What’s New in Primary Care? An Update for Myeloma Survivors

1. What’s New in Primary Care?An Update for Myeloma Survivors Ann M. Maguire, MD, MPH Clinical Associate Professor Department of Medicine September 13, 2014

2. 2014 Updates in Primary Care • Bone Health • Cardiovascular Risk • Vaccines • Screening

3. Estimated Number of Cancer Survivors in the US from 1975 to 2012 [Estimations and modeling provided by Angela Mariotto, PhD, based on: Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28. Epub 2011 Jan 12

4. Estimated Number of Cancer Survivors in the U.S. by Site January 1, 2012 by Site N=13.7 M Survivors) Estimations and modeling provided by Angela Mariotto, PhD, based on: Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28. Epub 2011 Jan 12.

5. Estimated Number of Cancer Survivors by Current Age January 1, 2012 by Site N=13.7 M Survivors) Estimations and modeling provided by Angela Mariotto, PhD, based on: Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28. Epub 2011 Jan 12.

6. Myeloma Therapies • Melphalan/ Alkeran • Cyclophosphamide/ Cytoxan  • Anthracyclines: Doxorubicin/ Adriamycin* • Bortezomib/ Velcade • Carfilzomib/ Kyprolis • Thalidomide/ Thalomid* • Pomalidomide/ Pomalyst* • Lenalidomide/ Revlimid* • Steroids: Prednisone, Dexamethasone* * Denotes Therapy with significant impact on comorbid medical conditions

7. Drug-Disease Interactions • Myeloma has impact on risk for systemic disease: • All patients have increased risk for Clotting • All patients have increased risk for Fractures • Myeloma therapies have side effects that may increase risk for some complications: • Thalidomide Analogs increase risk of clotting • Steroids increase risk for osteoporosis and fractures • Anthracyclines can cause injury to the heart muscle • Drug therapy can reduce but not eliminate these risks: • Aspirin reduces risk of clotting. • Bisphosphonate Drugs prevent Osteoporotic fractures

8. Osteoporosis and Bone Disease • Myeloma is a single clone of plasma cells producing a monoclonal immunoglobulin. • This clone of plasma cells proliferates in the bone marrow and often results in extensive skeletal destruction with osteolytic lesions, osteopenia, and/or pathologic fractures. • Steroids used to treat Myeloma also have a negative effect on bone health.

11. What can I do to keep my bones as healthy as possible? • Eat foods with a lot of calcium, such as milk, yogurt, and green leafy vegetables • Eat foods with a lot of vitamin D, such as milk that has vitamin D added, and fish from the ocean • Take calcium and vitamin D pills (if you do not get enough from the food that you eat) • Be active for at least 30 minutes, most days of the week • Avoid smoking • Limit the amount of alcohol you drink to 1 to 2 drinks a day at most

13. Do your best to keep from falling! • Make sure all your rugs have a no-slip backing to keep them in place • Tuck away any electrical cords, so they are not in your way • Light all walkways well • Watch out for slippery floors • Wear sturdy, comfortable shoes with rubber soles • Have your eyes checked • Ask your doctor or nurse to check whether any of your medicines might make you dizzy or increase your risk of falling

14. Drug Therapies for Osteoporosis • Oral Bisphosphonates: Alendronate, Risedronate, Ibandronate • IV Bisphosphonates:Zoledronic Acid, Ibandronate • Monoclonal antibody: Denosumab- safe in kidney failure • SERMS: Raloxiphene/ Evista – women only • Parathyroid Hormone: Forteo Decisions about Drug Therapy must be made in collaboration with your Hematologist/Oncologist.

18. Risk Factors for Cardiovascular Disease • Hypertension • Chronic kidney disease • Obesity/ Metabolic Syndrome • High Cholesterol • Diabetes including steroid-induced Diabetes • Family History • Anthracycline Chemotherapy • Radiation to the Chest

19. Cardiovascular Risk Assessment • Patients without established CVD should undergo periodic cardiovascular risk assessment every 3 to 5 yrs. • Periodic risk assessment offers the opportunity to identify CVD risk factors and offer guidance on the appropriate management of specific risk factors. • Dietary modifications for hypertension or cholesterol • Recommendations regarding regular exercise • Smoking cessation counseling, etc… • It is unknown at what age periodic risk assessment should no longer be performed.

20. 2013 Pooled Cohort Risk Equation • Updated Guideline from AHA and ACC • Assesses 10 year risk and lifetime risk for atherosclerotic CVD. • Pooled Cohort equations consider the following risk factors: • Age • Race • Gender • Total and HDL Cholesterol • Systolic Blood Pressure • History of Diabetes • Treatment for Hypertension • Smoking • If risk is > 7.5% patient is candidate for statin therapy

23. How can you reduce your risk? • Control and treat lipids early with statins • Control Blood Pressure (< 140/90) • Avoid Smoking • Screen for Diabetes and treat aggressively (A1c< 7.0) • Control Weight • Increase daily physical activity

24. Who Should Take Aspirin? Risk Levels at which CV Disease Events Prevented supports Men Taking Aspirin for Primary Prevention (source USPSTF) Age 10-Year Cardiovascular Risk 45-59 y ≥4% 60-69 y ≥9% 70-79 y ≥12% • Most patients with Myeloma are on daily Aspirin due to increased risk of clot formation caused by disease and medication-related factors.

25. Screening for Cardiac Toxicity after Doxorubicin/ Adriamycin • ECHO or MUGA plus ECG at baseline and periodically depending on results. • Evaluation should be done on entry into follow up care and repeated as needed based on results and symptoms • Cardiology consultation for patients with abnormal findings.

26. Vaccines in Multiple Myeloma • Vaccines in general are less effective during chemotherapy. • Flu shot is given seasonally, but it is best to wait 6 mos after chemo before giving most vaccines. • Live vaccines including Zoster/ Shingles vaccine and MMR/ Measles, mumps rubella are NOT recommended during chemo and for 2-3 years after transplant. • DO NOT get a live vaccine without talking to your Myeloma doctor since patients with blood cancers are at risk to get infections from live vaccines.

27. Everyone is a candidate for the Flu shot! • Death rates from influenza are disproportionately higher in older adults. The benefits of influenza vaccination outweigh the risks in most older patients. • The Flu shot is only contraindicated in patients with a history of a severe allergic reaction (anaphylaxis) to egg protein or prior vaccine administration. • Mild egg allergy (rash, hives) is no longer an absolute contraindication to influenza vaccination. • The efficacy of the Flu shot varies from year to year as the vaccine is created annually to match anticipated strains. • It is essential to vaccinate every fall given the high incidence and the morbidity and mortality associated with the disease. • Patients with blood cancers should AVOID live flu vaccines including Flu Mist.

28. Pneumococcal Vaccination • Pneumococcal Polysaccharide Vaccine (PPSV23/ Pneumovax) is recommended for: • all adults older than 65 yrs • patients < 65 yrs who are active smokers, have COPD/ asthma, or other disorders that increase the risk for invasive pneumococcal disease. • A single re-vaccination with PPSV23 is recommended in adults older than 65 yrs who: • Were vaccinated > 5 yrs ago at a time when they were < 65 yrs • Are immunosuppressed patients > 5 yrs after the first dose. • Updated CDC recommendation August 2014: Pneumococcal Conjugate Vaccine (PCV 13/ Prevnar) in all adults older than 65 yrs

29. Tetanus/TdaP • The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine has a modest mortality benefit. • Due to recent outbreaks of Pertussis, all adults should get at least one dose of Tdap regardless of the timing of the last tetanus booster. • TdaP protects adults and children they may be in close contact with against pertussis. • Immunization of adults prevents transmission to vulnerable children and infants.

30. Shingles/ Zoster Vaccination • Zoster vaccine is a live vaccine. • Zoster vaccination has been shown to decrease the incidence of zoster and post herpetic neuralgia • Zoster vaccination can be given to adults with a history of Zoster/ “The shingles” • Zoster vaccination does not have a mortality benefit. • Zoster vaccination is contraindicated in most patients with blood cancers(with very rare exceptions). • DO NOT get a Zostavax without asking your Myeloma doctor!

31. Cancer Screening and Surveillance • Myeloma survivors should adhere to USPSTF recommended guidelines. • Mammogram and Clinical Breast Exam • Colonoscopy or other Colorectal Screening • PAP testing/ Cervical Cancer Screening • PSA/ Prostate Screening? • All survivors should have an annual exam with a primary physician who is aware of your cancer history. • Annual exams are the best way to allow early detection of thyroid nodules, skin cancers, and other cancers for which there is no USPSTF screening recommendation.

32. Colorectal Cancer Screening • Colorectal cancer is a common disease with a high incidence, prevalence, and mortality. • Screening for colorectal cancer has been associated with a 20% to 30% decrease in overall mortality. • Colorectal cancer screening is given an “A” grade recommendation from the USPSTF for persons between the ages of 50 and 75 yrs. • Colonoscopy Q 10 yrs, Flex Sig Q 5 yrs and annual FOBT have all been proven to reduce colorectal cancer mortality.

33. Mammography and Breast Cancer Screening • Mammography also has an absolute mortality benefit that increases with age. • The USPSTF's recommendation that women between the ages of 50 and 74 yrs undergo screening mammography every 2 yrs is given only a grade B because of the high rate of false-positive findings (6.5%) and the high number of women needed to screen to prevent one death from breast cancer: • Ages 40-49 yrs: One death prevented for every 1,000 women screened annually for 10 years • Ages 50-59 yrs: Two deaths prevented for every 1,000 women screened annually for 10 years • Ages 60-69 yrs: Six deaths prevented for every 1,000 women screened annually for 10 years

34. Lung Cancer Screening • Annual low dose CT scan for lung cancer screening has been recommended by the USPSTF for adults 55-80 yrs with a high risk for lung cancer including: • >30-pack-year smoking history who are current smokers or quit < 15 yrs ago • Screening should be discontinued once a person has not smoked in 15 yrs or develops a health condition that substantially shortens life expectancy. • The mortality benefits of screening patients who are not high risk (>30 pack yrs) have not yet been established.

35. Ovarian Cancer Screening • Ovarian cancer screening with ultrasonography is not recommended for average-risk women and has not been proven to have a mortality benefit. • Women with known familial ovarian cancer syndromes (Lynch, BRCA1, BRCA2) who have not undergone prophylactic oophorectomy may undergo multimodal screening that includes the combination of CA-125 measurement with pelvic ultrasonography • There is limited evidence for mortality benefit even in this high risk group.

36. Interventions to Decrease Cancer Risk • Smoking cessation. • Decrease alcohol intake. • Reduce excess weight. • Minimize UV exposure. • Minimize exposure to other carcinogens. • Increase physical activity. • Increase intake of fruits and vegetables. LTFU Guidelines, 2006.

37. Summary • Primary care with a physician who is integrated into your cancer care can improve quality of life and prevent complications. • Cardiovascular disease is common. Know your risk! • Ask your oncologist to identify most appropriate areas to target for follow up care. • Be your own advocate!

38. “Top 10 Tips for Cancer Patients” in “No Such Thing as a Bad Day” by Hamilton Jordan “Tip #10 Your attitude and your beliefs are your most powerful weapon against cancer.”