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Doctors Need to Learn Long-Term Side Effects of Chemo

Renee DespresFriday, June 15, 2012 - 20:38

More than 90 percent of primary care doctors and 65 percent of oncologists do not know the major long-term side effects of four drugs commonly used to treat breast cancer and colon cancer, according to findings from a survey by the National Cancer Institute.

The National Cancer Institute began the  Survey of Physician Attitudes Regarding the Care of Cancer Survivors in 2009. The purpose of the survey is to identify perceptions, knowledge, and practices of primary care and oncology specialist physicians regarding post-treatment follow-up care of adult cancer survivors. Survey results were presented by lead author Larissa Nekhlyudov, M.D. at a telebriefing in advance of the annual meeting of the American Society of Clinical Oncology (ASCO). The abstract is currently available.

What the Researchers Did

For this phase of the survey, researchers mailed questionnaires to 1,072 primary care physicians and 1,130 oncologists who treat people with breast and colon cancers. Survey questions asked the doctors to identify five late-term effects of four common breast and colon cancer drugs:  doxorubicin (Adriamycin), paclitaxel (Taxol), oxaliplatin (Eloxatin), and cyclophosphamide (Cytoxan). They were asked whether they had observed the side effects in patients and/or had read about them in scientific literature.

What the Researchers Found

Only 6% of primary care physicians correctly identified the major long-term effects of the four drugs. While oncologists did better, more than one out of three did not correctly identify the late toxicities of the drugs. This is a major concern, considering oncologists prescribe the drugs routinely.

Both primary care physicians and oncologists were most familiar with one long-term effect of doxorubicin: cardiac dysfunction. More than half of PCPs (55%) and almost all oncologists (95%) correctly identified cardiac dysfunction as a late effect.

Oncologists also did well in recognizing peripheral neuropathy – nerve damage in the hands and feet – as a late effect of paclitaxel and oxaliplatin, with 97% identifying it as an effect. Most primary care doctors, on the other hand, were not aware of this common side effect. Only 27% recognized peripheral neuropathy as a late effect of paclitaxel and 22% identified is as an effect of oxalipatin.

Another late effect of these two drugs -- pulmonary fibrosis, a devastating lung disease – was woefully under-recognized by both groups of doctors. Only 5 percent of oncologists and 6% of primary care physicians recognized pulmonary fibrosis as a late effect of paclitaxel; for oxaliplatin, the percentages were 5 and 9 percent.

About 20% of oncologists and 13% of primary care physicians recognized pulmonary fibrosis as a side effect of cyclophosphamide. However, two late effects of cyclophosphamide – premature menopause and secondary cancers – were not on the radar screen of 85% of primary care physicians and about one third of oncologists.

Why It's Important

Nekhlyudov, a primary care physician with Harvard Medical School in Boston and Harvard Vanguard Medical Associates in Kenmore, Mass, told reporters that these results suggest physicians need more education about caring for the more than 12 million cancer survivors in the United States.

"These findings emphasize that in the transition of patients from oncology to primary care settings, primary care providers should be informed about the late effects of cancer treatment so that they may be better prepared to recognize and address these among cancer survivors in their care,” Nekhlyudov said. “Whether this will be achieved with survivorship care plans needs to be evaluated."

As more people survive cancer, it’s becoming more important that physicians are familiar with the late effects of chemotherapy drugs. Ironically, the more effective those drugs are at killing cancer cells, the more we need to know about the long-term damage they may cause.

Most cancer survivors transition to the care of primary care physicians, or family doctors. Nekhlyudov’s results clearly point to the need to educate primary care physicians about the late effects of chemotherapy drugs. These findings support previous results from the survey presented at last year’s ASCO meeting, which suggested that many primary care physicians feel ill-equipped to handle the often complex needs of breast and colon cancer survivors.

Lack of awareness among oncologists may be related to their focus on cancer treatment rather than cancer survivorship, Nekhlyudov said. Only in recent years have oncologists begun to recognize the importance of recognizing and addressing the potential late effects of these drugs. “While it is surprising that oncologists were not more aware of late effects, I think that as more and more attention is placed on cancer survivorship, oncologists will become more equipped with that information," Nekhyludov told reporters.

How Can I Use this Information?

If you are a cancer survivor, ask your cancer care team to work with you to develop an individualized cancer survivorship care plan. A care plan provides a history of your cancer diagnosis, treatment, and response -- and a roadmap for your future health care. The plan should include guidelines for maintaining and monitoring your health as you transition to a primary care setting and a list of potential long-term side effects of any chemotherapy or other medications you have taken during your cancer journey.

In 2006, the Institute of Medicine recommended that every cancer patient receive a survivorship plan. Since then, many groups have developed templates for developing the a cancer survivorship plan. Here are some examples:

  • The ASCO Cancer Treatment Plan and Summary. This plan is completed by your doctor. It is a brief record of your cancer treatment, using forms that provide help you to track about your cancer, cancer treatment, and follow-up care. The forms also provide basic information about your medical history to any doctors who will care for you in the future.
  • What's Next? Life After Treatment Developed by the Minnesota Cancer Care Alliance, this booklet provides a place for you to record your journey.
  • Journey Forward. This free software can help you create a custom survivorship care plan based on ASCO treatment summary templates and surveillance guidelines. The latest version of the software includes support for assessing and addressing psycho-social needs associated with cancer and its treatment, as well as a template for lung cancer survivors.
  • Prescription for Living. This succinct, two-page form was developed in 2006 by a group of key stakeholders, including social work, nursing, and survivor organizations. Project sponsors were the American Cancer Society, Oncology Nursing Society, the National Coalition for Cancer Survivorship, American Journal of Nursing, and the University of Pennsylvania School of Nursing.