Smilow Shares with Primary Care: Survivorship

Transcript

• 00:00Fantastic. Let's get started.
• 00:02I we have the pleasure of having Dr.
• 00:05Kevin Billingsley, our Milo CMO today to
• 00:09to start us off and welcome everyone. You
• 00:14know, I I am thrilled to be here
• 00:17and I want to thank the audience.
• 00:20For not just participating in this event,
• 00:22but for the participation over the
• 00:25months in this series of Smilow shares,
• 00:28the partnership and collaboration between
• 00:31clinical oncologists and primary care
• 00:34physicians is not only fun and rewarding,
• 00:37it's the best possible thing for
• 00:39all of our patients together.
• 00:42So I have to say I'm incredibly
• 00:44excited about the topic this evening.
• 00:49You know the the
• 00:49statistics in 2022 are that
• 00:52there are currently over 18
• 00:54million cancer survivors out
• 00:56there in the United States today.
• 00:59You know I think it is,
• 01:02it's extraordinarily gratifying.
• 01:03I think it's a testament to the
• 01:06development and our our abilities
• 01:09to treat patients and sustain them
• 01:11through the course of their illness,
• 01:14but it is also.
• 01:17A testament to our medical
• 01:19community in general,
• 01:20particularly our primary care
• 01:22physicians who support patients and
• 01:25families through the continuum of
• 01:27healthcare throughout their lifetime,
• 01:29including supporting them through
• 01:32significant illness like cancer,
• 01:34heart disease and other other
• 01:36chronic diseases that they manage
• 01:38them in partnership with specialists
• 01:42so. I think we have a
• 01:45fabulous panel this evening.
• 01:47I'm just going to say I'm incredibly excited.
• 01:49I think it's going to be a great discussion.
• 01:52And I want to also take a minute
• 01:56to recognize and thank our
• 01:58fearless Co leaders in this.
• 02:00In this program.
• 02:01Doctor Ann Chang who's the Associate
• 02:04Cancer Center Director here at the
• 02:06Yale Cancer Center and our Director
• 02:08of Clinical Initiatives and Dr.
• 02:10Karen Brown who's the Medical Director
• 02:11of Primary Care for Northeast.
• 02:13Medical Group,
• 02:15thank you both for really leading
• 02:18this effort and driving this level
• 02:21of communication and engagement
• 02:23between the primary care docs
• 02:25and our our oncologist.
• 02:27So terrific and I know you guys
• 02:29will introduce our panelists.
• 02:31So over to you Ann and Karen.
• 02:34Thank you Kevin,
• 02:38we. This is our last program for the
• 02:43year that Karen and I am working on
• 02:46and this really came out of discussions
• 02:48that we had where we felt that there
• 02:51could be a better relationship and
• 02:53better communication about cancer.
• 02:55And updates, but really from
• 02:57the primary care perspective.
• 03:00So I see some of you have been
• 03:02regulars and we really appreciate
• 03:05you coming and appreciate your
• 03:08feedback on this since we, you know,
• 03:10we're we're talking about what
• 03:17And I your audio just got quiet.
• 03:22OK Can you hear me OK?
• 03:24Yeah, OK. Sorry about that.
• 03:27So we're going to have three
• 03:30cases tonight and then we will
• 03:32have time about 10 or 15 minutes
• 03:34hopefully for for questions.
• 03:36And I know that you all have really
• 03:38great questions and I think that
• 03:40the presentation of the cases
• 03:41tonight will really prompt that
• 03:43we'll have questions for Dr.
• 03:44stamped around survivorship
• 03:47after the first case.
• 03:50And then the rest of the question.
• 03:51So please have a few questions
• 03:53ready and then we'll have time for
• 03:55the rest of the questions later.
• 03:57And then without further ado,
• 03:59I will introduced Dr.
• 04:01Tara Sam,
• 04:02who's an Associate Professor
• 04:04of Medicine and she's our Chief
• 04:07Patient Experience Officer and
• 04:09Smilo and the Medical Director
• 04:12of the Survivorship Clinic.
• 04:13She is doctor Stamp earned
• 04:15her medical degree from the
• 04:17Medical College of Wisconsin.
• 04:20She completed her residency
• 04:21and fellowship at Northwestern.
• 04:23She is board certified in both medical
• 04:26oncology and Hospice and palliative medicine,
• 04:29which she feels helps to her to treat the
• 04:32whole person and not just the disease.
• 04:35And as a breast oncologist,
• 04:36she is a very busy practice and
• 04:39enjoys taking care of women with
• 04:42newly diagnosed breast cancer and
• 04:44in her role as the chief patient.
• 04:46Experienced officer She focuses
• 04:48on how to improve care,
• 04:52especially where the provider
• 04:54and patient experience overlap.
• 04:57She is the director of our
• 04:59Smiler Survivorship Clinic,
• 05:00one of the nation's only
• 05:02multidisciplinary clinics,
• 05:03especially in specializing
• 05:05in cancer survivorship.
• 05:07And she learns from patients
• 05:09about key issues after treatment,
• 05:11which also informs her role as chair
• 05:13of the National Comprehensive Cancer.
• 05:16Network survivorship guidelines
• 05:17and finally her research interests
• 05:20focus on healthy lifestyles and
• 05:22quality of life after cancer
• 05:28and we welcome her tonight.
• 05:30Doctor Lesburg is an Associate
• 05:33Professor of Medical Oncology and
• 05:37the Director and Chief of the
• 05:41Breast Medical Oncology Division.
• 05:43She. Received her medical degree
• 05:46from the University of Maryland,
• 05:48where she completed her residency and
• 05:50she went on to complete a fellowship
• 05:53in Medical Oncology and Breast Medical
• 05:55Oncology at the Ohio State University
• 05:58before joining the faculty there in 2010.
• 06:00And she also earned the master's in
• 06:03Public health Public health from the
• 06:06Ohio State University in 2013. Her.
• 06:11Her he's been recognized for her
• 06:15patient focused care with awards,
• 06:17multiple awards and including being
• 06:22rated by Forbes is one of the top breast
• 06:25medical oncologists in the nation.
• 06:27She has an emphasis on improving
• 06:30longterm outcomes for patients
• 06:31with breast cancer who.
• 06:33Develop side effects associated with
• 06:35treatments and is doing novel and
• 06:38really exciting research on novel
• 06:40blood based biomarkers to identify
• 06:43recurrence and toxicity of treatment.
• 06:46Earlier she worked,
• 06:47she's an NCI funded investigator active
• 06:51in cancer cooperative group research
• 06:53and she collaborates widely with
• 06:56researchers from around the world and
• 06:58she really thrives in creating innovative.
• 07:00Multidisciplinary scientific teams,
• 07:05I'm going to turn that over
• 07:07to Doctor Brown to introduce
• 07:10Doctor Williams. Good, thanks.
• 07:12And and I'll just echo my welcome
• 07:15to everybody as well and to stress
• 07:19how important all of this is.
• 07:22Our relationship in primary care,
• 07:24new cancer is kind of an emergency.
• 07:28And and knowing that our Smile O
• 07:30team kind of has our backs and is
• 07:32able to help with that transition is
• 07:34is really important and we continue
• 07:37to work at doing that even better.
• 07:39And even though this talk is about
• 07:41kind of the other end where we're
• 07:43passing patients back to primary care.
• 07:46So it is my pleasure to introduce
• 07:48Doctor Brian Williams,
• 07:49a close colleague and friend.
• 07:52He is the Medical Director of
• 07:54Clinical Informatics within the
• 07:55Northeast Medical Group and one of
• 07:58the medical information officers
• 08:00offer EPIC in the system.
• 08:02His passion is streamlining clinical
• 08:04care to support both employee
• 08:07and clinician Wellness as well as
• 08:10patient experience and efficiency.
• 08:13He is an active primary care clinician
• 08:17in Mystic and where he serves
• 08:20with his wife in the same office.
• 08:23He's fortunate to serve as a medical
• 08:26director on in the beginning of
• 08:28his career at the How Come while?
• 08:31Oh no,
• 08:32it's a Health Center in Hawaii from
• 08:352005 till 2010 and that was where he
• 08:38learned from a visionary leadership team.
• 08:41On where integrating the electronic
• 08:43medical record and clinical
• 08:45quality programs had such potential
• 08:47to make patient care better.
• 08:50He subsequently came here East
• 08:52and was the Medical Director of
• 08:55Informatics at the LNM Medical
• 08:57Group through through 2016 when that
• 08:59group merged with Northeast Medical
• 09:01Group and he then became part of our
• 09:04informatics and clinical program.
• 09:07He graduated from the University
• 09:08of Colorado Health Science Center
• 09:10and completed his family.
• 09:11And us since the University of
• 09:13Texan in Austin, in Austin, TX.
• 09:17And Brian will actually start
• 09:19off the presentation with Case.
• 09:25Thank you, Dr. Brown. I'm so
• 09:27sorry to throw you the curveball.
• 09:29It's Hamakua Health Center.
• 09:32Thank you for the correction.
• 09:34Absolutely. Yeah.
• 09:35That's a tough one, but a beautiful place.
• 09:38And I'm really pleased to have been asked
• 09:40to participate in this particular topic.
• 09:42I think this you know survivorship
• 09:44sits squarely at the intersection
• 09:46of what our colleagues and oncology
• 09:48do and what we do in primary care.
• 09:51And I think this is, this is an area
• 09:53where more information is better.
• 09:57It's frequently I think a
• 10:00little bit vague in terms of.
• 10:02Concrete information that's
• 10:03available for us to kind of guide
• 10:05our decision making and care.
• 10:06So I'm really looking forward
• 10:08to this session.
• 10:08So we're going to kick it off with Case one,
• 10:12which is a 76 year old male that had
• 10:16a 60 pack year smoking history who
• 10:20presented in June of 2019 with complaints
• 10:22of increased difficulty swallowing.
• 10:24He was having a hard time getting food down.
• 10:27He was subsequently diagnosed
• 10:29with a squamous cell carcinoma.
• 10:31That affected the base,
• 10:32the left side of the base of his tongue.
• 10:35So during July and August of that year,
• 10:37he received definitive conformal radiation
• 10:40therapy with concurrent weekly cisplatin.
• 10:43He tried tolerated treatment quite well
• 10:46and had complete response to the tumor,
• 10:48fortunately,
• 10:48so since that time he's been followed
• 10:51every six months by his oncologist.
• 10:53And there's been no evidence of recurrence.
• 10:55But he missed his last followup appointment
• 10:57and in fact would rather not ever have
• 11:00to see a doctor again in his life.
• 11:02He has some residual longterm
• 11:03effects of treatment,
• 11:04including dry mouth and
• 11:06chronic neck stiffness,
• 11:07but overall doing well with no
• 11:09evidence of disease at the present.
• 11:12Go on to the next slide.
• 11:13So he presents today for his annual
• 11:16Wellness visit to his primary care.
• 11:18No ongoing concerns other than
• 11:20the usual aches and pains and the
• 11:23continued stable neck stiffness.
• 11:25He is stoic, though.
• 11:26This guy spends all of his time out on
• 11:29his fishing boat and in his garage working.
• 11:32He doesn't like doctors and he
• 11:33doesn't want to see anyone.
• 11:34He doesn't have to.
• 11:37So the questions associated
• 11:38with this case are first of all.
• 11:41What is survivorship?
• 11:42So I'm going to openly admit that
• 11:44this was a concept that was new
• 11:46to me approaching this webinar.
• 11:47And so I'm really glad that we're sharing
• 11:50about this because it's something
• 11:51that I found to be quite important.
• 11:54Second question,
• 11:54follow up is what kind of surveillance
• 11:57guidelines are there for high risk
• 11:59patients in general and maybe a little
• 12:01bit of specifics about this particular
• 12:03patient since this is a high risk cancer?
• 12:06And then a final question we're
• 12:08going to answer is what is the
• 12:10Smile of Survivorship clinic in
• 12:12which patients are appropriate
• 12:13for referral to this clinic?
• 12:15With that I'll turn it over to Doctor Sam.
• 12:20Thanks Brian. Coming off of five
• 12:23days of conferencing in Chicago,
• 12:26so forgive my hoarse voice.
• 12:28Really pleased to be here with all of
• 12:30you tonight and I see many familiar
• 12:32names on the participants list,
• 12:34so a shout out to my friends in the audience.
• 12:39But if we start with the definition,
• 12:42the NCI defines a cancer survivor
• 12:44as anyone who's been diagnosed with
• 12:47cancer and it starts at the time of
• 12:50diagnosis and extends through the
• 12:52balance of the individual's life.
• 12:56In that context, every patient
• 12:58who's ever been diagnosed with
• 13:01cancer is considered a survivor.
• 13:04And if you go to the next slide,
• 13:08there are three phases of survivorship,
• 13:11which I like to just briefly touch on.
• 13:14This was defined by a physician who
• 13:17had cancer and then wrote this article
• 13:19in the New England Journal in 1985.
• 13:22And he characterized these three phases
• 13:24as acute, extended and permanent,
• 13:26but I I renamed permanent to long term.
• 13:30The acute phase is really in
• 13:32that first diagnostic period.
• 13:33Probably Karen, like when you said
• 13:35this isn't an emergency like that is
• 13:37when you're going over the waterfall,
• 13:40you've just been diagnosed,
• 13:42there's lots of tests and imaging
• 13:44and you see an oncologist and
• 13:46surgeons and radiation doctors and
• 13:48you're going to have a treatment
• 13:50plan and you're in treatment.
• 13:52And the whole cancer community.
• 13:53Most a lot of times your whole
• 13:56support community comes together
• 13:57to carry you through this time,
• 13:59if you click through the animations here,
• 14:02the next period is the extended period
• 14:06which should be highlighted and then
• 14:09another Click to show the picture.
• 14:11I love this picture.
• 14:12I don't know if it's real,
• 14:13but you know the extended period
• 14:16starts after treatment is over.
• 14:18So usually treatments about.
• 14:21Maybe six months if you get chemotherapy,
• 14:24maybe a little less if it's not,
• 14:27maybe you might be on some maintenance
• 14:29therapy for the whole year.
• 14:30But generally in that,
• 14:32in that after that six months of
• 14:35really heavy going over the waterfall
• 14:37though the waters are calmer,
• 14:39but you're pretty sure the patients
• 14:41are pretty sure every something
• 14:42is going to get them every
• 14:44ache and pain is a recurrence.
• 14:47They might be dealing with
• 14:49their side effects.
• 14:50They might have a lot of post
• 14:52traumatic stress type symptoms.
• 14:54So they feel like they're it's a
• 14:58high uncertainty and that's where our
• 15:00clinic often comes in and I'm going to
• 15:02talk about that in in a few minutes.
• 15:03You click through the next animations.
• 15:072 more, one more click.
• 15:08So in long term survivorship.
• 15:10This is when the the waters
• 15:12are much more peaceful,
• 15:14the risk of recurrence goes down,
• 15:16but the late and longterm effects serve
• 15:19as a reminder of what you've been through.
• 15:22And so for each of these phases,
• 15:24survivors can have different needs.
• 15:26And I I think that's,
• 15:27you know,
• 15:28one of the reasons why can be so
• 15:30hard to wrap our minds around
• 15:32survivorship as a field because it
• 15:35really encompasses so much time.
• 15:37Next slide, please.
• 15:40There are certain themes that tie
• 15:44every single survivor together.
• 15:47So there's we can unify each unique
• 15:49person and they have a common set
• 15:52of of needs that need to be met.
• 15:54And this is simplification,
• 15:56but but we all agree that every
• 16:00survivor needs surveillance for
• 16:02both recurrence and a new cancer.
• 16:06And in general,
• 16:08at least in that first extended period,
• 16:11the oncologists want to be doing
• 16:14that kind of surveillance and and
• 16:16patients want their oncologists to
• 16:18be doing that kind of surveillance.
• 16:20As time goes on,
• 16:22that surveillance might get less frequent,
• 16:26less necessary and the needs of
• 16:28those survivors might change.
• 16:30And who who needs to do that?
• 16:32And then every survivor needs
• 16:34identification and treatment
• 16:35of late and longterm effects.
• 16:38And we can talk about incidence
• 16:39of all of that and different
• 16:41risks that would cause that,
• 16:43but we are all charged with
• 16:46identifying and addressing those.
• 16:49And then the topic of health promotions,
• 16:51what I personally is near and dear
• 16:54to my heart because there's very few
• 16:56times in an adult life where you're
• 16:58willing to change your behavior
• 16:59and cancer is often one of those.
• 17:01And so.
• 17:02Really using that teachable moment
• 17:05to help patients meet their goals
• 17:08for their diet, their exercise,
• 17:10maybe not drinking as much as they used to.
• 17:14Smoking cessation,
• 17:15especially in head and neck
• 17:17cancer patients as we know,
• 17:18can be so important.
• 17:19Every patient,
• 17:20but those are tenants of of
• 17:23survivorship care for everyone and
• 17:25then of course why we're here is.
• 17:28That we owe it to our patients to
• 17:29coordinate this care and make sure that
• 17:31nothing is falling through the cracks,
• 17:32which is so much easier said than done.
• 17:36Next slide,
• 17:36please.
• 17:39I was going to plug in this gentleman's.
• 17:45Profile on an app that I thought
• 17:47was available and show you like how
• 17:49we would solve this together if you
• 17:51didn't have a survivorship clinic.
• 17:53And I I don't know what happened to the app.
• 17:56I couldn't find it.
• 17:57So in head and neck cancer patients for
• 18:00instance if you Google survivorship and
• 18:03the American Cancer Society is a wonderful
• 18:06resource for both doctors and patients,
• 18:08you're going to get a PDF of guidelines and
• 18:11if you even click on the link that says.
• 18:14You know, a simple chart.
• 18:16This is one page on the left
• 18:19hand side of a three page chart.
• 18:22This is for head and neck cancer survivors.
• 18:24There's also the same information
• 18:26for breast cancer survivors,
• 18:28colon cancer survivors,
• 18:29prostate cancer survivors.
• 18:31And that's kind of where a Ch that's like
• 18:33a CS American Cancer side of the where
• 18:36their guidelines are sort of fitting.
• 18:38So instead I just summarized sort of what
• 18:41is in this document on the right hand side.
• 18:44So again it's a three page table.
• 18:46You'll see that there are
• 18:49recommendations for surveillance,
• 18:50screening and early detection
• 18:52of second primary cancers.
• 18:53They really call that out here because
• 18:55that's a particularly high risk in the
• 18:57head and neck cancer world because of
• 18:59the treatment that's given and the risk
• 19:02factors that are often associated with it.
• 19:04Then Assessment of Management
• 19:06of Physical and Psychosocial,
• 19:08Longterm and Late Effects.
• 19:09I listed those down there at the bottom.
• 19:12And then of course Health
• 19:13Promotion and Care Coordination.
• 19:15If you look at the list of late and
• 19:17longterm effects and you read the chart,
• 19:20every single one recommends that
• 19:22you primary care screen for each
• 19:25of these things detect and refer.
• 19:28And I feel overwhelmed just reading
• 19:30through that chart and can't imagine
• 19:33what it's like in a busy primary
• 19:35care clinic to maybe have that
• 19:37sense of duty to try to detect and
• 19:39treat and refer for specialized
• 19:42treatment for all of these issues.
• 19:44So I just, you know, curious on,
• 19:46on any comments on that,
• 19:48but this is what's in the
• 19:50literature right now.
• 19:51Next slide please.
• 19:54There is also you can find this on
• 19:55the American Cancer Society website.
• 19:57There is a link to this Cancer
• 20:00Survivorship e-learning series and
• 20:02there is a one hour webinar that focuses
• 20:06on head and neck cancer survivorship.
• 20:09What I was hoping to show is how you
• 20:11could figure all of this out in a few
• 20:13minutes and and it really I think
• 20:15illustrates the fact that it this is hard.
• 20:18I don't know how many people have an
• 20:20hour and a preparation for a patient to
• 20:22go and watch this to learn more about
• 20:24addressing this particular patient's needs.
• 20:27Next slide please.
• 20:30So I'm ending with just two slides
• 20:32about the Yale Survivorship Clinic.
• 20:37We have been around longer than I've
• 20:39been at Yale so it was started by
• 20:42a cancer survivor in 2006. He he.
• 20:48Explicitly said this is what I wished
• 20:50I had had in my cancer treatment.
• 20:52So this is what this is the team you
• 20:54must assemble if you want my money.
• 20:57And so Yale said Okay,
• 20:59we serve patients of all diagnosis.
• 21:03Any patient who's had a diagnosis of
• 21:06cancer is welcome to come to our clinic
• 21:09and we meet once weekly and we go to
• 21:12the different various greater New Haven.
• 21:16Locations. So we see patients in Smila,
• 21:18but we also go to Guilford,
• 21:20North Haven and Derby starting next month.
• 21:23Just a minute, I'm I'm going to call, sorry.
• 21:26I'm also have a couple kids hanging around.
• 21:28We give just a minute honey. Okay.
• 21:31All right, I'll, I'll help you.
• 21:33Amelia, can you help her get some food?
• 21:36We see patients for a one time
• 21:39consultation and then we usually have
• 21:41one or two follow up visits so we
• 21:44do not assume care of our patients.
• 21:46But they do get a 2 hour visit each
• 21:49time with four specialists and I'll
• 21:51tell you about them in just a minute.
• 21:54I think it's important to understand
• 21:56we do not take the place of either the
• 21:58oncologist or the primary care provider,
• 22:00but we do meet the patient where
• 22:02they are at and we provide a lot
• 22:05of individualized counseling and
• 22:07references based on what the survivor
• 22:09is hoping to achieve.
• 22:10And every single patient gets an
• 22:13individualized survivorship care plan.
• 22:15Next slide please. Okay.
• 22:16So who's the team?
• 22:18So I'm the medical director.
• 22:20I do see patients,
• 22:21but really the bulk of the patients are
• 22:24seen by my fabulous physicians assistant,
• 22:26Kevin Bretta,
• 22:27who would have loved to have
• 22:28been here tonight,
• 22:29but he's actually on a vacation
• 22:31and we want him to enjoy that.
• 22:34He he's the PA there in the top left,
• 22:36and he's the one who makes
• 22:39those survivorship care plans.
• 22:41He's the one who's making
• 22:43sure patients aren't lost.
• 22:44Can transition that they're that he
• 22:47that they understand you know what
• 22:49the plan is going forward who's
• 22:51going to be doing what and you know
• 22:53he addresses late and longterm
• 22:55effects from a medical perspective.
• 22:57The LCSW licensed clinical social
• 23:01worker is next to that.
• 23:03Right now it's Kristen Clark.
• 23:05They have our social workers have
• 23:07the highest level of training in
• 23:09their field for cancer and they
• 23:12really talk about the.
• 23:14Psychosocial aspects of coping with cancer
• 23:16and and so for instance back to this case.
• 23:18You know many of our head
• 23:20and neck cancer patients,
• 23:21though this man is stoic,
• 23:22he may be having some fear of eating.
• 23:25Could be that he's doing less socially
• 23:28because he's afraid of choking in
• 23:30public because of his chronic dry mouth.
• 23:32So this is would be an example
• 23:34of what the social worker might
• 23:36talk about and try to plug him in.
• 23:39With some help to to cope with
• 23:41that and and
• 23:43to validate those feelings and and
• 23:45maybe even treat anxiety and depression.
• 23:49Our physical therapist is a is actually
• 23:52also the head of our ank rehab program
• 23:55Scott Caposa and he is got he actually
• 23:58wrote the board of questions for
• 24:01the ACSM oncology certification for
• 24:03his for physical therapist. So he's.
• 24:06Been doing this for a very long time
• 24:08and he helps patients either get
• 24:10back to the physical functioning
• 24:13that they had before or maybe start
• 24:15a new plan to help meet new goals.
• 24:18And then of course as a PT he would be
• 24:21able to assess for this gentleman hit,
• 24:24you know, his range of motion,
• 24:26his ability to to stretch his neck.
• 24:29He would be able to prescribe a
• 24:31home exercise program to help with
• 24:34any symptoms that he's having.
• 24:36In his affected fields and then
• 24:39our last provider is a registered
• 24:41dietitian who's also a certified
• 24:43specialist in oncology.
• 24:44So again the highest levels of
• 24:46their of their field in cancer care.
• 24:49And right now we have a new dietitian
• 24:52named Natalie Smith and they
• 24:55really address you know not only
• 24:57weight gain and weight loss.
• 24:58So in this particular gentleman probably
• 25:00he's lost some weight through his
• 25:02treatment and possibly gaining that
• 25:04weight back can be really challenging.
• 25:06And lots of wellintentioned family
• 25:08members may have told him that all
• 25:10these supplements that he needs
• 25:12to take to prevent recurrence.
• 25:13And our dietitian really addresses
• 25:16myths about nutrition and cancer,
• 25:19of which there are many because the diet
• 25:21industry is a billion dollar industry.
• 25:26If we forget if there's one more slide,
• 25:30that's it. So I we.
• 25:34We would be happy to see any
• 25:37patient that you felt could benefit
• 25:39from what I just described.
• 25:41It doesn't matter if they're within
• 25:42that year or maybe they're three
• 25:44years and and sometimes we've even
• 25:47gotten patients who are 10 years out.
• 25:49And we we also try to face
• 25:51our patients every year.
• 25:53There's June is cancer survivorship
• 25:55month and we try to go directly to
• 25:58patients with webinars just like this
• 26:01to address issues and this will be our.
• 26:04I think our 4th June,
• 26:06that's virtual and it starts tomorrow.
• 26:08Now I'll just say that you can find this on
• 26:12our website if you yourself are curious.
• 26:14If you wanted to send a patient,
• 26:16they're going to be every Wednesday
• 26:18in June from 6:30 to 8:00 tomorrow.
• 26:20We start with a panel talking about
• 26:23restoring your body to integrity
• 26:26after cancer and on June 14th
• 26:29living with cancer chronically.
• 26:30On June 21st cancer and the family.
• 26:34How to advocate for your loved one And
• 26:36on June 28th, myths and social media.
• 26:40So thank you very much for your time.
• 26:42Oh, thank you.
• 26:44And yeah,
• 26:45I'll stop there.
• 26:47We do
• 26:47have a time. We do
• 26:48have time for a few questions,
• 26:50A couple of questions for Dr. Samt.
• 26:55And you can put them in the, the,
• 26:58the chat or you can actually.
• 27:01I think you have to put them to
• 27:02the chat, actually. Or the Q&A.
• 27:09So Dr. Sam is I'm going to
• 27:11just ask a quick question.
• 27:13Is there space for those of us in
• 27:15primary care to communicate with you
• 27:18offline just in terms of recommendations
• 27:20around particular patient cases?
• 27:24Absolutely, we would, I mean we would
• 27:27love to consult on any questions or
• 27:29issues that are coming through or even.
• 27:34Listen and help find the answers.
• 27:36If we are not like immediately got them
• 27:39on on the nose we because of what we do,
• 27:42we do know where to find these answers.
• 27:45Probably quicker than a Google
• 27:48search and certainly quicker than the
• 27:50time you have to try to to look and
• 27:53figure it out so you know my e-mail.
• 27:55Is tara.samptatyale.edu Jeff and Britta
• 27:59is my PA and this is his full time job
• 28:02outside of helping with some of the
• 28:06breast patients that we see together.
• 28:08But this is where this is where
• 28:09we spend all of our time.
• 28:11We'd be happy to to consult offline and
• 28:13then help plug patients in as needed.
• 28:16Yeah, I I really, truly appreciate that
• 28:20and you know it in in primary care.
• 28:24We're I think frequently overwhelmed
• 28:27with the number of recommendations and
• 28:30items that we have to pay attention to.
• 28:33And you know all the things we
• 28:34have to juggle with patients and
• 28:36knowing that we can kind of lean on
• 28:37you as colleagues is very helpful.
• 28:39You know, to me I think that the two big
• 28:42takeaways for this case are first that.
• 28:45You know, patients with certain cancers
• 28:47are at much higher risk for other cancers.
• 28:49And actually I've, you know,
• 28:50I've also learned that frequently
• 28:52their rate of appropriate screening
• 28:54is lower than the general population,
• 28:56which is surprising.
• 28:57But I think something for us to
• 29:00all to keep in mind.
• 29:01And the second thing is,
• 29:02is that there are, you know,
• 29:03great resources in place to help guide
• 29:05kind of care decisions for these patients.
• 29:09I'm curious the way.
• 29:11You know Dr. Williams, you set this up.
• 29:13Is this this gentleman really
• 29:15didn't want anymore followup,
• 29:18even though, you know,
• 29:19he probably needed ongoing surveillance,
• 29:21at least from primary care and and
• 29:24maybe also from oncology or ENT.
• 29:26Would would a trip to the survivorship
• 29:30clinic kind of been something that
• 29:32would help him to understand why or help
• 29:34him kind of come to closure on this?
• 29:36How would it have worked,
• 29:38you know, in this particular case?
• 29:41So given that this is a real patient
• 29:44that I hope quite well, there's not
• 29:47a prayer that he would ever go.
• 29:52He's he's a lovely gentleman,
• 29:53but he's let's just say that he's a
• 29:56tried and true New Englander little
• 29:58rough around the edges, you know,
• 30:01in this case, access for me.
• 30:03To some of these providership resources
• 30:05is going to be very beneficial because
• 30:08I can help guide him and we sort of have
• 30:12that ongoing connection even though he's
• 30:14never all that fond of even seeing me.
• 30:16But you know,
• 30:17that's a in this particular instance,
• 30:19that's a very helpful thing.
• 30:21I think other cases,
• 30:23definitely your suggestion
• 30:24that that might help,
• 30:26you know give him the context to
• 30:28think about this going down the road,
• 30:29it would be very beneficial.
• 30:31Can I just quickly comment on that?
• 30:33You know, there's we see
• 30:35men and women, you know,
• 30:37probably about 300 per year total that.
• 30:39So there's lots of people that don't
• 30:41make it into us for whatever reason.
• 30:44They either don't know or they don't
• 30:45want to or they don't think they need us.
• 30:47Often times for men,
• 30:50wives bring them or children bring them and
• 30:53really you know it is kind of a little bit.
• 30:56Against their will in some ways.
• 30:58The reason why we have 4 specialists there,
• 31:00including a social worker and
• 31:02you see every single one is to
• 31:05really give that space that yeah,
• 31:06you would never have agreed to
• 31:08see a social worker and talk about
• 31:09how you're coping with cancer.
• 31:11But when it's built in,
• 31:13it's shocking how therapeutic it
• 31:15can be and how much people say,
• 31:17I didn't know that I really how
• 31:19much I really needed that. So.
• 31:22So I appreciate all those points.
• 31:24One
• 31:25more question from Jill Banatowski and
• 31:28that is you know the role of community
• 31:31PT versus this specific PT is there,
• 31:34is there kind of handoff,
• 31:36is there something special about it?
• 31:39Yes and yes. So the cancer ank rehab
• 31:43is a is a specialized field and and
• 31:46our patients really do many of them
• 31:49do need someone who understands the.
• 31:51You don't want somebody who's going
• 31:54to be manipulating something that's
• 31:55not right and then cause more harm.
• 31:58Thankfully though,
• 32:00many of the P T's in Connecticut are
• 32:03extremely reputable and experienced
• 32:04and local physical therapies. Fine.
• 32:06What we do is we first try to get Scott
• 32:09to see the patient in clinic and then he
• 32:11knows all of these providers and he'll say,
• 32:14oh, in your area.
• 32:15This person,
• 32:16she's even lymphedema specialized,
• 32:17so she could even assess you for head
• 32:20and neck lymphedema, for instance.
• 32:21And you know,
• 32:22often times he'll even make the connection
• 32:25through e-mail or something like that.
• 32:27So, so yes and yes,
• 32:29local is fine and a rehab specialist
• 32:32can be really helpful to get
• 32:34the ball rolling and especially
• 32:36ours who maintain relationships
• 32:37with people all over the state
• 32:41been fantastic.
• 32:41Thank you Tara so much.
• 32:43And I, I know you have a
• 32:45family commitment to get to.
• 32:46So thanks for joining us and
• 32:49we'll move to the to the second.
• 32:52Case here. Thanks again,
• 32:59one that'll be close to many of our hearts.
• 33:00So it's a 71 year old female with
• 33:04medical history significantly
• 33:05for hypertension which is well
• 33:07controlled and hyperlipidemia.
• 33:08She was diagnosed at age 62 with
• 33:10right sided breast cancer that
• 33:12was an invasive ductal carcinoma.
• 33:14It was Grade 1 anatomic stage 1A estrogen
• 33:18and progesterone receptor positive,
• 33:19hair 2 new negative.
• 33:21So she was treated with the right
• 33:23mastectomy and a subsequent
• 33:25prophylactic left side of mastectomy
• 33:27and bilateral reconstruction.
• 33:29She continues to be followed by
• 33:31oncology annually and has been
• 33:33maintained on Mastrozole without
• 33:35any evidence of recurrence.
• 33:37She's very active.
• 33:38She stays healthy,
• 33:39takes care of herself,
• 33:40exercises daily good diet.
• 33:41Then we'll go on to the next slide.
• 33:48So she presented with subacute onset
• 33:51of localized mid lumbar back pain.
• 33:54Her pain was localized to the
• 33:56L23 region of the mid back.
• 33:58She described it as an ache with a
• 34:00maximum intensity of four out of 10.
• 34:02Gets worse when she's exercising and walking.
• 34:05It troubles her a little bit in bed as well.
• 34:07There's no other symptoms
• 34:09associated with this,
• 34:10and no bowel or bladder complaints.
• 34:13Her physical exam was largely unremarkable.
• 34:15She's not tender.
• 34:16In the area where she localizes her pain
• 34:19and her neurologic exam was non revealing.
• 34:22So the questions we might ask
• 34:24in this case include you know,
• 34:25how do we approach new complaints
• 34:27that may be related to cancer and
• 34:30maybe harbingers of recurrence and
• 34:32specifically in this situation,
• 34:34how common is recurrence in breast cancer?
• 34:40Thank you Brian for for
• 34:42for overview of that case.
• 34:44Hi everyone. Thank you.
• 34:46For joining out of your busy evening,
• 34:49as you heard, I've been treating breast
• 34:52cancer patients for a number of years and
• 34:55very thrilled to be speaking with you.
• 34:58So the question is,
• 35:00you know how often do you do recurrences
• 35:03happen in in breast cancer and we we tend
• 35:07to see two peaks of recurrences where
• 35:09we have an early peak of recurrences.
• 35:12That can happen in the first
• 35:14three to five years.
• 35:15In this particular case,
• 35:16if you remember,
• 35:17she's in her 9th year and she has this
• 35:22hormone receptor positive breast cancer.
• 35:24Late recurrences can happen sometimes
• 35:28more than five years or sometimes
• 35:30decades from the initial diagnosis,
• 35:32and these are more common in hormone
• 35:36receptor positive breast cancers
• 35:38where they're more favorable.
• 35:40But they also tend to have this
• 35:42period of dormancy where even if all
• 35:44the right treatments have been done,
• 35:46patients have done all the right things,
• 35:49we could see recurrences that
• 35:51happen here down the road.
• 35:53So next to the next slide,
• 35:57press one more time for this, yes, so.
• 36:00Kind of give you a little bit more about
• 36:05how common these late recurrences are.
• 36:08They're very much proportionate to the
• 36:11initial risk of the of the disease.
• 36:14In the yellow line,
• 36:16you see lymph node negative breast cancer,
• 36:18which was this particular patient's case.
• 36:21And as you can see, you know,
• 36:23five years, even up to 10 years,
• 36:27the rate of death from breast
• 36:29cancer can be quite low.
• 36:30However, as time passes,
• 36:32a proportion of these patients can actually
• 36:35progress to metastatic breast cancer,
• 36:38which is the predominant way that
• 36:40individuals from breast cancer actually.
• 36:43Die from breast cancer.
• 36:44It's not from early stage disease,
• 36:45it's from metastatic breast cancer.
• 36:47In the blue and red lines you can see how
• 36:51patients who have higher stages of disease,
• 36:54lymph node positive disease,
• 36:56then the curves are very steeply rising.
• 37:00For example,
• 37:01half of the patients who who had a
• 37:05number of lungs not positive disease,
• 37:08this would fall into the stage 3 category.
• 37:11Can potentially recur,
• 37:13sometimes several decades after
• 37:15initial diagnosis.
• 37:17So when we see those media campaigns
• 37:20saying breast cancer caught early is
• 37:23a curable disease, it absolutely is.
• 37:26But a lot of those fear statistics and
• 37:30American Cancer Society statistics are
• 37:32geared toward these first five years.
• 37:36However, what what,
• 37:37what our data are not showing is what
• 37:39can happen several decades later.
• 37:41So it can be actually quite hard
• 37:44for patients because the campaign
• 37:45has been just do what you're told,
• 37:48get your mammogram, get your treatments.
• 37:49And this is curable and treatable.
• 37:51And when these recurrences happen,
• 37:53it can be extremely
• 37:56psychologically traumatic.
• 37:57So next slide.
• 38:00So this patient, you know,
• 38:02had had some back pain.
• 38:03This is your bread and butter.
• 38:05You see, I'm sure multiple patients
• 38:07during the day present with back pain.
• 38:09And in no way are we suggesting that
• 38:13just because she has this distant
• 38:15history of breast cancer that you
• 38:18necessarily deviate from your standard
• 38:20algorithmic workup and your good
• 38:23clinical judgment of having taken
• 38:25care of patients for many years.
• 38:28But, but just I think the point of this
• 38:30case is that that you know that this,
• 38:32this history of breast cancer,
• 38:34even though it's almost nine years
• 38:36does raise the suspicion that it could
• 38:39possibly be related to metastatic
• 38:41breast cancer and to at least have
• 38:43that on the differential and an
• 38:46unexplained pain that doesn't go away.
• 38:50So let's say you do all your good
• 38:52primary care work up and conservative
• 38:55measures and she's not improving.
• 38:57I think what we would like to avoid
• 38:59for patients with with for example,
• 39:00this type of history is to perhaps
• 39:03raise that index of suspicion
• 39:04a little sooner or so,
• 39:06so that they would get a little bit of
• 39:07a closer work up sooner than a patient,
• 39:09let's say without a history of breast cancer.
• 39:12So pain is the one of the most
• 39:14common presentation of these
• 39:16types of distant recurrences,
• 39:17I tell my patients.
• 39:19As a human,
• 39:20you are going to have aches and pains.
• 39:22You're going to have back pain,
• 39:23you're going to have shoulder pain
• 39:25and knee pain.
• 39:25Not every sign of pain is a sign of cancer,
• 39:28but if something is persisting
• 39:30and not responding to these
• 39:32conservative measure measures,
• 39:34then then these patients should
• 39:35be absolutely worked up more.
• 39:37Shortness of breath and cough are also
• 39:40another more common presentation where again,
• 39:42you know people are going to cough,
• 39:45but if it's just not going away and
• 39:47lingering that that raises the suspicion
• 39:49that something more should be done.
• 39:51A vague abdominal pain can sometimes
• 39:53be be one of the initial presentation
• 39:55of liver metastases and breast cancer,
• 39:58and in the red box is this very general.
• 40:02Description that I also share
• 40:04with my patient,
• 40:05which is that any symptom that you're worried
• 40:08about that cannot be easily explained.
• 40:10I think we want to at least have
• 40:12have have our index of suspicion up.
• 40:15Thanks.
• 40:17And you know it's this partnership that
• 40:20the theme that we've been focusing
• 40:22on and we're so grateful that you're
• 40:25here so we can have this conversation.
• 40:28Patients often feel very lost in
• 40:31these junctures where they they they
• 40:33kind of don't know who to turn to
• 40:35and as much as we can do to show
• 40:38that we're partners that we are,
• 40:40I think it can be so helpful in terms
• 40:42of the anxiety and I apologize in a
• 40:45public setting, sorry for the background.
• 40:47So, so just the idea of this that we
• 40:50are triad together, working together
• 40:52to to to expedite the work up,
• 40:55these are the things that are really,
• 40:57really important.
• 40:58To patients next slide.
• 41:00And so just reemphasizing that
• 41:02this is a super vulnerable time.
• 41:06There are often a feeling of betrayal.
• 41:09There can be even some anger toward
• 41:12the original oncologist that
• 41:13diagnose them because we celebrated
• 41:15that they're cured with them we.
• 41:18There's a sense of why wasn't
• 41:20this found earlier.
• 41:20I went to my PCP and I complained
• 41:22about this two months ago.
• 41:24Why wasn't this worked up?
• 41:25So these are not that anybody
• 41:27did anything wrong,
• 41:28but I think it's that time of
• 41:31vulnerability for these patients.
• 41:33Obviously healthcare systems are
• 41:36very complicated and it it takes
• 41:40time to schedule testing.
• 41:41We completely understand that.
• 41:43But just just all of us being really
• 41:45cognizant that given half five anxiety
• 41:48state is for these patients when
• 41:50they're worried about potential recurrence.
• 41:52Anything we can do to even move
• 41:55things up by a day or two really goes
• 41:57a long way in terms of rebuilding
• 42:00trust within the healthcare system
• 42:02and making making them feel heard.
• 42:04And the the last point I've already said,
• 42:07but it's really important to repeat
• 42:09it which is the more we communicate
• 42:11with one another as as a primary care.
• 42:14Writers and oncologists,
• 42:15it is so absolutely reassuring to patients,
• 42:18so,
• 42:19so in this particular case it may have
• 42:21been a bread and butter musculoskeletal
• 42:24back pain or maybe something else,
• 42:28but but bone metastases are actually
• 42:31the most common presentation of receptor
• 42:33positive breast cancer metastases.
• 42:35So we wanted to.
• 42:38Kind of highlight that as as one
• 42:40of the more common presentations
• 42:42of test suites for this group.
• 42:50Thank you Doctor Lustberg and
• 42:51thanks for joining from the airport.
• 42:53I know that it's really over and
• 42:55above it's one other note that I just
• 42:58wanted to make about this particular
• 42:59case is you know this patient really
• 43:01took the heart the recommendations
• 43:03around self-care she know at the
• 43:05time of her diagnosis she really.
• 43:08Let's just say made some very
• 43:11appropriate and long lasting lifestyle
• 43:13adjustments and those do impact
• 43:15like longer term risk of recurrence
• 43:17and also risk of other health
• 43:21conditions and other primary cancers.
• 43:24So case 3, this is lung cancer and a
• 43:27video visit an 85 year old female.
• 43:30Without a significant past medical
• 43:32history that was diagnosed in 2019 with
• 43:35a non small cell adenocarcinoma of the
• 43:37right lung that was metastatic to her brain.
• 43:40So she was enrolled in the clinical
• 43:43trial in November of that year with
• 43:46pembrolizumab plus bevacisumab for
• 43:48asymptomatic brain metastases 4
• 43:51cycles of the combination followed
• 43:53by pimbolism and monotherapy.
• 43:54She completed a total of 34 cycles every
• 43:57three weeks which was tolerated quite well.
• 44:00And responded very well.
• 44:01And she's been followed by oncology since
• 44:04that time without evidence of recurrence
• 44:06and still remains in good health.
• 44:09And go to the next slide.
• 44:10So she presents today for a video
• 44:13visit complaining of nausea and
• 44:14vomiting for five days.
• 44:16She's been having a hard
• 44:17time keeping food down.
• 44:19She tested herself at home
• 44:21and was positive for COVID.
• 44:23So she continues to have nausea currently
• 44:26and is able to keep sips of water down.
• 44:29But she's not complaining of any
• 44:31other symptoms relatable to the COVID,
• 44:33such as congestion, cough,
• 44:34shortness of breath.
• 44:36She does feel achy all over and chilled,
• 44:39but no fever.
• 44:41Her physical exam limited,
• 44:42of course, by the video visit,
• 44:44but she appears mildly ill,
• 44:46but not emergently ill.
• 44:47She's alert and oriented and answers
• 44:49all of our questions appropriately.
• 44:51She doesn't appear to be short of breath,
• 44:53speaking in complete sentences,
• 44:54and there's no cough noted during her visit.
• 44:57Her mucous membrane, she sticks out
• 44:59her tongue and her tongue is moist.
• 45:01So that's good news.
• 45:03So a few questions related to this case.
• 45:07How do we monitor patients that are
• 45:09very high risk for recurrence and
• 45:11how do we approach patients with an
• 45:14acute illness that have a higher risk
• 45:17of complications of that illness?
• 45:18And then finally,
• 45:20what other options are there for
• 45:22patients to address survivorship in general?
• 45:27Thank you, Brian.
• 45:29So this case was selected to really
• 45:32highlight a few important points which
• 45:35is that advances in cancer treatment,
• 45:38particularly immunotherapy have
• 45:40dramatically improved survivorship
• 45:42outcomes in patients with lung
• 45:45cancer as well as Melanoma.
• 45:47So, so now we're seeing.
• 45:49Longterm survivors of these very serious
• 45:52malignancies who who are doing well,
• 45:55but they may have some complications
• 45:57related to the to the original cancer
• 46:00diagnosis or or to their treatments.
• 46:03So patients who are higher risk and
• 46:06have known metastatic disease typically
• 46:08depending on the type of malignancy,
• 46:12they are routinely followed
• 46:14with serial scans and so.
• 46:17So in this particular case patient
• 46:18had a known brain metastasis where
• 46:20her brain would be serially monitored
• 46:23and her body would be monitored.
• 46:24In other malignancies.
• 46:26Other types of surveillance modalities may
• 46:29be used such as bone scans and PET scans.
• 46:33You're going to see in your practice
• 46:36patients being surveillanced differently
• 46:38based on their type of cancer and where
• 46:41they are in their disease course and.
• 46:44In terms of symptoms,
• 46:46so, so,
• 46:47so often these patients with more
• 46:49advanced illness may get additional
• 46:51scans based on the new symptoms.
• 46:53So for example,
• 46:54a breast patient who may not be
• 46:56normally getting brain Mri's if she's
• 46:59suddenly reporting a headache that
• 47:02may necessitate additional imaging.
• 47:04Patient preference partially weighs in in
• 47:07terms of her surveillance some patients.
• 47:10Really are extremely anxious and about
• 47:12scans and if they've been stable for a
• 47:15very long time with advanced disease,
• 47:18we may actually lower the
• 47:19frequency of the scans.
• 47:21And then there are some patients who are
• 47:23be reassured on scans or if they're on
• 47:26a clinical trial that may necessitate
• 47:28additional scan frequency next,
• 47:33is it moving forward?
• 47:36And so with with our newer treatments,
• 47:39a lot of these patients with more
• 47:41advanced disease and reemphasizing the
• 47:43point made by doctor staff is that the
• 47:46definition of a survivor does not exclude
• 47:49patients with more advanced illness.
• 47:51So they're all survivors from
• 47:53day one of diagnosis throughout
• 47:55the balance of their life.
• 47:57So so but they may be on ongoing
• 47:59treatment and the checkpoint
• 48:00inhibitors which are the predominant
• 48:03immunotherapy costs that we're using
• 48:04in a range of malignancies can have
• 48:07many types of immune related cities
• 48:10and they may present your primary
• 48:12care office with symptoms that.
• 48:15You'll be kind of wondering is this
• 48:18an immune related toxicity or is it
• 48:21a common that just just a regular
• 48:23old symptom that may be unrelated.
• 48:25So these are the challenges that we all face.
• 48:27Is it related to cancer,
• 48:29is it related to cancer treatment
• 48:31or is it something else?
• 48:32There's also a range of oral targeted
• 48:35therapies that are now actively being used.
• 48:38So patient can essentially take a pill
• 48:41therapy that is specifically targeting
• 48:43a protein or antigen on their tumor.
• 48:46And again, impressive results
• 48:49in terms of treatment efficacy,
• 48:52but they can have a range of
• 48:53side effects including fatigue,
• 48:55rash, metabolic issues.
• 48:55So this is what we need your help with.
• 48:58So if they're developing hyperglycemia
• 49:00on these agents for example,
• 49:02we absolutely need your partnership
• 49:04to better these.
• 49:05Thanks.
• 49:08And so there's lots of resources
• 49:09in terms of toxicity management.
• 49:11And I think this may be a separate
• 49:14webinar if there's interest on this.
• 49:16But one thing I've highlighted
• 49:18because you will be seeing a lot of
• 49:20immunotherapy complications in the
• 49:21practice is that the American Society
• 49:24of Clinical Oncology guidelines for
• 49:26immunotherapy are readily available
• 49:28and it's a really good solid resource.
• 49:32Also, don't be afraid to reach out to us.
• 49:34Again, we're not asking you guys
• 49:36to be immunotherapy experts,
• 49:37but you just have that index of
• 49:39suspicion of if these patients are on
• 49:42targeted therapies or immunotherapy
• 49:43agents that some of the things that
• 49:45may seem routine may actually be
• 49:47related to the cancer treatment next.
• 49:51And then this was a really important
• 49:54article that really launched.
• 49:56An expansion of how we see survivorship,
• 49:58which is that patients with metastatic
• 50:01cancer, again, it fits the NCI definition.
• 50:04But for a long time as a community,
• 50:07we have sort of felt that, oh,
• 50:10it's it's only for patients with curable
• 50:11disease, which is absolutely false.
• 50:14And so Tom Smith and Terry Longbaum wrote
• 50:18this really wonderful article that was
• 50:20published in 2019 in the Journal of Medicine.
• 50:23Really highlighting a lot of the
• 50:26similarities and differences that can
• 50:28happen in the related to survivorship,
• 50:31related concerns in patients
• 50:32who are in remission.
• 50:34Kind of in that extended or
• 50:36longterm phase that you saw Dr.
• 50:38Dr.
• 50:38Singh talking about where patients
• 50:40who are actually living with cancer.
• 50:42And as you can see that could be
• 50:44physical issues, emotional issues,
• 50:46sexual health issues.
• 50:48There's actually more similarities
• 50:49than differences in terms of some
• 50:51of the domains of survivorship.
• 50:53So, so this is,
• 50:54this is an area that that we would
• 50:56love to partner with you to help
• 50:58support these patients that are
• 51:00actively being seen in both primary
• 51:02care as well as oncology offices and
• 51:06all of the survivorship resources
• 51:08that we've been talking about are
• 51:10available for these patients as well.
• 51:12Thanks.
• 51:14And so kind of coming back to the
• 51:17to those patients with who've had
• 51:19incredible responses to immunotherapy,
• 51:21there is not a body of literature
• 51:24really talking about the experience of
• 51:26how these patients actually feel after
• 51:29essentially being being told that,
• 51:31you know, you have advanced illness.
• 51:33We're not sure how long you have to live.
• 51:36And then because of the advanced
• 51:38advent of immunotherapy,
• 51:39they're actually living years
• 51:41and years after diagnosis.
• 51:43So there's a body of work developed.
• 51:44Working in terms of the this
• 51:46particular study showed that they feel
• 51:48like they live in a twilight zone.
• 51:50They feel like they're they're between the
• 51:52edge of death and the living and they not,
• 51:55they're not quite sure where they fit in.
• 51:57So kind of in the coming years you're
• 51:59going to see more of this type of work
• 52:02coming out where we're beginning to
• 52:04understand better the needs of these
• 52:06survivors with advanced illness next.
• 52:09So I want to make sure we
• 52:10have time for your questions.
• 52:12So just wanted to just highlight
• 52:14a few quick takeaways,
• 52:15which is that patients would advance
• 52:17cancer like this particular case,
• 52:20she may have just had COVID or she
• 52:22may have had COVID plus possibly
• 52:25a recurrence of her cancer.
• 52:27I think it's it's the,
• 52:28it's the differential that we
• 52:30all would think about.
• 52:32Brain metastasis recurrence
• 52:33can also present with nausea,
• 52:35vomiting and not not the malaise
• 52:38and not being able to eat so.
• 52:41So just kind of keeping that
• 52:43differential why it is important
• 52:45quality of life and symptom management
• 52:48is particularly important in these
• 52:50patients living with advanced illness and
• 52:53coordination of care with you guys is.
• 52:56Even more important in these patients
• 52:58with more complicated cancers on
• 53:00ongoing treatment and as much as we
• 53:02can regularly communicate the matter.
• 53:04So I'll stop there and make sure
• 53:06we have time for some questions.
• 53:08Thank you.
• 53:11There
• 53:17are no questions
• 53:18from the audience yet.
• 53:19So if you're listening,
• 53:20please enter questions after
• 53:23Williams. Do you have any?
• 53:24I do have a question.
• 53:26So the, you know immunotherapy is
• 53:29is a really recent occurrence and
• 53:32I think many of us in primary care
• 53:36don't have a tremendous number of
• 53:39patients that have actually received
• 53:41immunotherapy like the ones we discussed.
• 53:44What's the time horizon for
• 53:46us to be alert for potential?
• 53:50Adverse effects from those
• 53:52from those treatments,
• 53:53is it mostly during the treatment
• 53:55window or is it something that concur
• 53:58kind of longer subacute or even kind
• 54:01of great question, Dr. Williams.
• 54:03So so the majority of these would
• 54:06be first picked up on if that is
• 54:09more of an acute reaction while
• 54:12patients are receiving immunotherapy.
• 54:14Thyroid dysfunction issues for example
• 54:17are extremely common and we actually,
• 54:20if you wonder why is that oncologists
• 54:22checking thyroid function,
• 54:23that's what I do.
• 54:25It's actually part of our chemo plans
• 54:28to actually be checking thyroid
• 54:30function and adrenal function
• 54:32because these toxicities can be so,
• 54:34so, so common.
• 54:37Pneumonitis and cardiac issues
• 54:39are a little less common,
• 54:41but it's something that we if the
• 54:43patient is presenting with with
• 54:45shortness of breath during treatment
• 54:47or really any type of cardiac issue,
• 54:49the cardiac immune related
• 54:50toxicity can actually be deadly.
• 54:53That's not picked up early so so
• 54:55you're going to see if you see your
• 54:57oncologist doing certain types of
• 54:59work up that you're you're kind
• 55:00of like well cardiac work up it
• 55:02should be something I would be
• 55:04doing it's it's it's related to
• 55:06kind of kind of that that that
• 55:08high index of suspicion for these
• 55:11immunotherapy toxicities rashes are
• 55:13really common with immunotherapy
• 55:15as well as targeted therapies.
• 55:17So so so so so that's that's something
• 55:20that's very commonly seen and then we.
• 55:23I also worry a lot about colitis,
• 55:26immune related diarrhea where we
• 55:29typically if we're worried about it,
• 55:32we would have to hold the immunotherapy
• 55:35typically start high dose steroids and
• 55:38you can imagine if somebody already
• 55:41has metabolic syndrome or diabetes.
• 55:44All the things that you guys are expert at,
• 55:46we can kind of get into the cycle
• 55:48of trouble where we're struggling
• 55:50these hyper steroids and then their
• 55:52blood sugars are spiking etc.
• 55:53So that's another point where good
• 55:56close communication is super important.
• 55:58But to answer your question,
• 55:59most of the time these toxicities
• 56:02do happen during treatment,
• 56:05but then the endocanopathies that
• 56:07happen during immunotherapy do
• 56:08not necessarily go away after
• 56:10the immunotherapy is over.
• 56:12So,
• 56:12so we're sort of.
• 56:14The patients are left to continue
• 56:16to manage those complications.
• 56:18That's helpful. That's really helpful.
• 56:20So is it safe to say that you know,
• 56:21should a patient who's actively undergoing
• 56:24immunotherapy present with symptoms
• 56:26that could possibly really related,
• 56:29it would be important for us to get a hold
• 56:31of the treating oncologist immediately?
• 56:33Yes, yes. And I think I think
• 56:37pretty much from head to toe.
• 56:40Any organ can be involved in,
• 56:43in terms of immune related toxicity.
• 56:45So absolutely this is exactly we
• 56:49would want to hear from you and we
• 56:52are not expecting you to be the
• 56:55sole clinician managing these,
• 56:57but even alerting us that
• 56:59occasion is having trouble.
• 57:00They may have called you before
• 57:02they called us and I think
• 57:03that's why it's important.
• 57:07Well, I think we've run out of time.
• 57:10I just wanted to say that last patient
• 57:12was my patient and she's doing well,
• 57:14she just had COVID.
• 57:16So that was good news.
• 57:18But just wanted to to again thank
• 57:21you all for for participating
• 57:23this time and throughout the year.
• 57:25Please write something in the survey
• 57:27about it just because we can get
• 57:29your feedback as we just as we
• 57:30try to figure out what to do next
• 57:33year and and then I'll just hand
• 57:35it over to to Karen to to close.
• 57:40Just want to thank everybody
• 57:41for their attendance.
• 57:43Thank the panelists for their
• 57:45preparation and thoughtful
• 57:47approach to these issues.
• 57:49And actually and I want to
• 57:51thank you because it's the end
• 57:53of our first year doing this.
• 57:55So we will have a little
• 57:57celebration together,
• 57:58which does not mean we
• 57:59won't have recurrence.
• 58:03All right, good. Thank you all, everybody.
• 58:06Thanks, Brian. Thanks, Miriam.
• 58:10Yeah.