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Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance Professor, Medical Oncology, University of Washington School of Medicine.

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Presentation on theme: "Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance Professor, Medical Oncology, University of Washington School of Medicine."— Presentation transcript:

1 Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance Professor, Medical Oncology, University of Washington School of Medicine Member, Clinical Division, Fred Hutchinson Cancer Research Center Long-term Follow-up of Breast Cancer Patients

2 The Cancer Care Continuum Detection Treatment Survivorship & Diagnosis & Diagnosis Optimal care of an individual person differs along the continuum

3 Institute of Medicine 2005 Report From Cancer Patient to Cancer Survivor: Lost in Transition Hewitt M, Greenfield S, and Stovall E, eds. Transition from active treatment to post-treatment care critical to long-term healthTransition from active treatment to post-treatment care critical to long-term health Routine follow-up visits are opportunities to promote healthy lifestyle, check for cancer recurrence, manage lasting effects of the cancer experienceRoutine follow-up visits are opportunities to promote healthy lifestyle, check for cancer recurrence, manage lasting effects of the cancer experience Cancer survivors are a heterogeneous population, some having few late effects of cancer and its treatment, and others suffering permanent and disabling symptomsCancer survivors are a heterogeneous population, some having few late effects of cancer and its treatment, and others suffering permanent and disabling symptoms The good news is that there is much that can be be done to avoid, ameliorate, or arrest the late effects of cancerThe good news is that there is much that can be be done to avoid, ameliorate, or arrest the late effects of cancer

4 IOM Report: All Patients Should Receive a Cancer Treatment Summary SCCA Breast Cancer Treatment Summary (modified from asco.org) Patient Name: UW/SCCA medical record number: Date of Birth: Cancer Diagnosis:Date of Diagnosis: Age at Diagnosis: Tumor Stage: Tumor Size (T), Nodes (N), Metastases (M) Tumor grade: Hormone receptors: Estrogen receptor (ER), Progesterone receptor (PR) HER-2: IHC, FISH Oncotype DX (if done): Family History of Cancer:BRCA1/2 testing (if done): Significant Past Medical History and Medications: Cancer Treatment Surgery Breast Surgery: Procedure, date Lymph Node Surgery: Procedure, date Reconstruction: Procedure, date Systemic Therapy Chemotherapy:RouteDoseScheduleNumber of cycles Cumulative Anthracycline Dose Administered: Doxorubicin____ mg/m 2 Epirubicin___ mg/m 2 HER-2 Targeted Therapy: Drug, start date, stop date Endocrine (Hormonal Therapy): Drug, start date, stop date Bisphosphonate Therapy for Breast Cancer Indication: Drug, start date, stop date Enrolled in Clinical Trials? Radiation Therapy Date StartDate StopTotal Dose (cGy) Fields included: Complications of therapy: Providers Primary Care Provider:Surgeon: Radiation Oncologist:Medical Oncologist:

5 Breast Cancer Follow-Up Includes Three Major Goals: Surveillance for cancer recurrenceSurveillance for cancer recurrence Monitoring for toxicities related to therapyMonitoring for toxicities related to therapy Maximizing overall health and quality of lifeMaximizing overall health and quality of life

6 Breast Cancer Survivorship Care Plan (modified from asco.org) F OLLOW -U P C ARE T EST R ECOMMENDATION Medical history and physical Visit your doctor every three to six months for the first three years after the first treatment, every six to 12 months for years four and five, and every year thereafter. Post-treatment breast imaging The SCCA recommends a mammogram of the affected breast every 6 months for up to 3 years from cancer diagnosis, and annual mammography of the opposite breast. In some selected patients, a periodic breast MRI or ultrasound may be recommended. Breast self-examination. Perform a breast self-examination every month. This procedure is not a substitute for a mammogram. Inspection and palpation of irradiated skin and soft tissues every year. Report any unusual symptoms to your medical provider. Pelvic examination Continue to visit a gynecologist regularly. Women taking tamoxifen should report any irregular vaginal bleeding to their doctor. Laboratory tests Your oncologist will determine which blood tests are recommended in your case. This may include a periodic complete blood count (CBC), chemistry panel, liver and kidney tests, and tumor markers. Radiology tests Your oncologist will determine which radiology tests are recommended in your case. While a regular chest xray is sometimes indicated annually in higher-risk patients, it is uncommon to routinely recommend bone scans, CT scans, PET scans or MRIs in asymptomatic patients. Every few years a DEXA scan to evaluate bone density is indicated in postmenopausal breast cancer patients. Coordination of care Most patients diagnosed with invasive breast cancer continue to be followed by their medical oncologists for at least 5 years from diagnosis. It is important to also have a primary care doctor, to manage non-cancer related health issues.

7 Surveillance for Breast Cancer Recurrence Local/Regional RecurrenceLocal/Regional Recurrence Distant RecurrenceDistant Recurrence Assessment of risk of cancer recurrence and second cancersAssessment of risk of cancer recurrence and second cancers Interventions to further reduce risk of cancerInterventions to further reduce risk of cancer Early detection of recurrence and second cancersEarly detection of recurrence and second cancers

8 Assessing Risk of Cancer Recurrence Recurrence Hazard Rates for Breast Cancer After Primary Therapy Saphner et al, J Clin Oncol 14:2738, 1996 Years Recurrence hazard rate

9 Assessing Risk of Second Cancers How Much Breast Cancer Is Hereditary? 15-20% 5-10% 70-80%

10 Cancer Screening: Looking for Cancer Recurrence and Second Cancers MammographyMammography Health Professional’s ExamHealth Professional’s Exam Self-ExamSelf-Exam Breast MRI in some very high risk?Breast MRI in some very high risk?

11 Monitoring for Toxicities Related to Therapy Assessing risk of toxicitiesAssessing risk of toxicities Interventions to reduce risk of toxicityInterventions to reduce risk of toxicity Detection and treatment of side effectsDetection and treatment of side effects

12 Side Effects of Chemotherapy Cardiac Events vs. Cumulative Chemotherapy Dose Doxorubicin 450 mg/m 2 Cumulative anthracycline dose (mg/m 2 ) Cardiac events (%)

13 Side Effects of Chemotherapy Chemotherapy-induced Menopause in Breast Cancer Ovarian damage is a significant long-term consequence of adjuvant chemotherapy in premenopausal breast cancer patientsOvarian damage is a significant long-term consequence of adjuvant chemotherapy in premenopausal breast cancer patients –All are affected by resultant menopausal effects –Infertility seriously affects some For women who retain ovarian function after breast cancer, pregnancy is possible post-chemoFor women who retain ovarian function after breast cancer, pregnancy is possible post-chemo –Limited data do not show a worse outcome for women who become pregnant after breast cancer New techniques for preserving ovarian function and achieving fertility are under studyNew techniques for preserving ovarian function and achieving fertility are under study

14 Side Effects of Endocrine Therapy Adjuvant Hormonal Treatment of Breast Cancer: Weighing the Side Effects Arthralgia/myalgia Neurocognition?DVT, CVA HyperlipidemiaSexual function?Uterine CA Osteoporosis risk Cardiovascular Dz?Hot flashes TamoxifenAromatase Inhibitors

15 Assessing Risk of Side Effects Women Cancer Patients Are at Increased Risk for Osteoporosis Lack of estrogenLack of estrogen –Estrogen prevents bone breakdown (resorption) and preserves bone density –Estrogen may also help maintain normal levels of vitamin D, an important nutrient in bone protection Premenopausal womenPremenopausal women –Chemotherapy-induced menopause –Ovarian suppression Postmenopausal womenPostmenopausal women –Aromatase inhibitors

16 Maximizing Overall Health and Quality of Life The Effects of Breast Cancer Treatment on Emotional and Physical Well-Being Fatigue/decreased energyFatigue/decreased energy Nausea/vomitingNausea/vomiting Alopecia (hair loss)Alopecia (hair loss) MenopauseMenopause InfertilityInfertility Sexuality/body imageSexuality/body image LymphedemaLymphedema Depression, anxietyDepression, anxiety PainPain Fear of recurrenceFear of recurrence Etc….Etc….

17 Managing Menopause Prevalence of Menopausal Symptoms in Women with a History of Breast Cancer Couzi et al, JCO 1998 Hot flashes 65%Hot flashes 65% Night sweats 44%Night sweats 44% Vaginal dryness 48%Vaginal dryness 48% Pain with intercourse 26%Pain with intercourse 26% Insomnia 44%Insomnia 44% Depression 44%Depression 44%

18 Exercise, Physical Activity and Cancer Team Survivor Northwest Mt. Baker August 2008 Mt. Baker August 2008

19 Exercise Decreases Side Effects During Treatment Fatigue and QOL Outcomes of Exercise During Cancer Treatment Mock V et al, Cancer Pract 9: Patients: 52 breast cancer patients randomized to home-based walking program or usual care during chemotherapy or radiation therapyPatients: 52 breast cancer patients randomized to home-based walking program or usual care during chemotherapy or radiation therapy Results: Women who exercised > 90 minutes per week (divided over 3 or more days) reported significantlyResults: Women who exercised > 90 minutes per week (divided over 3 or more days) reported significantly –Less fatigue –Less emotional distress –Higher functional ability –Better QOL

20 Physical Activity Can Impact Breast Cancer Survival Exercise and Survival After Breast Cancer Diagnosis (Nurses Health Study) Holmes MD et al, JAMA 2005 Patients: 2,987 nurses with early stage breast cancer Physical activity categories: –LOW –MEDIUM –HIGH Results: Compared to women with LOW physical activity, risk of dying of breast cancer was:Results: Compared to women with LOW physical activity, risk of dying of breast cancer was: –20% less for MEDIUM exercise (at least 3 hours per week walking at average pace) –40-50% less for HIGH exercise

21 What About Lymphedema?

22 Carefully Monitored Exercise Does Not Increase Lymphedema Weight Training and Lymphedema in Breast Cancer Survivors Ahmed RL et al, J Clin Oncol 2005 Patients: 45 breast cancer survivors s/p axillary lymph node dissectionPatients: 45 breast cancer survivors s/p axillary lymph node dissection Study: Randomized to weight training program or notStudy: Randomized to weight training program or not –Weight training sessions 2x per week for 6 months –For upper body, initially used no weights or only wrist weights, weight gradually increased if no symptoms of lymphedema developed Results:Results: –None of the women in the weight training program experienced a noticeable change in arm circumference (> 2 cm) –Frequency of new lymphedema, or worsening of existing lymphedema, was similar in both groups

23 Nutrition, Body Weight and Breast Cancer -Maintain good body weight -Low fat diet -High fiber -Increase fruits and vegetables -Limit alcohol

24 Nutrition Can Impact Breast Cancer Survival Women’s Intervention Nutrition Study (WINS) Chlebowski R et al, 2006 Patients: 2,437 postmenopausal women with early stage breast cancerPatients: 2,437 postmenopausal women with early stage breast cancer Intervention: Randomized within 1 year of surgery to:Intervention: Randomized within 1 year of surgery to: – dietary intervention (8 biweekly counseling sessions by nutritionists and support throughout) –vs. control Results:Results: –At 1 year: Intervention group 1/3 less fat intake per day –At 5 years: 24% reduction in breast cancer recurrence Conclusion: Nutrition interventions can decrease recurrences in breast cancer patients

25 Weight gain during adulthood has been found to be a consistent and strong predictor of breast cancer riskWeight gain during adulthood has been found to be a consistent and strong predictor of breast cancer risk Overweight women (BMI > 25) are 1.3 – 2.1 times more likely to die from breast cancer compared to women with normal weight (BMI = – 24.9)Overweight women (BMI > 25) are 1.3 – 2.1 times more likely to die from breast cancer compared to women with normal weight (BMI = – 24.9) Weight Can Impact Breast Cancer Survival Body Weight and Breast Cancer

26 Cognitive Function Urogenital Atrophy PremenopausalPostmenopausal

27 Sexuality and Body Image

28 Strategies for Providing Patient Support Seattle Cancer Care Alliance University of Washington Women’s Wellness Follow-up Clinic Screening for cancersScreening for cancers Management of menopausal symptomsManagement of menopausal symptoms Screening for osteoporosis, cardiac risk factorsScreening for osteoporosis, cardiac risk factors Physical therapyPhysical therapy NutritionNutrition Psychology and social servicesPsychology and social services Reconstructive surgeryReconstructive surgery Genetic counselingGenetic counseling Education (newsletter, lectures, retreats)Education (newsletter, lectures, retreats)

29 OVERALL HEALTH AND WELLNESS RECOMMEDATIONS OVERALL HEALTH AND WELLNESS RECOMMEDATIONS Health Maintenance Make sure you keep up to date on vaccinations and routine health maintenance screening (cholesterol, blood pressure, skin checks, pelvic exams, colonoscopy, etc). Exercise and Physical Activity The SCCA encourages breast cancer survivors to adopt a physically active lifestyle. Try to engage in at least 30 minutes of moderate to vigorous physical activity 4-5 days of the week. Request a referral to physical therapy for help in setting goals, and/or aid in dealing with physical limitations. Lymphedema Review lymphedema prevention education. Consider a referral to physical therapy for lymphedema, range of motion, or general exercise recommendations if indicated. Nutrition The SCCA supports the nutrition guidelines of the American Cancer Society to optimize health and reduce cancer risk. These include a diet high in fruits, vegetables and whole grains, and low in fat. Choose foods and drinks in amounts that help achieve and maintain a healthy weight, and limit alcohol. Request a referral to our nutrition department if you’d like help in setting nutrition goals. Genetic counseling and testing If there is a history of cancer in your family, or if you were diagnosed with breast cancer at a very young age, consider genetic counseling and testing. Fear of Recurrence Develop and strengthen coping skills. Talk to friends and family. Request a referral to a therapist and information on community resources as needed. Heart Health Low fat diet, regular aerobic exercise and maintaining weight and blood pressure. Know what your cholesterol level is. Symptoms that should be reported are SOB, dizziness, and chest pain and new onset or worsening of fatigue. Bone Health Regular weight bearing exercise. Daily Calcium and vitamin D, limit ETOH and no smoking. Pain Regular exercise both aerobic and resistance training, stretching, yoga, acupuncture and massage can decrease pain. Fatigue Adequate sleep, regular exercise and good nutrition will facilitate recovery and reduce fatigue after treatment. Sexual Health/Body Image Communicate with your partner. Suggest vaginal lubricants/moisturizers and plan time for intimacy. Consider a referral to a therapist to address body image issues, or a gynecologist for help with vaginal atrophy and other physical issues. Memory/ cognitive concerns Look into organizational strategies such as establishing a routine and keeping a planner, taking notes, etc. Focus on addressing anxiety and depression symptoms, if present, and optimizing sleep and nutrition.

30 Strategies for Providing Patient Support Team Survivor Northwest An Exercise and Fitness Program for All Women Affected by Cancer Founded 1995 Weekly workoutsWeekly workouts Twice weekly walksTwice weekly walks RunningRunning HikingHiking BikingBiking Yoga and tai chiYoga and tai chi Dragon boatingDragon boating SwimmingSwimming Annual fitness retreatAnnual fitness retreat

31 Optimizing Health and Wellness After a Diagnosis of Cancer The majority of cancer patients can look forward to a long life after diagnosis and treatmentThe majority of cancer patients can look forward to a long life after diagnosis and treatment Clinicians must work with patients on all aspects of health and well-being:Clinicians must work with patients on all aspects of health and well-being: regular exerciseregular exercise weight controlweight control healthy diethealthy diet smoking avoidancesmoking avoidance sunscreensunscreen stress reductionstress reduction controlling co-morbidities: hypertension, diabetes, hyperlipidemia, osteoporosiscontrolling co-morbidities: hypertension, diabetes, hyperlipidemia, osteoporosis Team Survivor Northwest Dragon Boat Team


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