1. STRONACH REGIONAL CANCER CENTRE AT SOUTHLAKE CENTRE RÉGIONAL DE CANCÉROLOGIE STRONACH À SOUTHLAKE Follow-up care for Breast Cancer Survivors: Surveillance and Survivorship Dr. Farrah Kassam

2. Which of the following tests should be ordered as part of the routine surveillance of asymptomatic breast cancer survivors? a)Routine laboratory tests (+/- tumour markers) b)Mammography c)Bone Scan d)Chest x-ray/Abdominal US or CT thorax/abdomen e)All of the above

3. Evidence shows that well follow-up care provided by Primary Care Physicians is as effective as care provided by Oncologists? a)True b)False

4. Objectives: Surveillance of the Breast Cancer Survivor –Review current guidelines –Role of the Primary Care Provider –SRCC Breast Cancer Surveillance Program Survivorship –Management of common survivorship issues –SRCC survivorship resources

5. Breast Cancer Survivors – a growing population Significant advances in breast cancer diagnosis and treatment have led to a growing number of breast cancer survivors Most women (>80%) diagnosed with breast cancer do not die of their disease In 2008, over 60,000 breast cancer survivors in Ontario They require regular high-quality follow up to detect recurrences and to manage survivorship issues Ontario Cancer Registry 2009

6. Breast Cancer Surveillance Guidelines Relevant Evidence-based Guidelines –2012 American Society of Clinical Oncology –2005 Health Canada’s Steering Committee (recently endorsed by CCO) –Very similar recommendations Despite guidelines, significant variation in follow up care in Ontario –Half of patients having more than recommended surveillance imaging for metastatic disease –One-quarter having fewer than recommended mammography J Oncol Practice 6(4):174-181, 2010 CMAJ 172(10):3-4,2012

7. Summary ASCO Guidelines: Summary of BREAST CANCER SURVEILLANCE History/Physical ExamEvery 3 to 6 months for the first 3 years after primary therapy; every 6 to 12 months for years 4 and 5, then annually. Patient EducationCounsel patients about the symptoms of recurrence including new lumps, bone pain, chest pain, abdominal pain, dyspnea or persistent headaches. Referral for Genetic Counseling Criteria to recommend referral include Ashkenazi Jewish heritage; history of ovarian cancer in patient or any first- or second-degree relative; any first degree relative with a history of breast cancer diagnosed before age 50; two or more first- or second-degree relatives diagnosed with breast cancer; patient or relative with diagnosis of bilateral breast cancer; or, history of breast cancer in a male relative. Breast Self-ExamAll women should be counseled to perform monthly breast self-examination. MammographyFirst post-treatment mammogram 1 year after the initial mammogram that leads to diagnosis, but no earlier than 6 months after definitive radiation therapy. Subsequent mammograms should be obtained as indicated for surveillance of abnormalities. Pelvic ExaminationRegular gynecologic follow-up is recommended for all women. Patients who receive tamoxifen should be advised to report any vaginal bleeding to their physicians. Coordination of CareContinuity of care for breast cancer patients is encouraged and should be performed by a physician experienced in the surveillance of cancer patients and in breast examination, including the examination of irradiated breasts. If follow-up is transferred to a PCP, the PCP and the patient should be informed of the long-term options regarding adjuvant hormonal therapy for the particular patient. This may necessitate re-referral for oncology assessment at an interval consistent with guidelines for adjuvant hormonal therapy. BREAST CANCER SURVEILLANCE TESTING - NOT RECOMMENDED Routine blood testsCBCs and liver function tests are not recommended Imaging StudiesChest x-ray, bone scans, liver ultrasound, CT scans, FDG-PET scans, and breast MRI are not recommended Tumor markersCA 15-3, CA 27.29 and CEA are not recommended.

8. Physician Visits Years After Primary Therapy:History & Physical Exam Occurs: 1, 2, 3 Every 3 to 6 months 4, 5 Every 6 to 12 months 6+ Annually Endorse the role of the primary care provider Patients on hormonal therapy may require periodic oncology re-assessment as treatment strategies still evolving over time

9. History Screen for signs & symptoms of local or distant recurrence –Full ROS including constitutional, MSK, pulmonary, neurologic, GI….. –Radiographic evaluation for any concerning symptoms Assess for residual or late side-effects from primary treatment –Eg. lymphedema, premature menopause Assess tolerance and compliance of ongoing hormonal therapy (Tamoxifen, Aromatase Inhibitors) –Important to ask about vaginal bleeding in women on Tamoxifen Assess for pyschological distress (depression/anxiety)

10. Physical Examination Bilateral examination of the breast, chest wall and axilla to screen for new or recurrent disease General exam to screen for signs of distant recurrence and identify treatment related side-effects (e.g. Lymphedema, DVT on Tamoxifen) Gynecologic Exam – routine gynecologic follow-up - Patients on tamoxifen at small increased risk of endometrial cancer and should be advised to report any abnormal vaginal bleeding to their physicians

12. Patient Education Physicians should council patients about the symptoms of recurrence including new lumps, bone pain, chest pain, abdo pain, dyspnea or persistent headaches Patients should be encouraged to report new, persistent symptoms promptly, rather than waiting for their next scheduled appointment Women should be instructed on how to properly perform breast self-examination on a monthly basis (unless provokes high anxiety)

13. Breast Self Examination

14. Laboratory Evaluation No role for routine blood tests or tumour markers Do not improve outcomes

15. Imaging Surveillance Guidelines

16. Mammogram, Mammogram, Mammogram Only breast screening tool with evidence to suggest a mortality reduction in the general population In breast cancer survivors: –Risk of ipsilateral breast recurrence after lumpectomy up to 4% –Risk of a second non-inherited breast cancer 0.5-1% per year Should be done annually for screening purposes Breast ultrasound not recommended or beneficial for screening

17. Breast MRI Too sensitive for screening in the general breast cancer population, leading to unnecessary anxiety and biopsies, without any documented survival advantage over mammography alone Is recommend for screening of woman at very high risk for recurrent breast cancer –BRCA-mutation positive or very strong family history (lifetime risk >=25%) –<1% of general population & 5-10% of breast cancers –Referral to CCO’s OBSP High Risk Screening Program

18. Referral Criteria for Genetic Counseling Women at high risk for familial breast cancer syndromes should be referred to genetic counseling. ‡ Criteria for Genetic Counseling ► Ashkenazi Jewish heritage ► History of ovarian cancer at any age in the patient or any first- or second-degree relatives ► Any first degree relative with a history of breast cancer diagnosed before the age of 50 ► Two or more first- or second-degree relatives diagnosed with breast cancer at any age ► Patient or relative with diagnosis of bilateral breast cancer ► History of breast cancer in a male relative ‡ U.S. Preventive Services Task Force, Genetic Risk Assessment and BRCA Mutation Testing for Breast and Ovarian Cancer Susceptibility, Annals of Internal Medicine, 2005

19. Referral Criteria for OBSP High Risk Screening Program with Annual Mammography AND MRI men at high risk for failial brest cancer syndromes should be referred to genetic counseling.‡ men at high risk for failial brest cancer syndromes should be referred to genetic counseling.‡ High Risk Criteria Asymptomatic Woman, Aged 30 - 69 ► Known carrier of deleterious gene mutation (i.e. BRCA 1 or BRCA 2) ► First degree relative of a known mutation carrier who declines genetic testing ► ≥ 25% lifetime risk of breast cancer based on family history– must have been assessed using either the IBIS or BOADICEA risk assessment tools, preferably by a genetics clinic; ► Received chest radiotherapy before the age of 30 http//www.cancercare.on.ca/obsphighrisk *<1% general population and only 5-10% of breast cancers

20. Role of imaging to screen for early metastatic disease in asymptomatic woman

21. Symptom-guided approach RCTs have compared routine follow-up with history, physical and annual mammography to regimens with more intensive imaging (CXR/abdo US/bone scan/CT) Even with intensive imaging, asymptomatic recurrences only account for 15-25% Early detection of metastatic disease not associated with improved survival Frequent imaging tests can lead to unnecessary radiation, anxiety, biopsies and poorer QOL Guidelines have adopted strategy of imaging when symptoms develop

22. Imaging Studies The following imaging studies are NOT recommended for routine breast cancer surveillance:  Chest x-rays  Bone scans  Ultrasound of the liver  Computed tomography  FDG-PET scanning  Breast MRI

23. Coordination of Care Risk of breast cancer recurrence continues through 15 years after primary treatment and beyond. Follow-up by a PCP seems to lead to the same health outcomes as specialist follow-up, with good patient satisfaction. If care transferred to PCP, both PCP and patient should be informed of the appropriate follow-up and management strategy If patient is receiving adjuvant endocrine therapy, she may need periodic oncology re-assessment/referral as strategies evolving

24. Current model of Breast Cancer Surveillance *mean per patient per patient year Source: Grunfeld et al JOP 2010

25. Why do we need to change to our current model of care? 1.Current model is not sustainable  Incidence and prevalence of cancer increasing  Oncology resource shortage anticipated 2.Timely and appropriate acute oncology care at risk 3.Patient expectations are changing  Opportunity to better meet their “survivorship” needs  Patient Empowerment key 4.Accumulating evidence that primary care physicians deliver equivalent health and patient satisfaction outcomes to oncology specialists 5.Opportunity to provide care closer to home Grunfeld E et al. J Clin Oncol 24(6): 848-855, 2006

26. From the literature: What we know Primary care providers Need: Clinical practice guidelines - easy to access & understand A patient-specific discharge letter from the specialist Expedited re-referral and access to investigations for recurrence Case management tools across settings (EMR templates/reminders, web- based) Patients Need: Patient navigation services Proactive mental health monitoring and follow-up Advice on survivorship issues (eg fitness, nutrition, etc) Access to community resources/support (eg social work) Surveillance versus Survivorship There is no hard evidence or consensus on what model or intervention would work best Del Giudice, Grunfeld, et al. JCO 27:3338-3345, 2009 Cancer Care Ontario

27. STRONACH REGIONAL CANCER CENTRE AT SOUTHLAKE CENTRE RÉGIONAL DE CANCÉROLOGIE STRONACH À SOUTHLAKE SRCC Breast Cancer Surveillance Program

28. Objectives Provide survivors and their health care providers with a care summary & follow-up plan Empower patients to participate in the management of their care & well- being Improve knowledge of health care providers regarding survivor needs, assessment & management strategies Improve cancer system efficiency, and enhance transition & co- ordination of care for cancer survivors Purpose Ensure that all SRCC breast cancer patients who have completed active cancer treatment, have access to exceptional surveillance and survivorship care.

29. SRCC Breast Cancer Surveillance Program Standardized model of shared follow-up care between Primary Care Providers, Medical oncologists, & Surgeons Patients transition into program after active treatment (surgery, chemotherapy, radiotherapy complete), with early involvement of PCP Foundation based on empowering patients and PCPs to actively participate in breast cancer surveillance & survivorship Rich array of educational resources developed to support patients and PCPs through this transition process

30. SRCC Breast Cancer Surveillance Program Pathway Active treatment completed (chemotherapy/herceptin/radiotherapy) Patient enters follow-up pathway after 1 st post-treatment mammogram Transition Visit with Oncologist Orientation Session with NP PCP receives: via Referral Out 1. Transition Letter 2. Mosaiq Careplan Summary 3. Flyer with Link to online survivorship course material 4. Info on expedited “fast track” re-referral process 5. EMR template (via website) Patient receives in a package: 1. Transition Letter 2. Mosaiq Careplan Summary 3. Surveillance Passport 4. Flyer with info on live and online survivorship course 5. Info on approved OBSP mammography sites 6. Other (? community resources) 7. Appt booked for RTC for NP Orientation and MO in 8 months

31. BCSP Supports for Primary Care Transition Letter (guidelines) Guideline recommendations, including passport schedule Info on Tamoxifen/AIs Info on expedited referral back to Oncologist Copy of patient’s Mosaiq Careplan Summary Patient specific diagnosis details and treatment summary EMR surveillance templates downloadable from our website Links to survivorship website materials Educational Events – Annual Oncology Day at SRCC

32. Transition Letter

33. Mosaiq Care Plan Summary

34. EMR Templates/Link to Survivorship Material Available for Practice Solutions, Nightingale & Accuro Oscar in development Instructions on how to download/build EMR template on Southlake homepage: www.southlakeregional.org Patient Services < Cancer – Regional Cancer Program < Breast Cancer Survivorship < Health Professionals www.southlakeregional.org Useful Survivorship material also available online

35. SRCC BCSP Patient Folder

36. SRCC Patient Folder (Resources) Transition Letter Describes surveillance program and follow-up schedule Mosaiq Careplan Summary Record of tumour and treatment details Passport Paper and Web/Mobile friendly versions Place for patients to record compliance with visits & mammograms Flyer for Live and Online Survivorship Transitions Course Info on community support resources

37. Patient Transition Letter

38. Mosaiq Care Plan Summary

39. Passport

40. Breast Cancer Surveillance Portal Web & Mobile Passport

41. Flyer for Survivorship Course & Website www.southlakeregional.org < Patient Services < Cancer – Regional Cancer Program < Breast Cancer Survivorship

42. Survivorship Course Cancer Transitions Program running at SRCC 3-4x a year On-line version http://www.southlakeregional.org/Default.aspx?cid=825&lang=1

43. SRCC Breast Cancer Surveillance Program Benefits for Patients Provides clarity and confidence in follow-up plan Empowers patient compliance (passport) Avoids unnecessary duplicative visits Involves PCP early –Enhances communication with SRCC –Improve PCP knowledge –Improves patient confidence in PCP –Provides care closer to home Enhanced Survivorship care –involvement of PCP –SRCC surivorship course + website Benefits for SRCC/PCP Enhanced patient satisfaction Improved survivorship care delivery Improved cancer system efficiency & transition/co-ordination of care for cancer survivors –Reduced SRCC f/u visits, lower wait times Improved coordination/communication with PCP Improved knowledge of health care providers regarding survivor needs, assessment & management strategies Translatable model to other tumour types & across LHIN

44. From Breast Cancer Patient to Breast Cancer Survivor – more than just surveillance Help patients manage long-term and late effects of treatment Promote healthy living and psychological well-being

45. Management of Adverse Effects of Treatment

46. Local Complications of Breast Cancer Therapy NEJM 343(15) 1086-1094, 2000

47. Lymphedema Lower rates with sentinal lymph node biopsy Responds well to conservative measures – arm elevation, compression sleeves Physical therapy can improve those that do not respond to conservative measures Protect ipsilateral arm from infection, compression, venipuncture, exposure to intense heat and abrasion NEJM 343(15) 1086-1094, 2000

48. Late Complications of Chemotherapy Most adverse effects of chemotherapy resolve after treatment (eg. neuropathy with taxanes) Two rare, but life-threatening complications: –Secondary MDS or leukemias (0.2-1%) –Cardiac impairment (0.5-1%) No routine screening recommended, but patients with cardiac symptoms or cytopenias should be investigated

49. Tamoxifen Generally well tolerated Side-effects: hot flushes, vaginal dryness, irritation, and discharge. 1% risk of thromboembolism & uterine cancer Slight risk of earlier cataract formation Annual gynecological examination and Pap test Postmenopausal woman should see physician promptly if any vaginal bleeding, abnormal discharge or pelvic pain. Follow-up with ophthalmologist every two years

50. Aromatase Inhibitors Generally well tolerated arthralgias/myalgiasSide-effects: hot flushes, arthralgias/myalgias, vaginal dryness, nausea/emesis, diarrhea, headaches, asthenia and rash Increased risk of osteopenia/osteoporosis and fractures BMD q1-2 years Bisphosphonate for significant osteopenia/osteroporosis Calcium and vitamin D prophylaxis recommended Unclear if cholesterol levels altered but should monitor 1% risk of thromboembolism

51. Premature Menopause Adjuvant chemotherapy can result in temporary or permanent amenorrhea from direct toxicity to ovary Rapid drop in estrogen levels can cause more severe symptoms than natural menopause Hormonal agents can also cause menstrual dysfunction, urogenital and vasomotor symptoms Can significantly impair QOL and sexual function Typically less pronounced over time

52. Management of Menopausal Symptoms HRT generally not recommended Vasomotor Symptoms (Hot flushes/Night Sweats) –SSRIs (not with Tamoxifen), Venlafaxine, Clonidine, Gapapentin Anorgasma/Poor Libido –Vaginal lubricants, vibrators, couples counselling Insomnia –Sleep hygiene, hypnotic medications, treat night sweats & depression Urogenital Symptoms (Vaginal dryness/Dispareunia) –Vaginal lubricants, Estrogen rings/creams (need to weigh risks/benefits) JCO 30(30), 2012

53. Sexual Dysfunction – To be covered by Dr. Anne Katz One of the most common and distressing consequences of cancer treatment Premature menopause, post-treatment body image issues, and psychological distress are contributing factors Screening for sexual dysfunction, and providing support and suggestions for the management of contributing factors (eg. vaginal dryness, depression, reconstruction options) can go a long way to alleviating distress JCO 30(30), 2012

54. Pregnancy & Contraception after breast cancer Young breast cancer survivors may experience infertility due to chemotherapy or delays in childbearing to accommodate five years of hormonal therapy Limited data on the effects of pregnancy on breast cancer survival, however data to date does not suggest adverse effect Many experts suggest waiting at least two years post- treatment WHO recommends avoiding hormonal contraception in women with breast cancer in favour of non-hormonal options (condoms, diaphragm, copper IUD)

55. Cognitive Functioning – To be covered by Dr. Heather Palmer “Chemo-brain” - Treatment-related cognitive dysfunction (eg. impaired memory and decreased concentration) well described Extent of the deficits appear small and appear to improve with the passage of time Limited data on interventions to treat cognitive changes in cancer survivors, but psychostimulants and cognitive rehabilitation approaches under investigation JCO 30(30), 2012

56. Fatigue May affect one-quarter to one-third of breast cancer survivors May persist for years after cessation of treatment. Evaluate and manage treatable causes of fatigue including anemia, thyroid dysfunction, pain, depression, and lack of sleep Psycosocial interventions (eg. self-care/coping techniques) & exercise can be helpful JCO 30(30), 2012

57. Psychosocial issues Heightened anxiety after the completion of therapy common. –worry about the risk of recurrence and the loss of the security that many feel while they are actively undergoing therapy –Dealing with uncertainty and fear of recurrence is often the most difficult part of recovery, and can persist for years Patients should be routinely screened for psychological distress and mood disorders Fortunately psychological distress tends to improve with time with long-term QOL data quite high SRCC: survivorship program (information and peer support), social workers, and psychosocial clinic (Dr. M. Katz) NEJM 343(15) 1086-1094, 2000 JCO 30(30), 2012

58. Promoting Healthy Lifestyle – Diet & Exercise Moderate exercise, avoidance of obesity, and minimization of alcohol intake associated with decreased recurrence and death Weight gain common post adjuvant chemotherapy –Multidisciplinary efforts with nutritional advice, counseling, and exercise can help Moderate exercise programs shown to lessen fatigue, and symptoms of depression and anxiety –May also help reduce lymphedema Limit consumption of alcohol (no more than 1 drink/day) Healthy diet and moderation of soy (phytoestrogen) generally suggested NEJM 343(15) 1086-1094, 2000 JCO 30(30), 2012

59. Bone Health Cancer treatments can weaken bones –Chemo-induced early menopause –Direct chemo toxicity –Endocrine therapy (AI or tamoxifen if pre-menopausal) BMD suggested post chemotherapy Encourage smoking cessation, weight-bearing exercise, and adequate intake of calcium and vitamin D Osteopenia and Osteoporosis may require bisphosphonate

60. Algorithm for management of bone loss in cancer survivors. Lustberg M B et al. JCO 2012;30:3665-3674 ©2012 by American Society of Clinical Oncology

61. Most Breast Cancer Survivors will not die of their disease age-appropriate screening studies and preventive careShould receive ongoing age-appropriate screening studies and preventive care, consistent with recommendations for the general population, for conditions other than those related to breast cancer and its treatment. Management of CVS risk factors - hypertension, DM and hypercholesterolemia, as well as smoking cessation Cancer screening guidelines for other common cancers still applicable

62. Which of the following tests should be ordered as part of the routine surveillance of asymptomatic breast cancer survivors? a)Routine laboratory tests (+/- tumour markers) b)Mammography c)Bone Scan d)Chest x-ray/Abdominal US or CT thorax/abdomen e)All of the above

63. Evidence shows that well follow-up care provided by Primary Care Physician is as effective as care provided by Oncologists? a)True b)False

64. THANK YOU