Northeast ONCOLOGY News

Volume 9 Issue 2 December 2019

Regional Cancer Plan Renewal...What Matters to You? This past June, Cancer Care Ontario Regional Cancer Plan. How can we continue to strengthen released the 2019-2023 Ontario Cancer our Northeast Cancer Centre and Regional Cancer Program? Plan. This five-year provincial cancer plan What ideas do you have to make our Regional Cancer Program outlines how Cancer Care Ontario, the more patient-centred, safe, equitable, efficient, effective and Regional Cancer Programs, and health timely? system partners will work together to reduce Ontarians’ risk of developing cancer and to improve I look forward to your ideas and your input. Have you got outcomes for those affected by cancer. something to say? Feel free to contact me and share your views: [email protected]. Why is a province-wide cancer plan so important? Nearly 1 in 2 Ontarians will develop cancer in their lifetimes. More than Maureen McLelland, BScN, MHSc, CHE half of all cancers are diagnosed in people who are over the Regional Vice President, Northeast Cancer Care age of 60. As demographics in the Northeast continue to shift, Vice President, Social Accountability with growing numbers of older adults, this will mean more Health Sciences North northerners will be at risk for and living with cancer. And we know cancer care does not end at the completion of treatment. As more people survive and live longer with cancer, patients, caregivers and the health system will face new challenges.

This winter we will engage actively within the Northeast to sharpen the focus of the provincial plan into a multi-year

PET Scanning Program at HSN has Officially Launched According to the System and Infrastructure Planning and time and quality as other centres Cancer Analytics, Cancer Care Ontario (CCO), 747 patients across Ontario. All treating from northeast Ontario travelled to receive a PET scan in 2018. oncologists/physicians who have Since 2011, there have been 4,306 patients who have received been referring to other centres a PET scan by travelling to one of our neighbouring PET across Ontario will now have access centres. to booking their patients in Sudbury through the same venue.

It is thanks to the Northern Cancer Foundation, the members Until now our booking system has been on an as-needed basis of Sam Bruno’s family and the PET Steering Committee that and as the program continues to grow we will be offering more we have now officially opened the doors of Ontario’s 13th PET dates to accommodate the increased demand. Any treating scanner. This is the only PET scanner within a 400 km radius of physician can refer for a PET scan as long as a patient meets Sudbury. one of the indications outlined by CCO, or is approved by the PET access clinical expert reviewers. To better understand the We are now fully operational and can perform all CCO-funded referral process and approved indications please refer to the oncology indications. A few of these indications include non- CCO PET Scans Ontario website: small cell lung cancer, single pulmonary nodule, esophageal www.ccohealth.ca/pet-scans-ontario. cancer and lymphoma. We look forward to working closely with you as our program To date, our PET team has seen approximately 270 patients grows. from across the Northeast. We are now an officially registered Tyler Speck PET centre on the CCO website and will be receiving and Director of Medical Imaging booking all PET cases under the same goals for turnaround Health Sciences North New Regional Primary Care Lead

It is a privilege to have been appointed to Over the course of the next year, our team’s emphasis will be the role of Regional Primary Care Lead to focus on improving cancer screening rates by understanding for the Northeast, effective September 1, barriers faced by our patients and providers. As a fellow 2019. I am excited to bring to this position northerner who was born and raised in Sudbury, I look forward my previous experience as regional lead to working with my colleagues throughout northeastern Ontario, for the North East LHIN, and my practical and invite you to reach out with all of your cancer screening experience as a primary care provider at questions at [email protected]. the City of Lakes Family Health Team in Sudbury. This role has been derived from Dr. Amanda Hey’s Dr. Jason Sutherland MD, PhD, CCFP extensive work at the primary care level throughout the region. Regional Primary Care Lead I wish Dr. Hey all the best in her retirement from this position, Northeast Regional Cancer Program and hope to continue to expand on her excellent work.

New Regional Indigenous Cancer Lead

Aanii – I’m honoured to have been practicing family medicine at the Shkagamik-Kwe Health Centre appointed to the position of Regional in Sudbury, Wiikwemkoong Health Centre on Manitoulin Island Indigenous Cancer Lead - South with the and I continue to provide locum services to the James Bay Northeast Regional Cancer Program. Coast.

I’m from Wiikwemkoong First Nation on I look forward to collaborating with my colleague, Dr. Elaine Manitoulin Island and prior to attending Innes, Regional Indigenous Cancer Lead – North, to better medical school I was a Registered meet the cancer needs of Indigenous peoples across Nurse and Nurse Practitioner, servicing the remote and urban northeastern Ontario. Feel free to contact me at Indigenous communities of northern and eastern Ontario. I [email protected]. attended the University of Ottawa School of Medicine and completed my family medicine residency at the Northern Dr. Erin Peltier MD, CCFP Ontario School of Medicine in 2017. Following my residency Regional Indigenous Cancer Lead - South I was a staff physician at the Weeneebayko Area Health Northeast Regional Cancer Program Authority along the James Bay coast until 2018. I am currently

New Regional Surgical Oncology Lead It is with pleasure that I undertake member starting in November of that year. the appointment of Regional Surgical Oncology Lead with the Northeast My focus in the role of Regional Surgical Oncology Lead will be Regional Cancer Program. on Cancer Care Ontario’s surgical oncology-related initiatives within the region, where I will act as the primary contact. I look I’m originally from Newfoundland forward to working with my colleagues in the region and invite and obtained my MD from Memorial you to contact me at [email protected]. University in 2009. I then completed my residency in general surgery at the University of Ottawa in Dr. James Masters 2014, and my fellowship in thoracic surgery at the University Regional Surgical Oncology Lead of Manitoba in 2016. I’ve been at Health Sciences North since Northeast Regional Cancer Program 2016, first in the Department of Surgery as a surgical assistant and then in the Service of Thoracic Surgery as a full-time NorthNortheast East ONCOLOGY ONCOLOGY News News

Post-Polypectomy Surveillance Recommendations As our skill and technology evolves 2. 3 to 9 adenomas – CCO CCC recommends a repeat in the detection and removal of pre- colonoscopy in 3 years. Some endoscopists experienced malignant lesions in the colon, so must with complex polyp removal may recommend a 5-year our subsequent surveillance. Cancer surveillance if 3-5 diminutive polyps are removed. Care Ontario’s ColonCancerCheck (CCO CCC) program recently completed a 3. >10 adenomas – CCO CCC recommends a clearing review of new evidence and updated its colonoscopy in <1 year. Other major guidelines recommendations for post-polypectomy recommend a repeat in <3 years. Therefore, if an surveillance, which were released in March 2019 (see insert). endoscopist has fully visualized, and is confident in having cleared the colon, then waiting 1-2 years would be It remains true that myriad patient and endoscopist variables reasonable. can influence the quality of any colonoscopy (e.g. prep quality, tortuosity, colonic spasm, etc). Thus, while generally For primary care providers, it is best to follow the most recent endoscopists’ recommendations should align with guidelines, endoscopist’s recommendation. However, the recommendation there will be circumstances when endoscopists may diverge made by the endoscopist at the time of the patient’s previous from the CCO CCC recommendations for acceptable reasons colonoscopy may not reflect more recent knowledge. When I’ve highlighted below: sending a referral to the endoscopist, it is important to include the colonoscopy and pathology reports, if possible. This will 1. 1 to 2 low risk adenomas – CCO CCC recommends fecal allow the consulting endoscopist to review the reports to confirm immunochemical test (FIT) testing 5 years after resection. whether the patient is due for surveillance colonoscopy. The US Multi-Society Task Force guidelines still recommend consulting endoscopist will then determine the best course of colonoscopy 5-10 years after resection. So reasonably, an action. Hopefully these recommendations will allow us to avoid endoscopist could recommend colonoscopy until all major colon cancer while minimizing cost and invasive surveillance. guidelines change to FIT surveillance; although recent data suggests that there may not be good reason to repeat Dr. Scott Shulman MD, FRCPC colonoscopy in less than 10 years. Regional Colorectal Screening/GI Endoscopy Lead Northeast Regional Cancer Program

An Update on Well Follow-Up Care Patients with a cancer diagnosis who for primary care providers to use as a quick reference guide have completed their treatment course when assessing these patients. are returned to their primary care providers for follow-up at various points Cancer Care Ontario’s updated recommendations for the along their cancer journey. This transition delivery of follow-up care for cancer survivors in Ontario is often met with some questions by both are based on expert opinion as well as input from various patients and primary care providers. organizations, including the OMA’s Section on General and Frequently asked questions include: How Family Practice (SGFP). Primary care providers have been often should these patients be seen? Which tests should be identified as being in a position to provide follow-up care to ordered and how frequently? What symptoms are concerning? these patients, when equipped with a clear discharge plan. To help answer these questions and facilitate the transition, This is particularly true for patients in northeastern Ontario, the Northeast Cancer Centre and the Algoma District Cancer who often travel great distances to be seen at a cancer centre. Program had previously made available to primary care With the support of the treating oncologist as well as these providers a series of Well Follow-Up Care Guides concise guidelines, family physicians and nurse practitioners (https://wellfollowup.hsnsudbury.ca). can effectively manage breast, colorectal, and prostate cancer survivors, ensuring that all receive the same quality of care In April 2019, Cancer Care Ontario updated their own regardless of geography. As the primary care needs of patients recommendations on follow-up care for survivors of cancer: are becoming more complex, providers who have access to an EMR may consider adopting the use of encounters and Prostate (www.cancercareontario.ca/prostatefollowup), reminders for this specific population to help facilitate well Breast (www.cancercareontario.ca/breastfollowup), and follow-up care. Colorectal (www.cancercareontario.ca/colorectalfollowup). Dr. Jason Sutherland MD, PhD, CCFP Regional Primary Care Lead In this issue of Northeast Oncology News, there are inserts with Northeast Regional Cancer Program the summary of these recommendations which may be useful Northeast ONCOLOGY News

New Regional Cancer Program Administrative Director It is with pleasure that I undertake the Regional Cancer Program and system level performance and position of Administrative Director with the improvement. Northeast Cancer Centre and Regional Cancer Program. I’m excited to work with a strong and dedicated team both here in the region and provincially, to continue to bring innovation My history with Health Sciences North and quality in cancer care to the Northeast. With the recent spans almost 20 years, beginning as launch of the Ontario Cancer Plan 5, Cancer Care Ontario’s a staff RN in the Nephrology program comprehensive road map of goals, priorities and objectives for leading up to my most recent position as Regional Director improving the cancer system, I also look forward to broader of Nephrology where I was responsible for the North East engagement with our partners throughout the Northeast in Regional Renal Programs and the associated strategic the ongoing work to reduce the risk of developing cancer and initiatives. This was a joint appointment through Health improve outcomes for those affected by cancer. I can be Sciences North and the provincial oversight body for renal care reached at [email protected]. in the province, the Ontario Renal Network. This experience Stephanie Winn has positioned me well for the regional context of the Northeast Administrative Director Northeast Regional Cancer Program

Introduction of Indigenous Engagement Liaison Aanii. My name is Clifton Wassengeso I am looking to utilize my strengths as an educator in this role and I am honoured and privileged to to ensure that our First Nations, Inuit, urban Indigenous and begin a new adventure here as the Métis people have their voices heard and understood. I look Indigenous Engagement Liaison for the forward to continue to promote healthy living and to provide Northeast Regional Cancer Program. meaningful and informative education. But most importantly, I am very much looking forward to I look forward to building and strengthening relationships ensuring that the relationships between amongst my colleagues and all of the organizations and Health Sciences North, the Northeast communities involved in our journey. Contact me anytime at Regional Cancer Program, and the Indigenous, Inuit, Métis and [email protected]. Miigwetch. urban Indigenous communities continue to strengthen as we Clifton Wassengeso move forward. Indigenous Engagement Liaison Northeast Regional Cancer Program

Important Changes to Smokers’ Helpline On October 1, 2019 the Ontario government ended funding for referred person to initiate support. People can also contact the Canadian Cancer Society’s Smokers’ Helpline telephone Telehealth Ontario directly for support at 1-866-797-0000. service and moved to Telehealth Ontario delivering phone cessation support services. While phone support will cease, Smokers’ Helpline will continue to provide digital and text message smoking cessation services. Primary care practitioners can send fax referrals for smoking cessation support to Telehealth Ontario at 1-888-857-6555.  Visit www.hsnsudbury.ca/NECCforms to download a copy Once the fax referral is received, a Care Coach will contact the of the new fax referral form.

NORTH EAST ONCOLOGY NEWS PRODUCTION TEAM Northeast Oncology News is a triannual publication from the Northeast Cancer

Centre providing evidence-based guidance, and clinical and operational Editor: Maureen McLelland Assistant Editor: Dr. Jason Sutherland updates of interest with a focus on primary care in northeastern Ontario. Production Coordinator: Merci Miron-Black Production Assistant: Rhonda Lamothe References used for this issue of Northeast Oncology News are available upon request from the editor. Articles may be reprinted without permission, provided 41 Ramsey Lake Road - Sudbury, ON P3E 5J1 the source is acknowledged. Phone: 705-522-6237 - Fax: 705-671-5496 [email protected] Available online at www.hsnsudbury.ca/NECCprimarycareresources ColonCancerCheck (CCC) Recommendations for Post-Polypectomy Surveillance

Initial colonoscopy Subsequent colonoscopy

Findings Next test1 Time until next test Findings Next test1 Time until next test

No polyps Hyperplastic polyp(s) in rectum FIT* 10 years Not applicable or sigmoid

Low risk adenoma(s)2 FIT* 5 years Not applicable

No polyps, hyperplastic polyp(s) in rectum Colonoscopy 5 years High risk adenoma(s)2 Colonoscopy 3 years or sigmoid, or low risk adenoma High risk adenoma(s) Colonoscopy 3 years

Clearing >10 adenomas ≤1 year <3 years at endoscopist discretion3 colonoscopy3

Any sessile serrated adenoma(s) <10mm Colonoscopy 5 years without dysplasia

Sessile serrated adenoma(s) ≥10 mm Sessile serrated adenoma(s) Colonoscopy 3 years with dysplasia At endoscopist discretion4 Traditional serrated adenoma Colonoscopy to Large sessile polyp removed piecemeal check polypectomy ≤6 months site

Serrated polyposis syndrome2 Colonoscopy 1 year 1-2 years at endoscopist discretion

Notes: *Cancer Care Ontario is planning to replace the fecal occult blood test (FOBT) with the fecal immunochemical test (FIT) in the ColonCancerCheck program for people at average risk of colorectal cancer 1 In cases where the next recommended test is colonoscopy, FIT or flexible sigmoidoscopy is not required between surveillance intervals. 2 See reverse for definitions. 3 People with >10 adenomas should undergo genetic assessment for familial adenomatous polyposis syndromes. The subsequent surveillance interval will depend on the results of the genetic assessment and whether the colon is cleared of polyps. If there is no familial adenomatous polyposis syndrome and after the colon is cleared, surveillance recommendation is colonoscopy in <3 years. 4 Sessile serrated polyps and traditional serrated adenomas require surveillance, but there is currently insufficient evidence to make specific recommendations on subsequent surveillance intervals. Background

• The recall interval following a normal colonoscopy for people with a family history • Clearing colonoscopy: Repeat procedure performed to ensure that all neoplasia of colorectal cancer in a first-degree relative should be based on family history or has been removed from the colon. A clearing colonoscopy is performed earlier surveillance recommendations, whichever interval is shorter. than a surveillance colonoscopy. • The recommendations are adapted from Canadian1 and American2 colonoscopy • Hyperplastic polyp: hyperplastic polyps are very common and usually occur as surveillance guidelines, and informed by an additional systematic review on the diminutive (<5mm) nondysplastic polyps in the rectum and sigmoid colon. These risk of advanced adenomas, colorectal cancer and cancer mortality in people with polyps are not associated with an increased risk of colorectal cancer and are low risk adenomas at initial colonoscopy.3 therefore not considered to be screen-relevant lesions. • The recommendations are based on the size and histology of the most advanced lesion and assume a high-quality colonoscopy (i.e., adequate bowel preparation 1 Leddin D, Enns R, Hilsden R, Fallone C, Rabeneck L, Sadowski D, et al. Colorectal cancer surveillance to detect polyps 5 mm in size, complete procedure to cecum, careful examination after index colonoscopy: guidance from the Canadian Association of Gastroenterology. Can J of the colonic mucosa). Gastroenterol. 2013;27(4):224-8. 2 Lieberman D, Rex D, Winawer S, Giardiello F, Johnson D, Levin T. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143(3):844-57. 3 Dubé C, Yakubu M, McCurdy BR, Lischka A, Koné A, Walker MJ, et al. Risk of advanced adenoma, Glossary colorectal cancer, and colorectal cancer mortality in people with low-risk adenomas at baseline colonoscopy: a systematic review and meta-analysis. Am J Gastroenterol 2017; 112(12):1790-1801. • Low risk adenomas: 1 to 2 tubular adenoma(s) <10mm in diameter with no 4 National Colorectal Cancer Screening Network. Classification of benign polyps. Pathology Working high-grade dysplasia. Group Report. June 2011. 5 Snover D, Ahnen D, Burt R, Odze R. Serrated polyps of the colon and rectum and serrated polyposis. • High risk adenomas (also called advanced adenomas): Tubular adenoma In: Bosman F, Carneiro F, Hruban R, Theise N, editors. WHO classification of tumours of the digestive system. Lyon: IARC; 2010. ≥10mm, 3 or more adenomas, adenoma(s) with villous histology or adenoma with high-grade dysplasia. • Serrated adenomas: Either sessile serrated adenomas (SSA) (also called “sessile For more information and resources: serrated polyps” [SSP] or “sessile serrated adenoma/polyp” [SSA/P]) or traditional Visit: cancercare.on.ca/cccsurveillance serrated adenoma (TSA). Most serrated polyps will not have any dysplasia; Call: 1-866-662-9233 serrated polyps with dysplasia are considered advanced. Traditional serrated adenomas are uncommon and are often protuberant and left-sided. Email: [email protected] • Serrated polyposis syndrome: At least 5 serrated polyps proximal to the sigmoid colon, with 2 or more being >10mm; any number of serrated polyps proximal to the sigmoid colon in someone who has a first-degree relative with serrated polyposis; or 20 or more serrated polyps of any size, but distributed throughout the colon.5

Need this information in an accessible format? 1-855-460-2647, TTY 416-217-1815, [email protected] For an accessible online version, go to cancercareontario.ca/CCCsurveillance What is follow-up care? Follow-up care after the completion of cancer treatment is important to help maintain good health, which consists of activities and processes related to the following major areas: prevention of recurrent and new cancers; surveillance for cancer spread, recurrence, or second cancers; management of the consequences of cancer treatment (e.g., side effects, late effects); and, coordination of care. Surveillance includes monitoring for cancer recurrence or second cancers, and assessing the physical and psychosocial consequences of cancer and its treatment on the survivor. Surveillance should be coordinated and conducted in accordance with evidence-based clinical guidelines. Purpose: The purpose of this guideline summary document is to serve as an informational tool for health professionals who are engaged in the follow-up care of prostate cancer patients who have completed curative-intent treatment and are clinically disease-free. This information is based on a summary of current evidence-based recommendations from provincial and international clinical practice guidelines, existing published literature, and the consensus of provincial cancer experts where evidence is insufficient. These recommendations are not exhaustive nor intended to replace the independent clinical judgement of the treating professional, and should be considered in accordance with available resources and/or individual patient’s needs. Intended patient population: Adult prostate cancer patients who have undergone curative-intent treatment.¹

Prostate Cancer Follow-up Care Surveillance

Recommended Tests Year 1 Year 2 Year 3+

Medical follow-up care appointment:¹ Every 3 months Every 6 months Every 12 months a) Medical history and physical examination where indicated b) Any new and persistent or worsening signs/symptoms to watch for, especially: • Severe and progressive axioskeletal bone pain • Hematuria • New urinary symptoms • Signiﬁcant incontinence requiring changing of undergarments, pads, or diapers • Urgency • Obstructive symptoms • Voiding discomfort • Nocturia • New bowel symptoms • Rectal bleeding • Rectal pain • Urgency • Change in bowel movement • Vague constitutional symptoms such as: • Fatigue • Unexplained weight loss Note: For patients that present with symptoms that could suggest recurrence, a prostate-speciﬁc antigen (PSA) test should be performed and a referral back to the appropriate specialist should be considered. c) Health promotion and disease prevention counselling, including (but not limited to): • Diet, exercise, smoking status, alcohol, sun safety, mental health, sexual health, and other informational needs

Every 3 months Every 6 months Every 12 months a) For patients following curative-intent treatment with surgery*

b) For patients following curative-intent treatment with non-surgery Every 6 months Every 6 months Every 12 months primary therapy (e.g., radiation therapy, cryotherapy, or high- (until the end of intensity focused ultrasound)* year 5, then annually thereafter)

*CAUTION: PSA lab test results:² • PSA lab reports typically ﬂag a PSA value of >4 ng/ml as abnormal, which is considered abnormal and very late in the detection of a recurrence among prostate cancer survivors. Therefore, primary care providers should review the actual values and ensure patients are referred back to the oncologist if any measurable PSA is detected. Prostate Cancer Follow-up Care Surveillance

Recommended Tests (continued)

For patients on androgen deprivation therapy (ADT):³ • Consider annual complete blood count (CBC) to monitor hemoglobin levels, particularly in men presenting with symptoms suggestive of anemia • Assess risk of fracture for men treated with ADT through baseline DEXA (dual energy x-ray absorptiometry) scan and calculation of a FRAX (WHO fracture risk assessment) score

Special Considerations

Digital rectal exam (DRE):² ³ • There is insufficient evidence supporting the DRE, specifically as it relates to the detection of recurrence among prostate cancer survivors. Therefore, primary care providers should discuss and collaborate with prostate cancer specialists to identify those patients who may benefit from routine DREs to optimize the ratio of benefit to physical and psychological harm related to routine DREs in prostate cancer survivors.

• Adults who have a history of pediatric, adolescent, and/or young adult cancers (i.e., diagnosis and treatment prior to age 30) are at increased risk for additional late eﬀects and should also be followed according to the Long-Term Follow-Up Guidelines published by the Children’s Oncology Group

Common Long-term and La

Physical: • Sexual dysfunction (for all treatments) • Erectile dysfunction • Loss of libido • Anorgasmia • Dry ejaculate • Climacturia • Penile shortening or curvature • Infertility • Urinary dysfunction (for those treated with surgery or RT) • Obstructive symptoms • Urgency symptoms • Hematuria • Incontinence requiring urinary pads • Bowel dysfunction (for those treated with RT) • Rectal bleeding • Urgency and frequency symptoms • Other (mostly for those treated with ADT) • Anemia • Body composition alterations • Fatigue (for all treatments) • Gynecomastia/mastodynia • Hot ﬂushes • Bone health

For additional information and resources on symptom and side-eﬀect management, please refer to Cancer Care Ontario’s Symptom Management Guides available at: cancercareontario.ca/en/symptom-management

Psychosocial: • Psychological distress (e.g., depression, anxiety, worry, fear of recurrence) • Cognitive side-effects • Changes in sexual function/fertility • Challenges with body and/or self-image, relationships, and other social role difficulties • Return to work concerns and financial challenges For additional information and resources on psychosocial oncology care management, please refer to Cancer Care Ontario’s Psychosocial Oncology Guides available at: cancercareontario.ca/en/guidelines-advice/modality/psychosocial-oncology-care

References 1. Matthew A, Souter LH, Breau RH, Canil C, Haider M, Jamnicky R, et al. Follow-up care and psychosocial needs of survivors of prostate cancer. Toronto (ON): Cancer Care Ontario; 2015 June 16. Program in Evidence-based Care Guideline No.: 26-4. cancercareontario.ca/en/guidelines- advice/types-of-cancer/266 2. Finelli, T. Personal Communication, January 18, 2019. Ontario Genitourinary Cancer Lead, CCO Genitourinary Cancers Advisory Committee. 3. Resnick MJ, Lacchetti C, Bergman J, Hauke RJ, Hoﬀman KE, Kungel TM, et al. Prostate Cancer Survivorship Care Guideline: American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol 33:1078-1085. ascopubs.org/doi/full/10.1200/JCO.2014.60.2557?url_ ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed 4. Children’s Oncology Group. Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers. Version 5.0; October 2018. survivorshipguidelines.org/pdf/2018/COG_LTFU_Guidelines_v5.pdf

Last updated: April 2019

Need this information in an accessible format? 1-855-460-2647, TTY (416) 217-1815 publicaﬀ[email protected]

CPQ4046

What is follow-up care? Follow-up care after the completion of cancer treatment is important to help maintain good health, which consists of activities and processes related to the following major areas: prevention of recurrent and new cancers; surveillance for cancer spread, recurrence, or second cancers; management of the consequences of cancer treatment (e.g., side effects, late effects); and, coordination of care. Surveillance includes monitoring for cancer recurrence or second cancers, and assessing the physical and psychosocial consequences of cancer and its treatment on the survivor. Surveillance should be coordinated and conducted in accordance with evidence-based clinical guidelines. Purpose: The purpose of this guideline summary document is to serve as an informational tool for health professionals who are engaged in the follow-up care of breast cancer patients who have completed curative-intent treatment and are clinically disease-free. This information is based on a summary of current evidence-based recommendations from provincial and international clinical practice guidelines, existing published literature, and the consensus of provincial cancer experts where evidence is insufficient. These recommendations are not exhaustive nor intended to replace the independent clinical judgement of the treating professional, and should be considered in accordance with available resources and/or individual patient’s needs. Intended patient population: Adult breast cancer survivors who require follow-up care after treatment for breast cancer.¹²⁴

Breast Cancer Follow-up Care Surveillance

Recommended Tests Year 1-3 Year 4+

Medical follow-up care appointment:¹ ³ Every 6-12 months Every 12 months a) Medical history and physical examination where indicated, with a focus on: • Breasts, regional lymph nodes, chest wall, lungs and abdomen • Arms should be examined for lymphedema b) Any new and persistent or worsening signs/symptoms to watch for, especially: • Breast lumps • Mastectomy scar changes • Breast axillary and/or supraclavicular masses/lesions • Bone pain • Cough • Abnormal vaginal bleeding (for women taking tamoxifen) • Vague constitutional symptoms such as: • Fatigue • Unexplained weight loss • Anorexia Note: For patients that present with symptoms that could suggest recurrence, investigations should be performed and a referral back to the appropriate specialist should be considered. c) Health promotion and disease prevention counselling, including (but not limited to): • Diet, exercise, smoking status, alcohol, sun safety, mental health, sexual health, and other informational needs • Patients may also be assessed for other special issues, including: fertility, genetic testing, cardiotoxicity, bone health, musculoskeletal health, pain, and neuropathy⁴

Mammography:¹ ² Every 12 months Every 12 months • All breast cancer survivors without metastatic disease should receive surveillance mammography, unless they have had a bilateral mastectomy • Mammography for surveillance of women who have had breast reconstruction post- mastectomy is not recommended, but there may be a possible beneﬁt in women who have had reconstructions using tissue from another place on their body (i.e., autologous reconstruction), and who have a moderate to high chance of breast cancer occurring again Special Consideratio

Breast magnetic resonance imaging (MRI) for high risk women in Ontario Breast Screening Program (OBSP):¹ • Breast cancer survivors who are thought to be at high risk should be referred to Cancer Care Ontario’s OBSP High Risk Screening Program for assessment of their eligibility to participate in the program. The OBSP screens eligible high risk breast cancer patients with annual breast mammography and MRI (or, if MRI is not medically appropriate, screening breast ultrasound). This kind of testing is based on scientific evidence and ensures that high risk women receive the benefits of organized screening. • Women ages 30 to 69 who meet any of the following criteria may be considered for referral to participate in the High Risk OBSP: • Is known to have a gene mutation (e.g., BRCA1, BRCA2) • Is a first-degree relative (parent, brother, sister or child) of someone who has a gene mutation (e.g., BRCA1, BRCA2) • Has a personal or family history of breast or ovarian cancer • Has had radiation therapy to the chest to treat another cancer or condition (e.g., Hodgkin’s lymphoma) before age 30 and at least 8 years ago For additional information on the OBSP and requisition details, please visit: cancercareontario.ca/en/guidelines-advice/cancer-continuum/screening/breast-cancer high-risk-women

Bone mineral density (BMD): • Screening recommended for patients who are post-menopausal, or are pre-menopausal with risk factors of osteoporosis, or are taking aromatase inhibitors¹³ • Baseline dual-energy x-ray absorptiometry (DEXA) scans should be repeated every 2 years for women taking an aromatase inhibitor, premenopausal women taking tamoxifen and/or a gonadotropin-releasing hormone (GnRH) agonist, and women who have chemotherapy- induced, premature menopause³⁴

Breast self-exam (BSE):¹ • Breast self-examination should be taught to patients who express this preference

Survivors of Childhood, Adolescent, and Young Adult Cancers: • Adults who have a history of pediatric, adolescent, and/or young adult cancers (i.e., diagnosis and treatment prior to age 30) are at increased risk for additional late eﬀects and should also be followed according to the Long-Term Follow-Up Guidelines published by the Children’s Oncology Group

Tests NOT Recommended for Routine Surveilla

• Routine blood tests for certain biomarkers (e.g., CEA, CA15-3, CA27-29) are NOT recommended • Advanced imaging tests (e.g., PET, CT, radionuclide bone scans) are NOT recommended • Routine laboratory and radiographic investigations should NOT be carried out for the purpose of detecting distant metastases

Common Long-term and La

Physical: • Surgery-related: pain, numbness or stiﬀness • Irradiation-related: erythema, swelling, tenderness and skin edema • Lymphedema • Menopausal symptoms associated with systemic therapy For additional information and resources on symptom and side-eﬀect management, please refer to Cancer Care Ontario’s Symptom Management Guides available at: cancercareontario.ca/en/symptom-management

Note: For additional information and resources on breast cancer follow-up care, please refer to the Breast Cancer Survivorship Tool developed by the College of Family Physicians of Canada. References 1. Cancer Care Ontario’s Position on Guidelines for Breast Cancer Well Follow-up Care based on: Grunfeld E, Dhesy S. -Thind, Mark Levine, Clinical practice guidelines for the care and treatment of breast cancer: follow-up after treatment for breast cancer (summary of the 2005 update). CMAJ • 172 (10), 2005. cancercareontario.ca/en/guidelines-advice/types-of-cancer/37786 2. Muradali D, Chiarelli AM, Kennedy EB, Eisen A. Breast Screening for Survivors of Breast Cancer. Toronto (ON): Cancer Care Ontario; 2015 October 27. Program in Evidence-based Care Evidence Summary No.: 15-15. cancercareontario.ca/en/content/breast-screening-survivors-breast-cancer 3. Eisen, A. Personal Communication, February 8, 2019. Ontario Breast Cancer Lead, CCO Breast Cancer Advisory Committee. 4. Runowicz C, Leach C, Henry N, Henry K, Mackay H, Cowen-Alvarado R et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. Journal of Clinical Oncology 34, no. 6 (February 20 2016) 611-635. ascopubs.org/doi/pdf/10.1200/ JCO.2015.64.3809 5. Children’s Oncology Group. Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers. Version 5.0; October 2018. survivorshipguidelines.org/pdf/2018/COG_LTFU_Guidelines_v5.pdf

Last updated: April 2019 Need this information in an accessible format? 1-855-460-2647, TTY (416) 217-1815 publicaff[email protected] CPQ4046 What is follow-up care? Follow-up care after the completion of cancer treatment is important to help maintain good health, which consists of activities and processes related to the following major areas: prevention of recurrent and new cancers; surveillance for cancer spread, recurrence, or second cancers; management of the consequences of cancer treatment (e.g., side effects, late effects); and, coordination of care. Surveillance includes monitoring for cancer recurrence or second cancers, and assessing the physical and psychosocial consequences of cancer and its treatment on the survivor. Surveillance should be coordinated and conducted in accordance with evidence-based clinical guidelines. Purpose: The purpose of this guideline summary document is to serve as an informational tool for health professionals who are engaged in the follow-up care of colorectal cancer patients who have completed curative-intent treatment and are clinically disease-free. This information is based on a summary of current evidence-based recommendations from provincial and international clinical practice guidelines, existing published literature, and the consensus of provincial cancer experts where evidence is insufficient. These recommendations are not exhaustive nor intended to replace the independent clinical judgement of the treating professional, and should be considered in accordance with available resources and/or individual patient’s needs. Intended patient population: Adult patients who have completed primary treatment for stage II or III colorectal cancer cancers and who are without evidence of disease.¹ While there is insufficient evidence to support the inclusion of stage I patients, whether these recommendations can be extrapolated to and can benefit stage I patients is left to the discretion of the healthcare provider.

Colorectal Cancer Follow-up Care Surveillance

Recommended Tests Year 1-3 Year 3-5

Medical follow-up care appointment: Every 6 months Every 6 months a) Medical history and physical examination where indicated b) Any new and persistent or worsening signs/symptoms to watch for, especially: • Abdominal pain • Rectal bleeding • Changes in bowel habit • Vague constitutional symptoms such as: • Fatigue • Nausea • Unexplained weight loss rectal cancer: • Pelvic pain • Sciatica • Diﬃculty with urination or defecation Note: For patients that present with symptoms that could suggest recurrence, investigations should be performed and a referral back to the appropriate specialist should be considered. a) Health promotion and disease prevention counselling, including (but not limited to): • Diet, exercise, smoking status, alcohol, sun safety, mental health, sexual health, and other informational needs

Carcinoembryonic antigen (CEA) blood test: Every 6 months Every 6 months • Assess for rising levels; however, primary care providers should be aware there still may be a recurrence in patients with normal CEA levels

Diagnostic imaging: Every 12 months Not routine • Abdominal / Pelvic / Chest Computed Tomography (CT) Note: Alternatively, if local resources and/or patient preference preclude the use of CT, an ultrasound (US) can be substituted for the CT of the abdomen and pelvis, and a chest x-ray can be substituted for the chest CT. Every six to 12 months for three years and then yearly for years four and ﬁve is considered a reasonable schedule for these tests. Colorectal Cancer Follow-up Care Surveillance

Recommended Tests (continued)

Colonoscopy: • At 1 year following initial surgery OR within 6 months of completing surgery if a complete colonoscopy was not performed pre-operatively • Frequency of subsequent surveillance colonoscopies should be dictated by the ﬁndings of the previous one, but generally should be performed every 5 years, if the ﬁndings of the previous one are normal Note: If a complete colonoscopy was not performed in the course of diagnosis and staging (e.g., due to obstruction) the included guidelines consistently state that one should be done within six months of completing primary therapy Sigmoidoscopy: • For rectal cancer patients who are considered at high risk of local recurrence by the treating physician, sigmoidoscopy may be considered at intervals less than 5 years

Special Considerations

Survivors of Childhood, Adolescent, and Young Adult Cancers: • Adults who have a history of pediatric, adolescent, and young adult cancers (i.e., diagnosis and treatment prior to age 30) are at increased risk for additional late eﬀects and should also be followed according to the Long-Term Follow-Up Guidelines published by the Children’s Oncology Group

Tests NOT Recommended for Routine Surveilla

• A complete blood count (CBC) and other routine blood work, aside from CEA, are NOT recommended • A Fecal Occult Blood Test (FOBT) and Fecal Immunochemical Test (FIT) is NOT recommended

Common Long-term and La

Physical:¹ • Surgery-related: frequent and/or urgent bowel movements or loose bowels (often improves over first few years), gas and/or bloating, incisional hernia, increased risk of bowel obstruction • Medication-related: peripheral neuropathy (associated with treatment using oxaliplatin), chemotherapy-related cognitive side effects (including difficulty with short-term memory and the ability to concentrate) • Radiation-related: localized skin changes (i.e., colour, texture, and loss of hair), rectal ulceration and/or bleeding (radiation colitis), anal dysfunction (incontinence), bowel obstruction (from unintended small bowel scarring), infertility, sexuality dysfunction (e.g., vaginal dryness, erectile dysfunction, retrograde ejaculation), second primary cancers in the radiation field (typically about seven years after radiotherapy), bone fracture (e.g., sacral region • Other: for patients who received ostomy, stoma care and life-style adjustments will be required For additional information and resources on symptom and side-effect management, please refer to Cancer Care Ontario’s Symptom Management Guides available at: cancercareontario.ca/en/symptom-management

For additional information and resources on ostomy care and management, please refer to applicable sources such as Ostomy Canada Society available at: ostomycanada.ca/information/ostomy-care-2/

Psychosocial:² • Psychological distress (e.g., depression, anxiety, worry, fear of recurrence) • Cognitive side-effects • Changes in sexual function/fertility • Challenges with body and/or self-image, relationships, and other social role difficulties • Return to work concerns and financial challenges For additional information and resources on psychosocial oncology care management, please refer to Cancer Care Ontario’s Psychosocial Oncology Guides available at: cancercareontario.ca/en/guidelines-advice/modality/psychosocial-oncology-care

References 1. Members of the Colorectal Cancer Survivorship Group. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer. Toronto (ON): Cancer Care Ontario; 2012 Feb 3. Program in Evidence-based Care Evidence-Based Series No.: 26-2 Version 2. cancercareontario.ca/en/guidelines-advice/types-of-cancer/256 2. El-Shami K, Oeﬃnger KC, Erb NL, Willis A, Bretsch JK, Pratt-Chapman ML et al, American Cancer Society Colorectal Cancer Survivorship Care Guidelines. CA Cancer J Clin 2015;65:427–455.VC 2015 American Cancer Society. onlinelibrary.wiley.com/doi/epdf/10.3322/caac.21286 3. Children’s Oncology Group. Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers. Version 5.0; October 2018. survivorshipguidelines.org/pdf/2018/COG_LTFU_Guidelines_v5.pdf

Last updated: April 2019

Need this information in an accessible format? 1-855-460-2647, TTY (416) 217-1815 publicaﬀ[email protected]

CPQ4046