Cancer Survivorship

Colin

I'm happy to introduce Karla Wilson as our guest for this episode Karla is a nurse practitioner who has more than 45 years of experience in pediatric oncology and in the last fifteen years has experience working with.

 

Dustin 

As push.

 

Colin

Childhood and adolescent young adult cancer survivorship programs. So welcome Carla um wanted to have you just tell us about your work in research.

 

Karla

Thank you Colin.

Karla

All right I'm happy to do that I work at the City of Hope in Duarte California and we have a very robust clinical research program where we actually screen childhood. Adolescent young adult cancer survivors for potential late effects of their cancer treatment. Um, it is a clinical research program. So patients who come to our clinic end up enrolling in ah in this study we collect data to help us have a better understanding. What's happening with cancer survivors. Both the good and the bad we need to have that type of knowledge. So that changes can be made to improve quality of life because ultimately when we treat people with cancer. Our goal is give is to give them. The least amount of therapy to give the greatest cure rate with the least amount of long-term late effects since we've had such an increase in cancer survivorship in both the pediatric and young adult population over the last 40 years our focus has changed not just from how do we cure people. But how do we cure them well and so there's been a lot of attention paid to what happens to survivors when they're you know several years off therapy when they're.

Karla

10 years off therapy 20 years off therapy 40 years off therapy et cetera so we have a very um, active component in the children's oncology group and that is the long-term survivorship our late effects committee where lots of professionals physicians researchers.

 

Karla

Psychologists nurse practitioners social workers et cetera all work together to look at the literature to look at the evidence that's published look at the research that's been published because sometimes we don't have research. We only have evidence to look at and so how do we screen people. What are the side effects that we see that people have and so from that we have a development of something called the children's oncology group long-term follow-up guidelines that first came out in 2003 as a very kind of I'll call it a. Ah.

 

Karla

Very brief kind of overview and things to look at and through time that has become very robust and I call it our recipe book. It's what we look at to screen patients So when a patient comes to our survivorship program and survivorship programs throughout the Country. Do. Things in similar ways. We give a patient a copy of their treatment summary that is very personalized to them. You were treated for this Cancer. You had these? um you know, whatever stage if it's a cancer that staged. Um. You receive this protocol to treat your cancer. You receive these chemotherapy agents to treat your cancer. We know that this chemotherapy has the potential to cause this problem down the road. We know that this chemotherapy that we don't have any evidence that there are any long term. Um. Side effects from that Chemotherapy So then based on the patient's individual treatment and we actually call it treatment exposures. We then say you had this with our current knowledge level. We need to do this. So for an example would be you had chemotherapy that included. A chemotherapy agent called Doxorubicin That's in a category of of chemotherapy agents referred to as anthracyclines we know that anthracyclines can impact your heart Function. We also know that the the risk of it impacting your heart function is based on the dose.

Karla

So if you had very low dose. You don't need very frequent screening if you had high dose you need to be screened every two years and the reason for that screening is if you're starting to develop a problem we want to find that problem early and intervene hopefully prevent that problem from worsening and so that's one of the reasons that we do screening. We want to catch anything that's happening that's going to be negative to find it early intervene early and usually in early intervention. Appropriate intervention and continuing monitoring puts the patient at a lower risk of that problem escalating and causing them more severe issues. We also like to be able to tell patients what's reality and what's myth. Are so many myths out there and sometimes I'm truly amazed at what patients tell me that they have either been told or what their perception is of something that has been told and a good example of that is related to fertility. I have so many patients who come in and tell me that they were told they'd never be able to have children because they had cancer and they had cancer treatment. So now that they're infertile. Well we know which chemotherapies and which radiations put a person at risk for infertility. We also know.

 

Karla

It's also ghosts Related. So I have patients who told me that they're infertile and they're never going to be able to have children and they actually had no treatment that puts on them at any greater risk of having infertility than what occurs in the general population and so we want to give them that accurate Information. You know you. You know there's we don't want them to to go through life thinking a certain thing when that isn't accurate and I will be honest I've had a lot of patients who end up having unplanned pregnancies because they thought that they were infertile and so. We give them that information we dispel that myth Now. Sadly, there are many patients that do have treatment that can cause infertility and we give them that information as well and we tell them what interventions can potentially help with that. For example, there's a. Category of Chemotherapy agents called aalating agents and that includes things like Cycloposphamide. Um I Phummide etc. We also know that the risk of infertility is based on the dose that they received. We also know that. When patients have those chemotherapy agents the female patients that is they are at greater risk of going into premature Menopause meaning they'll go into Menopause younger than the age of 38 So for for women who had high dose ocalating agent chemotherapy.

 

Karla

If they are in their twenty s and they haven't gone through Menopause We always suggest that they have an evaluation by a fertility specialist to see what their risk is of developing premature Menopause and so early intervention I've had. Female patients in their twenty s who got checked out. They still had fertility but it was so significantly lower than the fertility you would anticipate for someone of their age and part of that How they're looking at that is there's a. Thing that can be done such as high resolution ultrasounds of the ovaries that can tell you how many eggs are in in the ovaries or the follicles that are in the ovaries. Um, so there is so if you have someone who doesn't have the amount of of um.

 

Karla

Eggs that you would anticipate for their age then they can have discussions about. Do they want to do an egg harvest if they you know want to aren't at a prey point in their life that they want to have children but they might want to have children down the road. So It's ah also about just giving options knowing information. And then giving options about what you can do with that information. You've been towed.

 

Dustin 

Karla. So what drew you to participate in this kind of work and research.

 

Karla

I think a lot of different things. Did I started out working in pediatric oncology in the 1970 s when the cure rate was relatively low and throughout my career. Um I was a bedside nurse. For 10 years before I became a nurse practitioner and I've seen so much happen in the field of pediatric oncology some of the older survivors can appreciate some of these things I started out in the days when we did not have iv pumps. We did not have central lines. Um, we did not have good medicines to give conscious sedation for doing painful procedures and as time went on and technology changed and we had so many improvements one of the biggest things that I thought was a fabulous improvement was when we had. The access to good anti-nausea medicines and that revolutionized people's ability to tolerate. You know their therapy things like colony stimulating factors that helped the white count to recover quicker and allowed us to give more therapy. Um. Having good um screening tools such as ct scans and mri scans when I started out in pediatric oncology. There was one ct scan in the state I lived in and now every hospital in the country has more than one ct scan.

 

Karla

And mri scans didn't come out until the mid 80 s central lines came out pretty much in the late 70 s and early eighty s and that really revolutionized the comfort level for patients getting therapy. So I saw so I've been on that whole continuum. For a long time I subspecialize in working with kids with neural tumors. So brain tumors neuroblastoma things like like that I also specialized in pain management and end of life care and as we have more and more survivors and i'm. Going through my own trajectory of being a pediatric oncology nurse. It's like what's that next step and so in 2006 when I was asked to join this newly developed program at city of hope that was going to be a clinical research program looking at issues for survivors I thought it was just. Kind of a good way to continue in my own growth as a professional working with patients who had been treated for cancer. We initially had our program patients. We follow the classic age that. Childhood cancers for anyone who was diagnosed prior to the age of 22 then in the last probably ten to fifteen years there became a big focus on what was called the a y a movement and that's adolescent young adult.

 

Karla

And that is for people who were diagnosed prior to the age of 40 and so our program decided to include patients who had pediatric types of tumors such as leukemia lymphoma certain types of germ cell tumors brain tumors et cetera. Oh and the other big one in that age group is. Soft tissue sarcomas and bone tumors so we started seeing those patients and screening them so our program now screens patients for late effects of treatment if they were diagnosed prior to the age of 40 so we're probably the only place in the country that has that aya component. As part of a childhood cancer survivorship program and so it's kind of I have to be honest as a professional working with pediatric pediatric oncology patients and I started in the 70 s when if you lumped all pediatric oncology patients into one category. There was about a 20 to 25% survivorship now. It's an 80% survivorship for that same population of patients are the most common type of leukemia that occurs in children. The cure rate is over 90 um, so I've seen these huge. Increases in people being cured and so now as as I'm coming towards the end of my professional career being able to work with survivors being able to see all of the wonderful things that have happened for these people and I still call them kids even though they're.

 

Karla

Many of them are now young adults and even older um seeing that what they made of their life. What a cure did for them and being able to give people information that helps them become better advocates for their own general health long term and so. I think that's I look at survivorship as being part of the entire package of pediatric and aya cancer. It's just it's part of the continuum and I'm been so fortunate and so blessed to be able to to see. All of the things and all the improvements and all of the the good that has come out of the treatments and how many people have not only survived they've thrived they've become adult professionals. They have families. Now we have childhood cancer survivors. Not only do they have grandchildren some of them have great grandchildren because we have people who are in their late sixty s and early mid 70 s who are actually childhood cancer survivors and it's been such a rewarding part of my career to see. All of the positive things that have happened in these people who have survived and what many survivors have done There's an amazing amount of survivors that have gone into health care related fields. There are amazing number of survivors that have.

 

Karla

Become advocates for fundraising. For research we have many patients who tell us that they come to our clinical research program. Not just to learn about things related to themselves but they feel it's a way of giving back and that can help. Further the improvements that come in the treatment of childhood and Ai cancers.

 

Colin

I absolutely I love that. Karla I wanted to have you ah, perhaps maybe speak to late effects or ah long-term side effects for survivors that you've seen in the survivorship clinic.

 

Karla

Yes, and right before I start speaking of that I think I want to add 1 other thing to what you were asking about the work in research and I mentioned how many cancer survivors become some type of health care professional or researcher. It's not only the survivors. It's the siblings and sometimes even the parents have gone back and done a second career in a healthcare related field. So I think that's another important part of survivorship care. What's happening to the family members of the patient. So now I'll switch in and and answer the current question. Um.

 

Karla

We've learned a lot about late effects over the last you know thirty five 40 years and particularly in the last twenty some years we know for many of the chemotherapy agents if you receive this chemotherapy it puts you at risk for this particular side effect. We've also learned that some of the side effects. Are not just that you had the chemotherapy agent but the side effect might be based on what was the dose you received might be the the dose at the single administration or it might be the cumulative dose of that chemotherapy over long term. So when we think about side effects we can really kind of categorize them into into multiple areas so we look at what are treatments that could impact cognitive function when we know that people who receive something called intrathecal methotrexate. And for all those patients with. Leukemia and non-hodgkin's Lymphoma. You're probably very familiar with this. You may not know it was called intrathecal but what it means is that you received chemotherapy with the um.

 

Karla

Chemotherapy Agent called methottrexate and it was delivered directly into your spinal fluid by doing a spinal tap. So We know that people who had Inttraino methotrexate may have some executive functioning issues. Might be related to speed of processing. It might be related to math comprehension et cetera and again I think one of the things That's so important to remember about late effects. It's risk just because you have a risk for something doesn't mean you will develop the problem. And as I mentioned there are the other things that might affect cognitive Cognitive Function Chemotherapy called high dose methottruxate or high dose cyerbinene can affect cognitive function. The worst treatment that potentially can affect cognitive. Cognitive function is cranial radiation and again the risk of the cranial radiation affecting cognitive function is based on the age that the child received it as well as the dose they received and. Also once their entire brain radiated are just the area where the tumor was so we know that there are a lot of factors that contribute to contribute to the actual risk a patient may have from that type of radiation. We know that anthropcycling chemotherapy which I mentioned earlier.

Karla

Put you at risk for heart related problems. We also know that that risk is based on dose the cumulative dose. We used to think that it was also based on the age the child received the first dose. We now know that the age doesn't matter. It's only the cumulative dose that matters somebody who had a very low cumulative dose is at lower risk of developing the heart problem patients who had high dose are at higher risk so our screening for heart related issues is based on the dose if you were low dose. You were so you're screened every two years I'm sorry sorry you're screened every five years if you're high dose. You're screened every 2 years and if we find an abnormality and this screening is primarily done by echocardiograms if we find an abnormality. Depending upon the abnormality we would refer you to a cardiologist and the screening might change based on what the cardiologist feels is appropriate screening if you do have an issue we know chest radiation can affect your heart as well. And so. Depending upon the dose of chest radiation depends again on the frequency that we would screen your heart. We know as I mentioned earlier too that alcalating agents may affect your potential fertility again. The cumulative dose.

 

Karla

Is important high cumulative dose puts you at greater risk low cumulative dose puts you at lower risk. This is a late effect though that is also related to whether you're a male or a female females who receive. Alcalator Chemotherapy if they are prior to puberty. They can actually tolerate a much higher dose before it impacts their potential fertility males. It doesn't seem to matter how old they are when they received alccolating chemotherapy their risk tends to be the same based. Just on the Dose. So This is a situation again. Female versus male does make a difference on on a risk for a particular problem occurring there are you know if you have radiation to an extremity are. Your spinal area that can affect your growth. It can affect your overall height things like that Chemotherapy doesn't impact your overall growth. Radiation Therapy can affect your ah overall growth depending what area of the body was radiated indocrine. Late effects are another problem and we it might be if you had radiation that affected your Thyroid Gland or you had radiation to the brain that affects the pituitary Gland you might have thyroid issues. Yeah, you might have growth hormone issues if you had radiation that hit your pituitary Gland Um, So we also know.

 

Karla

Area radiated dose that you're given again impacts your risk for particular late effects. Um, then other issues are pulmonary. There are a couple of chemotherapy agents that can affect your lung function radiation to the chest can affect your lung function. So we typically as a baseline will do pulmonary function test and depending upon what we find on that test depend will impact what we recommend that is done so again getting the knowledge of where you're at. Can be very helpful to tell you what direction you need to go for continued monitoring and screening certain chemotherapies can affect your bone health. Um, we know that steroids can cause something called avascular necrosis where you have. Deterioration to the bone within a joint and the classic ones that really tend to get affected are your your femur. So your large like bone in your upper leg the top of that bone becomes kind of flat and raggedy and so it doesn't move well within the hip joint. Same thing can happen in the shoulder joint. It can happen in the knees. Those are the most common bones affected then the other thing that can happen is that your bone density decreases and you can develop something called Osteopenia which is premature thinning of the bones.

 

Karla

You going to develop osteoporosis which is a more severe farm and if you have thinner bones than what you should have that puts you at greater risk for having a fracture and people tend to know about Osteopenia and osteoporosis. When you think about the elderly particularly postmenopon so women. That's when you tend to be at greatest risk for that developing it can occur at a younger age if you've had certain chemotherapy agents particularly again steroids and then actually methyltrexate are the the big ones. So. We've learned a lot.. What's your risk what agents what treatment affects what different organs so you may if you had something that can impact your liver. We look at what's your liver function is your liver function healthy if you had therapy that can affect your kidneys is your Kidney function normal. Is it healthy. What are things you can do to continue to have good liver health and good Kidney Health as you age and so when we look at Chemotherapy agents and radiation. We really look at what organs do they affect and what. Is the risk factor for the individual patient and again based on their treatment exposures then we can tell them this is what you need to have screened This is how often you need to have the screening and go forward.

 

Karla

Forward from there as far as what we're going to recommend that they do if a problem is found.

 

Karla

See oh and then the other thing that kind of falls into that late effect component that I didn't mention at all and it's extremely important are issues related to um your psychiatric function.

 

Karla

Do you have issues with depression. Do you have issues with anxiety. Do you have issues with fatigue and chronic fatigue can be um, a huge problem for many people. Do you have issues with residual pain. Did you have a bone tumor and you have a limb salvage procedure and. Your joint isn't functioning quite like it should be as far as compared to your normal or did you have an amputation and you have problems with your prosthesis and how your amputated extremity fits into the prosthesis.

 

Dustin 

Wow.

 

Karla

Many people tell me I want me to stop there. Okay, many people tell me that they start getting anxious a few days before they have to come to the clinic and they remain anxious until they get all their test results back.

 

Dustin 

Oh no I just said wow.

 

Karla

Um, so I personally feel it's imperative that we communicate with patients as rapidly as possible as soon as we get the test results back and I have patients who tell me when I call them with with their say their their breast cancer screening result or. You know their echocardiogram or whatever they say? Oh now I have a huge sigh of relief and I don't have to worry until the next time. Um, so I think having that knowledge can really help people I have a lot of patients who will come into the clinic and their blood pressure is high higher than it should be for their age and their. General health condition and they'll say when I go to my primary care doctor. My breast. My blood pressure is normal. It's only when I come here that it's elevated and it's because there's a certain degree of anxiety about am I going to get bad news or sometimes it's because it brings back the memories of going through the treatment. Have a young woman that I see who actually had leukemia as an infant and she was actually in the days before we had central lines so all of her therapy was related through ivy sticks in her extremities. She tells me. And actually I shouldn't say she's actually not just a young woman anymore. She's now in her 40 s she tells me she remembers nothing about her cancer treatment because it was done by the time she was eighteen months old but she has horrible needle phobia and I'm sure that Needophobia is related to.

 

Karla

All of the needle sticks that she had while in their treatment and even though she doesn't remember the actual treatment. There's something in her her brain that makes her afraid of needles and I'm I'm 100 % sure that it's related to that treatment. So sometimes people will. Not realize they have a problem or they can't express it and so it's part of our clinic. The first time a patient comes we offer them an assessment by a psychologist and then depending upon. What they feel what the psychologist feels et cetera and we might recommend that they get counseling or therapy or follow them up in another year or so to see if things are still going. Okay, we do have patients with cognitive issues as I mentioned. And we offer them neuropsych testing so they can get an assessment of how they learn what are their strengths and weaknesses in their learning. What are strategies that they can use to help use their strengths to compensate for some of their weaknesses. So we don't want to just screen people and say hey you have this you have that we want to screen people and then give them the information needed to address the problem that has been found.

 

Dustin 

Okay, um I am curious how prevalent are secondary cancers and reoccurrences.

 

Karla

That's a really good question and I can't give you total data but I will give you general information for most people, the incidence of relapse for people with leukemia and lymphoma is within the first couple of years

 

Dustin 

Okay.

 

Karla

Of coming off therapy and it's actually a very low incidence and it depends on on the type of tumor someone with Hodgkin's disease the relapse might be a year or two later usually with leukemia less than 5 to 10 percent of people will relapse. Um.

 

Karla

When they are off therapy and it's usually the first year out the longer you go the less likely you are to have relapse and what are your risk of secondary cancers part of it's dependent upon your treatment if you had radiation. There's a pretty high risk of developing skin cancer. If you had radiation that hit your thyroid gland you have a higher risk of developing thyroid cancer than someone who did not have radiation just because you had this treatment does it mean you're going to develop those issues. No, but realistically, you do have a greater incidence than the general population. Women who receive receive chest radiation have a much greater incidence of developing breast cancer within um, probably twenty years thirty years of their treatment so developing breast cancer at a much younger age than what you. Think of as the average age of someone developing breast cancer. Um from kind of a general statement about 1 in 8 women will develop breast cancer in their lifespan or their life span.

 

Karla

Let me say that over 1 in 8 women will develop breast cancer within their lifespan if a woman has had radiation to their chest 1 in 3 women will develop breast cancer within their lifespan and that's why we start breast cancer screening. At age Twenty five or eight years after the radiation was done in those women women who did not have radiation to their chest to our current knowledge are not at greater risk of developing breast cancer than the general population. So. We know certain things are put you at risk and when something is going to put you at risk we do screening if you did not receive treatment that puts you at risk for developing breast cancer. There's no need to start screening earlier than. The general population which is recommended at age 40 now I'm taking into account. We're not discussing whether there's a genetic predisposition certainly if a patient has a genetic predisposition. Things might be recommended, differently. There are certain types of of syndromes that put people at greater risk for cancers. So if somebody has something called neuro fiberromatosis they're at greater risk for developing a cancer than someone who doesn't have Neuro fibromatosis um retin noblastoma which is a cancer of the retina of the eye.

Karla

If your parent had retinoblastoma. You have a greater chance of developing that now that's a tumor that occurs in infants and preschoolers primarily. So if you have a child who you are a survivor of retinoblastoma and you have a child that child's gonna get screened for. With good eye exams to make sure that they don't develop Retinoplastoma or I shouldn't say don't don't develop it but that if they do develop it intervention occurs early so it really kind of There's a lot of factors into. The risk of secondary cancers and most reoccurrences occur early, but nothing's written in stone I've had patients who have relapsed 20 years out not unheard of but it's rare. So. Think it's important to know for people to know potential risk factors. We know that people with leukemia again the most common in time of relapse is while on initial treatment are within a year or so of finishing treatment the further out the less likely. Um, in fact, this children's oncology group long-term follow-up guidelines say that there's the incidence of of recurrence is so low that we don't need to do routine cbcs once they come to survivorship clinic because they're.

Karla

Incidence of relapses very very low not 0 because nothing 0

 

Colin

Yeah, well Karla I wanted to ask if you ah could speak a little bit to the maybe recommendations for preventative care I was certainly hearing that you were starting to talk about just like normal screenings and other things that would be helpful for for those ah who are survivors so I just wanted to. Perhaps have you ah speak to that.

Karla

Okay, so if a person has a risk factor because of their treatment then they're going to start screening early and I already mentioned breast cancer women start screening um either at age Twenty five or eight years after their radiation treatment. Colon cancer screening for people had radiation to their gi tract starts at age thirty or five years after radiation if you did not have those treatments you follow the normal screening practices normal screening for the general population. Women is for breast cancer is starting at age 40 for Colon Cancer it actually used to be age 50 for the general population that has decreased to age 45 and so I believe like prostate cancer screening is age 50 for men. So. Whatever the general health screening guidelines are is what we recommend to people who do not have a treatment that puts them at a particular risk for those early screenings now skin cancer screening. Based on again radiation so people who had radiation need to be checking their skin and I frequently. Do recommend people who have total body radiation. They might want to have a yearly appointment with a dermatologist to do a full skin cancer screening. Um.

Karla

But people who had a history of sunburns as children. They might also need to start screening early for skin cancer with a dermatologist. Um, so it's It's very individualized based on your history. Now if you have in a family member who had colon cancer and there's been a genetic evaluation Even if you didn't have um radiation to your Gi track you might need to start Colon Cancer screening. But that's based on. Recommendations from a genetic counselor and it's only if you have that gene if your family member has the gene and then you get tested and you have the gene that's going to impact screening. But in general, many cancer survivors. Just. Get the screening done for the average population meaning people who have not had cancer treatment. But again, it's very specific based on what your cancer treatment was as to what screenings you should start and when.

 

Colin

And I imagine this question is going to have maybe the same flavoring here but I was just curious if you could speak to maybe some multiple cultural issues. You know I'm hearing that really the survivorship clinic is going to be looking at individualized treatment and care. And what that means for the patient in the clinic but just wanted to have you maybe speak to that as well.

Karla

Yeah, if we can look at multicultural issues in a lot of ways and if you're in the healthcare world. 1 of the big things that's really been being looked at in the last several years is access to care are people who are of different ethnicities not having the same access to care. Um, and that's a whole another area and it's not just related to survivorship. It's just it's related to health care for the general population. But when I look at multicultural issues and survivorship I look at a couple of different things. We always ask people what their ethnicity is. And the reason it's important to know ethnicities certain ethnic populations may be at greater risk for certain types of um issues. So for example, people of indian heritage and what I mean India the continent of India. They tend to have a higher incidence of having issues with cholesterol particularly with something called the triglycerides people who are of Hispanic Heritage might be at greater risk for developing gallbladder disease at a younger age. People who are of African-american Heritage might be at greater risk for hypertension. Um certain ethnic populations are at greater risk potentially for things like diabetes so knowing ethnicity as well as.

Karla

And when I look at the cultural area I look at the family culture families. Do you have a lot of people in your family who've had heart Disease. Do you have a lot of people in your family who have diabetes um, particularly type 2 but diabetes. Do you have a lot of people in your family that have high blood pressure. Do you have people have Kidney Disease. So. It's really important to know that family history as well because you might be at Greater risk for a problem related to your your family history than you are related to your cancer treatment History. So It's really helpful to kind of. For a health care provider to also read the literature about what cultural issues might impact screening um for patients in survivorship. So just because somebody is whatever ethnic or cultural Race. It. It might mean they need this screening a little bit differently than someone who's of a different cultural race. But in survivorship we we really screen based on the treatment exposures but knowing what multicultural types of of risk Factors. You might have. Can be taken into account when you're thinking of screening as well as far as what it you might recommend to the patient What you recommend to the patient regarding diet and exercise all of those things are so important it would be life would be so much easier if none of us had risk factors for anything.

Karla

But in reality all of us have potential risk factors and when you look at your your basic risk factor based on your family history and now you add on that you had a treatment that also increases your risk factor for a particular disease. So for example. If you have a strong family history of type 2 diabetes and then you had total body radiation that increases your risk of developing type 2 diabetes because of the radiation. But if you have a family history sometimes it's kind of like 1 plus one equals 3 so if you're got a risk factor based on your culture or your are your family history and now you have treatment. Maybe your risk factor is going to be escalated and so it becomes even more important that you try to have. Good healthy lifestyle practices like exercise healthy diet making sure you have omega 3 s and fiber and lots of fruits and vegetables. Um and things like that in your diet to decrease the chance of those diseases coming out.

Karla

And I'm not quite sure if I really answered your question there.

 

Dustin

Like that sounds like a good answer to me Karla yeah I mean there's a lot of different risk factors associated with different ethnic groups which I think you kind of answered.

Karla

Yeah, and I'm sure as ah, a nutritionist Dustin you see a lot of that.

 

Dustin 

Ah, yeah, and I also see a ah bit of resistance to share that information as well. Um, for just I guess personal reasons people just want to be treated the same um and they go ahead.

Karla

You know? and ah I agree with that.

 

Dustin 

Yeah I Guess there's like less awareness around some of the research that's out there for different ethnic groups have different health risks that you know we have to screen for.

Karla

Yes, I Actually sometimes I'll have a very occasionally I'll have a patient to say why do you care? what race I am and then and I so I when I've had people ask me that I tried to make sure now that when I'm seeing a new patient that I upfront say.

 

 

Karla

Really like to know what your ethnicity is because there are certain things that put you at greater risk based on your ethnicity or your family history and that's why it's so important to have that as part of your medical record because it tells us you know you might be at greater risk because of this ethnic or family history.

Karla

And it's not just related to the cancer treatment as to what your risk factor is.

 

Dustin 

As a cancer survivor what type of long-term screening do I need and how does my past cancer treatment History impact Normal Health screenings. This is just like a general ah question for our listeners I I feel like you did touch on some of this. But. Maybe you could go into it. Ah um, in more depth. Um, you know age or any other factors that might be related.

Karla

Sure. Okay, so as I said we now have the long-term follow-up guidelines to the children's on technology group and that really directs us into what screening is needed so before. Ever see a patient in our clinic prior to them coming to the clinic and develop a comprehensive treatment summary that says you had this disease you had this treatment based on the treatment you had. We know that we need to screen you if you had anthrocyclines we'll screen your heart if you had. Steroids and methytrexate we will screen your bone density if you had radiation that hit your thyroid gland we will screen your thyid function testing if you had total body radiation or radiation that out to your abdomen. We're gonna screen you for diabetes and for cholesterol issues and we're gonna start those screenings now if you had breast are sorry if you had chest radiation in your female we will start your breast cancer screening when you're 25 we will start at 8 years if you happen to be 20 when you had chest radiation will wait till your age 28 so we screen for 8 years after the radiation our age 25 whatever occurs last and now that we see um.

Karla

Patients who are diagnosed up to the age of of 39 we look at just when we have patients who are diagnosed at 22 onward. We start that breast cancer screening 8 years after um colon cancer screenings the same way. We only screen for colon cancer if you had radiation that affects your gi tract that starts at age thirty or five years after the radiation. So for both of those diseases for the general population are for patients who had cancer treatment but didn't have. A treatment that puts them at greater risk they start colon cancer screening at age 45 and breast cancer screening at age forty so they get the normal general population based screening if they're cancer treatment. Did not put them at risk for developing it at a younger age bone density in our clinic we screen patients who are at risk for premature thinning of the bones at age 18 the general population is usually around 50 for bone. Um, density screening. So again, you're going to start that at a much earlier age if you have treatment that puts you at risk if you didn't have treatment that puts you at risk again, you would start that screening at the same time as the general population.

Karla

I'm trying to think what other screenings that are done for the general population. Those are the big ones breast cancer colon cancer and bone density also prostate cancer screening and and males. 1 ne's a little bit different I in general the screening just starts at the normal age and those are developed by those age ranges are developed by the United States preventive task force and their recommendations of of screening for the general population. Ah, so everything is again screening based on your treatment exposures starts at a specific time based on the recommendations through the children's oncology group and we were pretty um.

Karla

Dedicated to following the children's oncology group screening now. Obviously ah if I saw a patient and as part of her physical exam I did ah a breast exam on her and I find something on the Exam. We're not going to wait till she turns 25 to do that breast Cancer screening. So Of course you take in what are the patient's current symptoms as well.

 

Colin

I think I just wanted to thank Karla for her expertise and and willing to then share her work and research at the survivorship clinic and city of hope. So. Thank you so much for for being able to. Ah. You know, shared that ah wealth of knowledge that do you have.

Karla

Well thank you very much for asking me and kind of off the record could I put in a plug for our program or or would that not be appropriate for your podcast.

 

Colin

Sure.

Colin

Um, would we typically have ah the ah link with ah the survivorship like website. Um, so we we haven't done things in the podcast. Um, and.

 

Karla

Is.

 

Colin

Yeah I think maybe we just hope we'll have it as a link for don't all right? Oh I can go ahead and stop recording now then.

Karla

That's perfect. All right, all right? and I'm.