Pharmacists play key role in guiding adolescents, young adults through cancer survivorship
FORT WORTH, Texas — Adolescent and young adult cancer survivors are more likely than their peers to develop chronic health conditions, and pharmacists play a key role in helping to alleviate their symptoms, according to two presenters at HOPA Ahead 2019.
Joseph Sciasci, PharmD, BCOP, BCPS, clinical pharmacy specialist with the cancer center and blood and marrow transplant program at Children’s Hospital of Philadelphia, and Mary Mably, RPh, BCOP, pharmacy manager at UW Health in Wisconsin, provided an overview of how cancer treatment for adolescents and young adults (AYA) impact their risk for long-term morbidity. They also identified opportunities for pharmacists to reduce incidence of long-term morbidity among AYA cancer survivors who received chemotherapy, explained treatment strategies for hormone-related symptoms, and offered insights into fertility preservation methods for this population.
Protocol-based chemotherapy plans have greatly benefited children, adolescents and young adults with cancer, helping to increase the cure rate for childhood malignancies to more than 80%. As the number of survivors has increased, however, so has incidence of therapy-related toxicity later in life.
Prior research showed 23% of survivors experience at least two significant toxicities by age 35 years.
These include psychosocial, orthopedic, endocrine or cardiovascular effects, such as anxiety, depression, osteoporosis, diabetes or hypertension.
A study by Oeffinger and colleagues, published in 2006 in The New England Journal of Medicine, showed treatment-related toxicities that led to death — such as secondary malignancy, or cardiac or pulmonary toxicities — were responsible for 18% of the excess risk for death among children with cancer.
“Decisions made during therapy will impact toxicities that occur after therapy,” Sciasci said during his presentation. “Pharmacists must consider therapy differences, both at protocol planning [or] design stages and while providing direct patient care.”
For example, among adolescent patients with acute lymphoblastic leukemia, those who received dexamethasone experienced significantly more toxicities than those who received prednisone. Most were bone-related toxicities and developed while patients were still undergoing cancer-directed therapy.
Cisplatin has been shown to have a detrimental effect on hearing, which can hinder neurocognitive development. The use of sodium thiosulfate or amifostine may reduce chemotherapy’s effect on hearing.
Prior research also demonstrated a dose-dependent risk for long-term cardiac toxicities with anthracyclines. Dexrazoxane — although not consistently used — has been shown to reduce anthracycline-induced cardiomyopathy (RR = 0.29; 95% CI, 0.2-0.41) and should be considered when lifetime anthracycline exposure is anticipated to be greater than 300 mg/m2 doxorubicin equivalents, Sciasci said.
Although the availability of many immunotherapies has expanded treatment options, their differing toxicity profiles must be considered, Sciasci added.
“Increased use of targeted agents, such as chimeric antigen receptor (CAR) T-cell therapies, has reduced the burden of additional chemotherapy exposure in some relapsed/refractory patient subsets,” Sciasci said. “As use of targeted agents continues to grow, we expect the number of survivors to increase. Reduced exposure to chemotherapy may lead to less toxicities, but [CAR T-cell therapy] and other targeted therapies may present their own unique long-term effects.”
Many institutions have created survivorship or late-effects clinics to help AYA patients transition from pediatric or acute care and build relationships with family or adult internal medicine practitioners, Sciasci said. This allows for a health assessment after therapy that can serve as a baseline for subsequent monitoring and also can help address compliance issues that may arise with health issues — such as hypertension or diabetes — that these patients develop, he added.
When caring for young adult cancer survivors it is important to consider their mental state, health behaviors and sexual function, Mably said.
“Survivors are at greater risk for distress, anxiety, depression and fear of recurrence,” she said during her presentation. “They should be monitored regularly — particularly at times of stress, such as times of scans looking for recurrence, screening for cancer, major life events or times of loss in their life.”
Survivors should be referred to mental health services as necessary. Although pharmacologic interventions are available, nonpharmacologic interventions also can be helpful, Mably said.
“As pharmacists, we sometimes forget about these,” she said. “If you can identify the source of their anxiety or distress — such as pain, sleep disturbances or substance abuse — those should be treated. Also, assuring patients that this is common among survivors provides them with emotional support and a feeling that they are not alone in this.”
Mindfulness and meditation also should be considered, Mably said.
Health behaviors that can influence future cancer risk also must be carefully evaluated, Mably said. These include maintaining a healthy weight, eating a plant-based diet, getting sufficient exercise and undergoing recommended cancer screenings.
As many as 80% of patients with cancer take dietary supplements — often without their health care team’s knowledge — even though there is no evidence to suggest any benefit in the absence of deficiencies or comorbidities, Mably said.
“Although the FDA does regulate some dietary supplements, analyses of supplements from multiple manufacturers showed many products don’t contain the purported active ingredients and can contain unlisted ingredients, such as fillers or banned pharmaceutical ingredients that can be harmful to our patients. ... It’s really important to tease that out ... as part of doing a medication history.”
Mably also provided an overview of fertility preservation options for young cancer survivors.
“Providers should have the earliest possible discussion, before treatment, with patients treated during their reproductive years, as well as parents or guardians of children or adolescents,” she said. “Patients should be referred to appropriate specialists and, of course, we should the discussion with these patients or their parents should be documented appropriately in the electronic health record.” – by Mark Leiser
Sciasci J and Mably M. Survivorship in young adults and adolescents: Current and future challenges. Presented at: HOPA Ahead 2019; April 3-6, 2019; Fort Worth, Texas.
Disclosures: Mably reports advisory board roles with Alnylam Pharmaceuticals, Juno Therapeutics and Stemline Therapeutics. Sciasci reports no relevant financial disclosures.