CLINICAL CONSIDERATIONS CASE CATALOG

This catalog corresponds to the Stanford Health After Cancer course. You will find a
timecode references and screen shot next to each clinical pearl, which extends the
information covered in that section of the cases. You will also find a cummulative Clinical
Considerations Case Catalog in the Resources Lesson of the course.

CASE 1: AMELIA

Radiation increases the risk of subsequent cancers in the radiation field. (ref 11-18) As
a result, screening recommendations (ref 19) may differ from the general population
for:
- Breast cancer (ref 20,21)
- Skin cancer (ref 19,22)
- Colon cancer (ref 23–25)
Timecode: 00.59

In the latter half of the 20th century, cure rates for most types of childhood cancer
increased dramatically. With improvements in survival came the recognition that
adults who were treated for childhood cancer are at increased risk for late effects.
Large cohort studies have enabled researchers to link therapeutic exposures with late
health complications that can emerge decades after the initial cancer treatment.(ref
27) International collaborative groups continue to develop evidence-based guidelines
Timecode: 01:20 for surveillance of late effects of childhood cancer. (ref 28,29) Additionally, many
contemporary treatment protocols aim to de-intensify treatment whenever possible
to maintain cure rates while minimizing the risk of treatment-related late effects.

Chest radiation can increase the risk of developing:

- Cardiomyopathy with reduced ejection fraction
- Coronary artery disease
- Valvular heart disease
- Conduction disorders
(ref 32-36)
Timecode: 01:50
Examples of anthracycline or anthracycline-like chemotherapy are Doxorubicin
(Adriamycin), Daunorubicin/Daunomycin, Mitoxantrone, Idarubicin, and Epirubicin.
These drugs are commonly used to treat cancers in both kids and adults.

Modifiable cardiovascular risk factors like hypertension and obesity amplify the risk
of cardiovascular late effects related to treatment exposures among childhood cancer
survivors, as shown in Table 4 in this article. (ref 33)

Timecode: 02:44

Early conversations about fertility and family building help patients stay
informed,initiate fertility preservation if needed, and prepare psychologically and
emotionall for alternative family building options. (50). Referral to reproductive
medicine specialists may help your patients to become better informed about their
options.

Timecode: 03:32
CLINICAL CONSIDERATIONS CASE CATALOG
CASE 1: AMELIA (cont.)
Alkylating agents include cyclophosphamide, ifosfamide, melphalan, busulfan, and
procarbazine, among others. The risk of infertility from alkylating chemotherapy
is related to cumulative dose and is an important determinant in calculating what
fertility specialists call fertility risk.

Timecode: 04:26

Professional organizations and specialized clinics provide consultative services to

cancer survivors. Many use decision aids and risk calculators to help estimate fertility
risk based on prior exposures. Experts in these clinics can provide personalized advice
and support.

Timecode: 05:16

The oncology community increasingly recognizes the need to address future fertility
needs and aspirations for patients diagnosed with cancer during their reproductive
years.

The American Society of Clinical Oncology provides clinical practice guidelines for
fertility preservation based upon available evidence. (ref 50)
Timecode: 05:28

A 2006 Institute of Medicine report called attention to the fact that many cancer
survivors described feeling lost in transition and recommended that cancer clinicians
complete a survivorship care plan to facilitate the transfer of information from cancer
clinician to primary care clinician, and to provide the patient with a ‘road map’ for
testing and follow-up visits. (ref 51)

Timecode: 07:16

CASE 2: BOB
Epidemiologists have estimated a 225% increased incidence of HPV-positive
oropharyngeal cancer from the late 1980s to early 2000s. This serves as an important
reminder of the role that primary care physicians can play in counseling, screening
and referring patients at risk for this disease. (ref 58)

Timecode: 01:00

The multidisciplinary approach that is necessary for the treatment of head and neck
cancer is reflected in treatment summaries and survivorship care plans. Patients like
Bob benefit from multispecialty care that includes speech and swallow specialists.
(ref 62-65)

Timecode: 01:44
CLINICAL CONSIDERATIONS CASE CATALOG
CASE 2: BOB (cont.)
Associate professor of radiation oncology Beth Beadle MD reminds us that 5% of
patients develop late dysphagia, largely related to cranial nerve issues, with a median
time of onset of about 5 years after radiation.

Timecode: 03:55

A comprehensive swallowing assessment may include video fluoroscopic swallowing

studies (VFSS/MBS) and FEES (Ref 66)

Efforts to prevent osteoradionecrosis include maintaining good oral hygiene and

treating dry mouth. Some experts recommend 3x per year dental visits. It is important
to involve radiation oncology before extractions, implants, or bone surgery.
Timecode: 04:57

Explore the patient’s mood and assess for distress and depression as possible
contributors to fatigue.

Prophylactic antidepressants have been shown to decrease rates of depression

among newly diagnosed non-depressed patients with head and neck cancer. (ref 77)

Timecode: 010:07

CASE 3: SEEMA
Although some degree of fear of cancer recurrence is expressed by nearly all cancer
survivors and generally improves with time, severe fear of cancer recurrence that
presents with intrusive thoughts needs an in-depth assessment and referral to a
mental health professional.

Timecode: 03:22

Multiple meta-analyses and systematic reviews show that adjuvant bisphosphonates

reduce the rate of recurrence and improve survival in women with non-metastatic
breast cancer, especially those who are post-menopausal or undergoing ovarian
suppression. The benefit appears to be greater for women at higher risk of recurrence.
(ref 82-85).

Timecode: 06:51

Tips for vaginal dryness: Silicone-based lubricants don’t dry out as quickly as water-
based lubricants. Coconut oil is a natural alternative. However, oil-based lubricants
may cause breakdown of latex condoms.

Vaginal dryness can cause pain with Pap smears; some women find that lubrication or
self-dilation 1-2 weeks before a Pap can help.
Timecode: 07:34
CLINICAL CONSIDERATIONS CASE CATALOG
CASE 4: RICHARD
The best available evidence suggests that screening confers a small absolute benefit
for reducing prostate cancer mortality, but the potential harms from screening are
increasingly being taken into consideration in conversations with patients. Clinicians
need to open the conversation with patients and we encourage patients to decide for
themselves whether the benefits of screening possibly outweigh the harms, including
overdiagnosis. This refers to detecting a cancer that would not have become clinically
Timecode: 01:50 significant in the patient’s lifetime. (ref 95-96)

This approach is based on the long natural history of prostate cancer and is an
attempt to balance the risks and side effects of overtreatment against a theoretical
lost opportunity for cure. The challenge lies in identifying appropriate candidates and
engaging them in a surveillance protocol that may include testing at regular intervals.
(ref 97)

Timecode: 02:10

Although long-term or late urinary tract toxicity affects a relatively small percentage
of prostate cancer survivors, the effects on quality of life can be quite bothersome. It
is important to elicit symptoms and to rule out contributing causes that are unrelated
to cancer therapy, especially those that are amenable to treatment. Often radiation
toxicity is a diagnosis of exclusion.

Timecode: 04:20 Men treated for prostate cancer with surgery are at risk for stress urinary incontinence
and irritative symptoms such as urgency, frequency and dysuria as well as
hematuria in irradiated patients. Urethral strictures may occur as a long-term or late
consequence of surgery or radiation. (ref 98-99)