Top Takeaways from ASCO: Survivorship
From depression to debilitating fatigue, experts ponder the ‘price of cure’.
CHICAGO — In forums including a data-driven plenary and a special educational session, attendees of ASCO 2015 gathered to discuss Top Takeaways on survivorship in pediatric and adult cancer.
Results from a late-breaking abstract offered clinicians evidence on the improvements, both in quantity and quality of life, that childhood cancer survivors stand to gain through careful monitoring and thoughtful therapy selection.
A presentation updating the 2014 ASCO Survivorship Guidelines and detailing their application in practice showcased the importance of screening patients for depression, anxiety, neuropathy and fatigue.
Long-term health concerns
Modifying therapy to reduce late treatment effects has led to a decrease in all-cause mortality over the past 3 decades among pediatric cancer survivors, according to a plenary presentation by Gregory T. Armstrong, MD, MSCE, HemOnc Today editorial board member, of the department of epidemiology and cancer control, St. Jude Children’s Research Hospital, Memphis, Tenn.
The discussant for the abstract, Michael P. Link, MD, professor of pediatrics in the division of hematology/oncology, Stanford University School of Medicine, explained how these results add to existing knowledge.
Michael P. Link
“We found out from previous research by the Childhood Cancer Survivors Study and other studies that survivors of childhood cancer are left with a number of health effects from their tumors and from therapy that have diminished the quality and quantity of their lives,” Link told Healio.com.
Prior data have indicated that approximately 8% of 5-year survivors of childhood cancer die within 30 years of diagnosis. Link noted that childhood cancer survivors have a 10-fold increased rate of death when compared with age-matched controls.
With nearly 80% of children with cancer now being cured of their underlying malignancy, Link said the risk for late side effects — and particularly the risk for late deaths among survivors — raise the question: “What is the price of cure?”
“The ‘price of cure’ includes late side effects that are substantial enough to shorten patients’ lives, to lead to early death,” he said. “Armstrong discovered that the late death rate dropped substantially, from 12% for patients diagnosed between 1970 and 1974 to 6% for those diagnosed between 1990 and 1994, and dropped steadily over time.”
Link noted that pediatric oncologists have sought to modify therapies over the past few decades to reduce exposures in an effort to reduce these late effects, with an awareness that children are particularly sensitive to anthracycline-induced cardiomyopathy and treatments that can cause secondary cancers.
“We recognized all the side effects of the therapies that we administered, and knowing those side effects were substantial, we tried to modify the therapies we were giving in the hopes that we could maintain the cure rate while reducing those late effects of therapy,” Link said.
Whether or not these modifications of therapy actually resulted in diminished late effects and a reduction in the rate of late deaths was unknown until now.
“We now see, for the first time, that children treated more recently who have had the benefit of the reductions in the intensity of therapy and removal of some of the unnecessary components of therapy, actually have markedly-reduced risk of death, and the patients are surviving longer,” Link said. “This strategy of modifying the therapy has been successful because we’ve cut the late death rate in half.”
Link called the findings “proof of principle” that adjusting therapies to align with the risk of tumor recurrence leads to improved quality and quantity of life among childhood cancer survivors. “Deaths from cardiac toxicity, deaths from lung toxicity, have been reduced,” he said.
However, these findings extend beyond this population of survivors, Link said. He underscored that therapy modification should be a focus for all oncologists and oncology practitioners caring for patients of any age who are treated with curative intent — with forward-thinking to what the person will confront years later as a cancer survivor.
“We have a duty to make certain that we pay attention to patients who we hope to cure ... so we can make sure we only administer those therapies that we know work and try to eliminate those components of therapy that only contribute to toxicity and don’t really enhance their survival,” Link said.
Putting guidelines into practice
Circulated by the society’s Cancer Survivorship Committee since its release in 2014, the ASCO Survivorship Guidelines were publicly addressed at the 2015 annual meeting.
“These are really the first of what we hope will be a series of guidelines looking at the most common, long-term or persistent effects of cancer and what clinicians can do about managing them,” Julia H. Rowland, PhD, director, Office of Cancer Survivorship, National Cancer Institute, NIH, and member of the ASCO Cancer Survivorship Committee, told Healio.com.
Julia H. Rowland
Rowland described the guidelines as a “very practical” means to help physicians improve the care of patients, many of whom are often reluctant to express they are struggling with persistent effects of illness or other problems beyond their cancer and cancer treatment.
“What we’re hearing from clinicians is, ‘I don’t ask about this because I don’t know what to do about it’ or ‘I’m not aware that this is a problem for my patients because they’re not coming into the office and telling me about it,'” she said.
Screening is the “first and foremost” step the society is urging physicians to take, said Rowland, also a member of the ASCO Guideline Committee.
“Each of the guidelines has a quick screener; generally recommended is use of a well-validated tool to identify people having problems in the respective domain of interest,” she said.
After asking initial questions, clinicians may conduct more in-depth assessments. Provided score ranges are helpful in specifying parameters within which to consider patients’ problems.
“It walks physicians through: ‘Does this person simply need more education or counseling? Is a more thorough assessment warranted? Do they need a referral to a specialist?’” Rowland said. “It gives them a sense of what they can do in their practice and the evidence base for doing it.”
To create the guidance, the society searched what was already in existence. Certain categories had more evidence upon which to make recommendations than others.
“The guidelines for anxiety/depression and fatigue are based on what the Pan-Canadian group has looked at,” Rowland said. She co-authored the anxiety/depression guideline, published in the Journal of Clinical Oncology and presented in the session by Barbara L. Andersen, PhD, of Ohio State University, Columbus, Ohio.
“It’s more challenging for chemotherapy-induced peripheral neuropathy; there are not a lot of interventions we’ve seen that are efficacious.”
For clinicians who have busy practices and want readily-available options and points-of-contact to care for their patients right away, this information is essential, she said.
However, another important takeaway from the guidelines is simply recognizing the battle is not over for patients who survive cancer.
“Many of them have persistent effects they are struggling with that do not necessarily resolve readily over time,” Rowland said. “Having a way to assess how problematic these are, what the patient can be doing and what resources are available is really helpful.” - by Allegra Tiver
For more information:
ASCO Survivorship Guidelines: www.instituteforquality.org/practice-guidelines, under the Patient & Survivor Care tab.
Andersen BL, et al. J Clin Oncol. 2014;doi:10.1200/JCO.2013.52.4611.
Armstrong GT, et al. Abstract LBA2.
Depression, Anxiety, Neuropathy, and Fatigue: An Update on the 2014 ASCO Survivorship Guidelines and How to Incorporate Them into Practice
Presented at: ASCO Annual Meeting; May 29-June 2, 2015; Chicago.
Disclosure: Link and Rowland report no relevant financial disclosures.