes, breast cancer risk was more than 50% lower among women who took statin drugs, according to a study conducted at Overton Brooks VA Medical Center in Shreveport, La.

Although not yet ready to say that all women, regardless of cholesterol levels, should be prescribed a statin, Vikas Khurana, MD, assistant professor of medicine at Louisiana State University Health Sciences Center in Shreveport, who presented the findings, said they were one step closer to a randomized placebo controlled trial to continue to test the finding.

In other news, findings from a prospective study of two chemotherapy regimens after surgery for colon cancer indicated that patients who took aspirin regularly fared better after surgery, reducing their risk of disease recurrence and death by half, compared with nonusers. The study was a randomized trial of 846 patients with stage III disease that had spread to lymph nodes but not elsewhere.