LIFE AFTER CANCER/CULTURAL AND LINGUISTIC COMPETENCY
| LIFE AFTER CANCER: ROLE OF THE PRIMARY CARE PHYSICIAN —Judith A. Luce, MD, Clinical Professor of
Medicine, University of California, San Francisco School of Medicine, and Director of Oncology Services, San Francisco
General Hospital
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| Why primary care physicians will be seeing more cancer patients: pool of cancer survivors growing (current
5-yr survival rate 2 in 3 patients); most oncologists limit their practices to treating cancer; of every 30 Americans, one is
cancer survivor; of every 7 people >65 yr of age, one is cancer survivor
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| Goals of survivorship: established during 2005 consensus conference by National Cancer Institute, National Academy
of Sciences, and Institute of Medicine; outlined 4 components of survivorship care, including prevention of recurrent and
new cancers and other late effects; surveillance of cancer spread; intervention for cancer consequences, including psychosocial
ones; and coordination of care among specialists and primary care providers
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| Cancer prevalence: ≈25% of survivors had breast cancer, ≈20% had prostate cancer, and ≈20% had gynecologic and
colorectal cancers; lung cancer common, but survival low
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 | Long-term survivors: people who had cancer >25 yr ago; women predominate because of high survival rates of breast
and cervical cancer
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| Functional limitations: ≥1 experienced by ≈58% of all cancer survivors; usually considered consequence of treatment;
because of functional limitations of aging, difference between cancer survivors and others not strong in >65-yr age
group; overall incidence of limitations in activities of daily living (ADL) 11%
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| Delayed effects of treatment: treatment-associated cancers from toxicity of chemo- or radiation therapy; incidence of
myelodysplasia and acute leukemia associated with alkylating agents ≈1% up to 10 yr out; genotoxic effect of topoisomerase
inhibitors seems limited to ≈2 yr after exposure; radiation-induced cancers may occur >30 yr after exposure
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| Risks for second primary cancers: 5-yr risk for second smoking-related cancer in upper aerodigestive tract 10% to 15%;
risk for second primary hormone-related cancer (eg, breast, endometrial) diminishes rapidly after cessation of therapy
(cancer promotion effect rather than genotoxicity); cancer risk associated with inflammatory or autoimmune disease
(eg,colon cancer with ulcerative colitis) remains high unless end organ removed; cancer risk associated with virus such
as human papillomavirus also remains high in target organ (virus changes field, making it vulnerable to cancer); people
with genetic cancer risk also have much higher than average rates of second primary tumors; certain familial genotypes
increase cancer risk in other organs as well, eg, some inherited forms of breast cancer associated with increased risk for
ovarian or pancreatic carcinoma; childhood cancers—associated with highest cumulative lifetime risk; survivors of
Wilms’ tumor or retinoblastmoma have lifetime risk for second primary tumor 30- to 50-fold higher than their peers
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| Delayed effects of cancer surgery: depends on target organ; difficult to assess effects of prostatectomy because statistics
vary by urologist; in general, early outcomes of complex procedures better when performed at high-volume centers of
expertise, but little evidence of improvement in long-term outcomes
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| Delayed effects of radiation therapy: difficult to project because of continuous technologic improvement; mechanism
of injury small-vessel occlusion, leading to ischemia; evolves slowly and dose- and organ-dependent; ≈ 2000
rads—sufficient to destroy kidney, but not muscle or bone; may injure lung and damage (but not destroy) heart
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| Neurotoxicity: exacerbated by vascular effects; after whole-brain irradiation, incidence of dementia ≥25% (patients
rarely survive long enough to develop dementia); use of potentially neurotoxic radiation in children decreasing dramatically
due to risk for delayed effects
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| Cardiac toxicity: includes ischemia and heart failure; relatively uncommon now, thanks to improved technology (also
true for pulmonary fibrosis and bony changes)
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| Effects on oral cavity: without meticulous care, damage to salivary glands associated with rapid dental loss; jaw osteonecrosis
common complication of irradiation
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| Hypothyroidism: occurs in ≈50% of patients with Hodgkin’s disease who receive radiation therapy to neck; develops
slowly and insidiously; incidence approaches 100% in patients who receive higher radiation doses to treat head and
neck cancer
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| Ischemic changes in bowel and bladder: often follow pelvic irradiation
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| Hypogonadism: common unless gonads shielded
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| Delayed effects of chemotherapy: anthracyclines—produce dose-dependent loss of myofibrils and heart failure; risk
for permanent damage especially high among people with underlying heart disease or cardiovascular risk factors; rate of
anthracycline-associated heart failure <1% among patients treated for breast cancer or lymphoma if dose <300 mg/m2 ,
and if people at high risk for heart disease excluded; warn patients to control cholesterol, blood pressure, and other risk
factors; cyclophosphamide—excreted in urine, eliciting concerns about bladder cancer; risk highest among people who
took small doses for long periods; patients can decrease risk by remaining well hydrated and taking mesna (Mesnex; cytoprotective
agent that neutralizes cyclophosphamide in urine)
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| Fertility: after chemotherapy, men remain infertile for ≤1 yr (affects sperm production, not testosterone levels); women experience
loss of primary ovarian function; majority of premenopausal women aged ≥40 yr who undergo chemotherapy
experience menopause; variable and unpredictable for women <40 yr of age; no evidence of genotoxicity among children
born to women who underwent chemotherapy
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| Other late effects of chemotherapy: immunologic—graft-versus-host disease (GVD) in transplant recipients; immunosuppression
associated with cancer treatment “real, but highly overrated, especially by patients”; immunologic consequences
of most cancer treatments minimal; chemotherapy, surgery, and radiation therapy all contribute to
immunosuppression; only people who develop GVD, or lymphoma patients who take T cell inhibitors, require prophylaxis
for immunosuppression; patients on high doses of steroids deserve prophylaxis against Pneumocystis jiroveci
(formerly carinii) pneumonia; reactivation of latent tuberculosis or hepatitis occurs early in treatment course
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| Evaluation for cancer recurrence: 2 prospective randomized trials showed no benefit of routine surveillance with
computed tomography (CT) and bone scans for detecting recurrences of lung and breast cancer; guidelines for following
patients must be disease-specific; patients most likely to come out of remission should be followed more often than those
deemed cured
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| National Cancer Center Network (NCCN) guidelines for follow-up: scans seldom recommended; breast
cancer—history and physical examination every 4 to 6 mo for 5 yr, and annual mammography; if patient on tamoxifen,
perform pelvic examination; women on aromatase inhibitors should have bone health monitored by dual emission x-ray
absorptiometry (DEXA); lymphedema should be treated but does not indicate recurrrence or require scan; risk for new
primary tumor exceeds that of recurrence in these patients, so regular mammography essential; prostate cancer—
prostate-specific antigen (PSA) every 6 mo for 5 yr, then yearly; digital rectal examination annually; treatment may affect
potency and bladder function; androgen suppression may turn off pituitary-gonadal axis; colon cancer—screen men
for new primary tumors; frequency greater than for polyps (colonoscopy every 2-3 yr, rather than 3-5 yr)
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| Patient’s role in preventing recurrence: quit smoking; develop heart-healthy habits after treatment with anthracyclines;
low-fat diet commendable but difficult to follow; no evidence that any vitamin or herb prevents recurrence of second
primary; effects of exercise on survival uncertain; keep recommendations reasonable and consistent with healthy
lifestyle
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| Psychosocial consequences of cancer: issues include loss of control, coming to grips with diagnosis and its meaning,
and fear of cancer recurrence; diagnosis also has profound impact on patient’s work, family, and insurance status;
usually, patients recover quickly from emotional trauma (de-pression ratings among women 1 yr after breast cancer diagnosis
same as in other patient populations); impact in 4 domains (physical, psychologic, social, and spiritual)
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| Depression: 10% to 25% of patients meet criteria for frank depression shortly after cancer diagnosis (usually resolves
over time); more common among patients with advanced-stage disease, pain, history of depression, comorbidities, or
poor social support; diagnosed with standard office questionnaire; little known about antidepressant therapy in this
population
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| Distress: distinguish from depression; usually coincides with crises or milestones after cancer diagnosis; talking appears
best treatment; support groups helpful
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| Family issues: concerns about sexuality, fertility, and discovering that entire family may be at risk if cancer genetic
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| Positive outcomes: reported by virtually all cancer survivors >1 yr out; include living more in moment, increased spirituality,
stronger personal relationships, and realization that cancer survivable
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| Resources: ASCO web site for survivors (plwc.org); survivors’ site from American Cancer Society (cancer.org); Children’s
Oncology Group site for professionals following children with cancer (survivorshipguidelines.org); Institute of
Medicine report (iom.edu); NCCN guidelines (nccn.org)
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| CULTURAL AND LINGUISTIC COMPETENCY: WHAT IT IS AND HOW TO ACHIEVE IT —Leah S. Karliner, MD,
Assistant Professor of Medicine, University of California, San Francisco, School of Medicine
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| Cultural competence: defined by Joint Commission on Accreditation of Healthcare Organizations as “the delivery of
health care services in a manner that is respectful and appropriate to an individual’s language and culture”
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| Disparities in care: in United States, encountered by ethnic minorities in almost every area studied, including access to
care, asthma care, cancer survival, cardiac care, diabetes, pain management, and preventive care; in addition to cultural
factors, reasons include poverty, illiteracy, inadequate housing, poor diet, and inadequate insurance
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| Cultural formulation: appendix to Diagnostic and Statistical Manual, Fourth Edition (DSM-IV); indicated if clinician
suspects problems in communication, evaluation, or treatment due to cultural differences; 5 components
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| Cultural identity: ask patient about country of origin, preferred language, and ease of communicating in English; try to
determine degree of patient’s acculturation; communication style may be direct or indirect, depending on culture
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| Explanatory models of illness: ask what patient thinks triggered symptoms and how culture of origin would explain them;
ask if symptom set has name in culture of origin and about usual treatment for it
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| Cultural stressors and supports: ask who is at home to help care for patient, and how much family members and culture in
general prefer to know about illness; immigration history may offer insight—patient may have left family behind and
lack social support; patient may have supportive community or come from culture that discourages individual decisions
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| Cultural elements of relationship with clinicians: ask patient about previous experiences with physicians, eg, what
helped, and what did not; if patient or family member experienced racism or disparity in care in past, current interaction
with physician probably affected; clinician’s willingness to ask and hear about this engenders trust
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| Clinician self-assessment: clinicians should explore effects of their own previous experiences and stereotypes of certain
races and ethnicities on patient care and communication
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| Language barriers: in 2000 United States census, 47 million people reported speaking language other than English at
home; 50% said they spoke English less than “very well”; strong evidence that language barriers exacerbate disparities
in access, physician visits and preventive services, adherence to treatment and follow-up for chronic illnesses, time
spent in emergency department, hospital admissions, complications, and satisfaction with care
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| Language concordance: present when physician and patient speak same language; associated with better clinical care, experience
with medication, follow-up, and patient satisfaction; however, even if physician speaks same language, other
caregivers patient encounters may not
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| Legal obligation: any provider who receives federal funding must provide linguistic assistance in threshold language
(spoken by >5% of population served)
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| Interpreter: any third party present during clinical interaction who facilitates oral language interpretation; ad hoc
interpreter—untrained person called upon to interpret; professional interpreter—anyone paid and provided by health
system to interpret during clinical interactions; training levels vary, but professionals associated with better clinical care
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| Working with professional interpreters: allow enough time during visit; take sex and confidentiality into account
when selecting interpreter; review relevant clinical information and goals with interpreter before visit; remind interpreter
that tone and meaning of message more important than verbatim translation; speak directly to patient and maintain eye
contact; introduce interpreter to patient; observe patient during interaction with interpreter, watching for body language
and behavioral cues; confirm your comprehension of interpreter’s remarks; speak in short sentences and ask short questions;
explain medical terms in simple language; ask patient to repeat instructions
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| Working with ad hoc interpreters: their proficiency in English and other language may be unequal; they may be unfamiliar
with medical terms in either language; ask if they are comfortable with issues of sex and confidentiality; review
goals of visit before speaking with patient; verbatim interpretation sometimes necessary; remind them to avoid answering
for patient; give them permission to ask you to slow down or rephrase when necessary; if interpreter is friend or relative,
avoid using minor
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Educational Objectives
| The goal of this program is to educate the listener about challenges faced by primary care providers when managing cancer
survivors and patients with limited English proficiency. After hearing and assimilating this program, the clinician will be
better able to:
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| 1. List the goals of cancer survivorship established in 2005.
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| 2. Recognize the common delayed effects of cancer treatment.
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| 3. Utilize the major online resources for more information and support.
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| 4. Define cultural competence as it relates to health care.
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| 5. Work with an interpreter when needed to improve communication with a patient.
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Suggested Reading
Cardous-Ubbink MC et al: Risk of second malignancies in long-term survivors of childhood cancer. Eur J Cancer
Nov 30, 2006 [Epub ahead of print]; Collins S: Communicating for a clinical purpose: strategy in interaction in healthcare
consultations. Commun Med 2: 111, 2005; Demark-Wahnefried W et al: Promoting health and physical function
among cancer survivors: potential for prevention and questions that remain. J Clin Oncol 24: 5125, 2006; Ferrell BR,
and Winn R: Medical and nursing education and training opportunities to improve survivorship care. J Clin Oncol 24:
5142, 2006; Gerber LH et al: Functional outcomes and life satisfaction in long-term survivors of pediatric sarcomas.
Arch Phys Med Rehabil 87: 1611, 2006; Hewitt M, and Ganz P, eds: From Cancer Patient to Cancer Survivor -- Lost
in Transition: An American Society of Clinical Oncology and Institute of Medicine Symposium. Washington, DC: The National
Academies Press, 2006; Jacobs E et al: The need for more research on language barriers in health care: a proposed
research agenda. Milbank Q 84: 111, 2006; Jensen BVet al: Functional monitoring of anthracycline cardiotoxicity: a
prospective, blinded, long-term observational study of outcome in 120 patients. Ann Oncol 13: 699, 2002; Jensen BV:
Cardiotoxic consequences of anthracycline-containing therapy in patients with breast cancer. Semin Oncol 33(3 Suppl 8):
S15, 2006; Karliner LS et al: The language divide. The importance of training in the use of interpreters for outpatient
practice. J Gen Intern Med 19: 175, 2004; Sheridan I: Treating the world without leaving your ED: opportunities to deliver
culturally competent care. Acad Emerg Med 13: 896, 2006; Stull VB et al: Lifestyle interventions in cancer survivors:
designing programs that meet the needs of this vulnerable and growing population. J Nutr 137: 243S, 2007;
Takigawa N et al: Second primary cancer in survivors following concurrent chemoradiation for locally advanced non-
small-cell lung cancer. Br J Cancer 95: 1142, 2006; Travis LB: The epidemiology of second primary cancers. Cancer
Epidemiol Biomarkers Prev 15: 2020, 2006; Vivar CG: Long-term cancer survivors: ‘who is there to work with these
people?’ Eur J Cancer Care 15: 503, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Luce was recorded at Advances in Internal Medicine, June 19-23, 2006; Dr. Karliner at Primary Care Medicine:
Principles and Practices, October 25-27, 2006; both meetings sponsored by the University of California, San Francisco,
School of Medicine and held in San Francisco. The Audio-Digest Foundation thanks the speakers and the sponsor
for their cooperation in the production of this program.
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