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Cancer Teaching Materials

Cancer Care Powerpoint - Presentation on the role of primary care providers in their patients' cancer care, including integrative treatment options

Handout - Handout to accompany above lecture, with information as below.

Breast Cancer Care and Prevention - Online Module from the University of Wisconsin

Cancer Survivorship Internet Resource Guide for Primary Care

Cancer Survivorship in Primary Care – Provides general primary care info and links
www.cancersurvivorshipprimarycare.org

American Society of Clinical Oncology – Guidelines for follow up by cancer type
www.cancer.net
http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Guidelines/Clinical+Tools+and+Resources

American Cancer Society
www.cancer.org/treatment/survivorshipduringandaftertreatment

National Cancer Institute – Information on cancer screening
www.cancer.gov/cancertopics/pdq/screening

National Comprehensive Cancer Network – Supportive care guidelines for depression, pain, etc
www.nccn.org/professionals/physician_gls/f_guidelines.asp#supportive

Children's Oncology Group – Specific guidelines for follow up after pediatric cancer
www.survivorshipguidelines.org

Fertile Hope – Information on fertility issues and cancer treatment
www.fertilehope.org/healthcare-professionals/index.cfm

Journey Forward – Provides survivorship care plan templates and general follow up information
www.journeyforward.org

Livestrong Care Plan – Survivorship care plan template
www.livestrongcareplan.org

Memorial Sloan Kettering – Good website to look up basic information on complementary therapies
www.mskcc.org/cancer-care/integrative-medicine/about-herbs-botanicals-other-products

Natural Medicine’s Database – Good resource for supplement and herb information
www.naturaldatabase.therapeuticresearch.com

Primary Care and Cancer Care

Failure of the �War on Cancer�
Cancers, not cancer
Treating cancer as if one cell type has �gone awry� is not effective, doesn�t match reality
Importance of the terrain
Metastasis as Natural Selection

�Oncogenic Potential�

Genetic Instability
Environmental and other mutagens
Altered mitochondrial functioning
Oxidative stress
Altered epigenetic methylation, protein phosphorylation, glycation, histone acetylation, etc.

Permissive Environment

Abnormal insulin signaling
Chronic inflammation
Chronic infections (HPV, HBV, EBV, H. pylori, etc.)
Cellular hypoxia, shift toward anaerobic metabolism
Altered Immune surveillance
Hypercoagulability
Angiogenesis

Primary Care and the Cancer Care Continuum

First, Do No Harm � be aware of the risk of radiologic studis

Cancer Prevention in Primary Care

Tobacco
Alcohol
Diet Exercise
Sleep deprivation
Observational:
Tricyclics decrease colorectal CA and glioma
Metformin may decrease breast CA in diabetics
Cox-2 inhibitors decrease breast cancer risk - celecoxib > 1 year assoc with 16% decreased risk.
Vitamin D
Fish oil associated with reduced risk of breast cancer (HR, 0.68; 95% CI, 0.50-0.92).
Green Tea in Prostate Cancer Prevention
And tons of other possibilities:
Curcumin, Red ginseng, Quercetin, Resveratrol, Pomegranate, Broccoli sprouts, Citrus, Berries
Caution � individual vitamins may be harmful (I suspect botanicals are safer)
Keep in mind early diagnosis does not always translate into improved survival
Risk of the test, Risk of false positives and our response to them, e.g. PSA testing, CA-125
Educate patients that screening is not prevention; Use the opportunity to discuss actual prevention

Diagnosis

Very little will be remembered after hearing �the Big C�
Plan on a phone follow-up or a return appointment with family member
Recommend an ally � friend/family member who accompanies them to all appointments
Emotional Responses
Positive meaning
Increased vulnerability
Continuity of Primary Care improves survival
Most cancer patients other chronic comorbidities
33% - 50% have three or more chronic conditions, care of these other conditions is important
FP Behaviors Associated with Improved QOL Scores
The family doctor :
Discusses how I am feeling about having cancer
Helps me with medical problems unrelated to my cancer
Answers my questions about cancer and cancer treatments
Discusses with my family how they are feeling about my illness

Treatment �what can we add?

Empowerment (Depending on your setting, helping patients assess quality of recommendations received for their care)
and Evidence-based interventions many oncologists overlook
1. Physical activity and diet during treatment
2. Psychological Support, Mind-body - � earlier the better
Support groups � Am Cancer Society, SWMC (Look Good Feel Better and others)
Many in Portland, including MBSR groups. See the database at www.nwcancer.com/resources/
Fighting Cancer from Within, Martin Rossman � Guided imagery recordings
Online support groups
3. Immune support
Adjuvant PSK (Mushroom Tx), Astragalus
Other adjuvant therapies to watch
Bisphosphonates
Enzymes
NSAIDs, Cox-2
Statins - Breast Cancer Res Treat. 2010 Jan;119(1):137-44
And in the integrative world:
Antiangiogenesis foods and nutrients, zinc, etc.
Antithrombotic foods
Antiinflammatory foods � incl many spices

Cautions: Antioxidants � jury is out
?Vitamin E interfered with radiotherapy in smokers
?Prospective cohort study -vitamin use first 6 mos after breast CA dx assoc w/ 18% ?mortality risk
Melatonin with chemotherapy improved survival in metastatic solid tumors,
but caution in heme malignancies, maybe melanoma
Astragalus may augment platinum-based therapies
DHA sensitizes to anthracyclines, possible benefits in cachexia, dec tumor drug resistance
Also caution with herbs/herb-drug interactions

Dealing with Complications of Tx

L-glutamine decreases neuropathy after paclitaxel and protects the gut lining in chemo and XRT
Carnitine can help weakness and fatigue as well as prevent cardiotoxicity
Coenzyme Q10 is helpful for preventing cardiotoxicity
Weight lifting decreases development of lymphedema in breast cancer patients
Ginger and nausea (effective when added to ondansetron and dexamethasone)

Cancer Care Continuum Branch Point:

Remission/Long Term Survivorship vs. Terminal care
Healing if not curing
Preserving hope � even stage IV cancers have some (low!) percentage of 5-year survival
Bernie Siegel�s Love, Medicine, & Miracles, Rachel Naomi Remen

Follow-up care:

look for new primaries and local recurrence; distant surveillance less clearly beneficial
Still, be aware of recurrence possibility at every acute visit therafter . . . Vigilance about complaints of bone pain, earlier imaging for symptoms, e.g. headache, abdominal pain, elevated LFT�s
Secondary prevention

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