Presentation on theme: "Long-term Follow-up of Breast Cancer Patients"— Presentation transcript:
1Long-term Follow-up of Breast Cancer Patients Julie R. Gralow, M.D.Director, Breast Medical Oncology, Seattle Cancer Care AllianceProfessor, Medical Oncology, University of Washington School of MedicineMember, Clinical Division, Fred Hutchinson Cancer Research Center
2The Cancer Care Continuum Detection Treatment Survivorship& DiagnosisOptimal care of an individual person differs along the continuum
3Institute 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 healthRoutine follow-up visits are opportunities to promote healthy lifestyle, check for cancer recurrence, manage lasting effects of the cancer experienceCancer survivors are a heterogeneous population, some having few late effects of cancer and its treatment, and others suffering permanent and disabling symptomsThe good news is that there is much that can be be done to avoid, ameliorate, or arrest the late effects of cancer
4Complications of therapy: 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, FISHOncotype DX (if done):Family History of Cancer:BRCA1/2 testing (if done):Significant Past Medical History and Medications:Cancer TreatmentSurgeryBreast Surgery: Procedure, dateLymph Node Surgery: Procedure, dateReconstruction: Procedure, dateSystemic TherapyChemotherapy:RouteDoseScheduleNumber of cyclesCumulative Anthracycline Dose Administered:Doxorubicin____ mg/m Epirubicin___ mg/m2HER-2 Targeted Therapy: Drug, start date, stop dateEndocrine (Hormonal Therapy): Drug, start date, stop dateBisphosphonate Therapy for Breast Cancer Indication: Drug, start date, stop dateEnrolled in Clinical Trials?Radiation TherapyDate StartDate StopTotal Dose (cGy)Fields included:Complications of therapy:ProvidersPrimary Care Provider:Surgeon:Radiation Oncologist:Medical Oncologist:IOM Report: All Patients Should Receive a Cancer Treatment Summary SCCA Breast Cancer Treatment Summary (modified from asco.org)
5Breast Cancer Follow-Up Includes Three Major Goals: Surveillance for cancer recurrenceMonitoring for toxicities related to therapyMaximizing overall health and quality of life
6Breast Cancer Survivorship Care Plan (modified from asco.org) Follow-Up Care TestRecommendationMedical history and physicalVisit 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 imagingThe 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 examinationContinue to visit a gynecologist regularly. Women taking tamoxifen should report any irregular vaginal bleeding to their doctor.Laboratory testsYour 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 testsYour 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 careMost 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.
7Surveillance for Breast Cancer Recurrence Local/Regional RecurrenceDistant RecurrenceAssessment of risk of cancer recurrence and second cancersInterventions to further reduce risk of cancerEarly detection of recurrence and second cancers
8Recurrence hazard rate Assessing Risk of Cancer Recurrence Recurrence Hazard Rates for Breast Cancer After Primary Therapy Saphner et al, J Clin Oncol 14:2738, 19960.30.2Recurrence hazard rate0.1Saphner and colleagues analyzed the annual hazard of recurrence of over 3500 breast cancer patients after surgery.While the hazard of recurrence was greatest between years 1 and 2 after surgery and then decreased consistently until the interval between years 5 and 6, the average hazard of recurrence between years 5 and 12 was still 4.3% per year.In summary, even more than 5 years post-surgery, the risk of breast cancer recurrence remains elevated.This indicates the need for an effective treatment option in the extnded adjuvant setting.123456789101112Years
9Assessing Risk of Second Cancers How Much Breast Cancer Is Hereditary? 15-20%5-10%70-80%
10Cancer Screening: Looking for Cancer Recurrence and Second Cancers MammographyHealth Professional’s ExamSelf-ExamBreast MRI in some very high risk?
11Monitoring for Toxicities Related to Therapy Assessing risk of toxicitiesInterventions to reduce risk of toxicityDetection and treatment of side effects
12Side Effects of Chemotherapy Cardiac Events vs Side Effects of Chemotherapy Cardiac Events vs. Cumulative Chemotherapy Dose10080Doxorubicin60Cardiac events (%)40This Kaplan-Meier plot depicts the rate of cardiac events(defined by left ventricular ejection fraction < 35) in patients with metastatic breast cancer by cumulative dose of anthracycline received.Among patients receiving Doxil (indicated by the insert color line), cumulative doses exceeding 450 mg/m2 were not associated with an increasing risk for cardiotoxicity.The risk for developing a cardiac event was significantly lower in Doxil-treated patients vs conventional doxorubicin-treated patients. Among all treated patients, at cumulative doses above mg/m2, there was a 40% risk of developing a cardiac event with conventional doxorubicin compared with only an 11% risk with Doxil.Wigler N, et al. [abstract] Proc Am Soc Clin Oncol. 2002;21:45a. Abstract 177.450 mg/m22010010020020030030040040050050060060070070080080090090010001000Cumulative anthracycline dose (mg/m2)
13Side Effects of Chemotherapy Chemotherapy-induced Menopause in Breast Cancer Ovarian damage is a significant long-term consequence of adjuvant chemotherapy in premenopausal breast cancer patientsAll are affected by resultant menopausal effectsInfertility seriously affects someFor women who retain ovarian function after breast cancer, pregnancy is possible post-chemoLimited data do not show a worse outcome for women who become pregnant after breast cancerNew techniques for preserving ovarian function and achieving fertility are under study
14Side Effects of Endocrine Therapy Adjuvant Hormonal Treatment of Breast Cancer: Weighing the Side EffectsArthralgia/myalgia Neurocognition? DVT, CVAHyperlipidemia Sexual function? Uterine CAOsteoporosis risk Cardiovascular Dz? Hot flashesTamoxifen AromataseInhibitors
15Assessing Risk of Side Effects Women Cancer Patients Are at Increased Risk for Osteoporosis Lack of estrogenEstrogen prevents bone breakdown (resorption) and preserves bone densityEstrogen may also help maintain normal levels of vitamin D, an important nutrient in bone protectionPremenopausal womenChemotherapy-induced menopauseOvarian suppressionPostmenopausal womenAromatase inhibitors
16Maximizing Overall Health and Quality of Life The Effects of Breast Cancer Treatment on Emotional and Physical Well-BeingFatigue/decreased energyNausea/vomitingAlopecia (hair loss)MenopauseInfertilitySexuality/body imageLymphedemaDepression, anxietyPainFear of recurrenceEtc….
17Managing MenopausePrevalence of Menopausal Symptoms in Women with a History of Breast Cancer Couzi et al, JCO 1998Hot flashes 65%Night sweats 44%Vaginal dryness 48%Pain with intercourse 26%Insomnia 44%Depression 44%
18Exercise, Physical Activity and Cancer Team Survivor NorthwestMt. Baker August 2008
19Exercise 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 therapyResults: Women who exercised > 90 minutes per week (divided over 3 or more days) reported significantlyLess fatigueLess emotional distressHigher functional abilityBetter QOL
20Physical Activity Can Impact Breast Cancer Survival Exercise and Survival After Breast Cancer Diagnosis (Nurses Health Study) Holmes MD et al, JAMA 2005Patients: 2,987 nurses with early stage breast cancerPhysical activity categories:LOWMEDIUMHIGHResults: 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
22Carefully Monitored Exercise Does Not Increase Lymphedema Weight Training and Lymphedema in Breast Cancer Survivors Ahmed RL et al, J Clin Oncol 2005Patients: 45 breast cancer survivors s/p axillary lymph node dissectionStudy: Randomized to weight training program or notWeight training sessions 2x per week for 6 monthsFor upper body, initially used no weights or only wrist weights, weight gradually increased if no symptoms of lymphedema developedResults: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
23Nutrition, Body Weight and Breast Cancer -Maintain good body weight-Low fat diet-High fiber-Increase fruits and vegetables-Limit alcohol
24Nutrition Can Impact Breast Cancer Survival Women’s Intervention Nutrition Study (WINS) Chlebowski R et al, 2006Patients: 2,437 postmenopausal women with early stage breast cancerIntervention: Randomized within 1 year of surgery to:dietary intervention (8 biweekly counseling sessions by nutritionists and support throughout)vs. controlResults:At 1 year: Intervention group 1/3 less fat intake per dayAt 5 years: 24% reduction in breast cancer recurrenceConclusion: Nutrition interventions can decrease recurrences in breast cancer patients
25Weight Can Impact Breast Cancer Survival Body Weight and Breast Cancer Weight gain during adulthood has been found to be a consistent and strong predictor of breast cancer riskOverweight 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)
26Cognitive Function Urogenital Atrophy PremenopausalPostmenopausal
28Strategies for Providing Patient Support Seattle Cancer Care Alliance University of Washington Women’s Wellness Follow-up ClinicScreening for cancersManagement of menopausal symptomsScreening for osteoporosis, cardiac risk factorsPhysical therapyNutritionPsychology and social servicesReconstructive surgeryGenetic counselingEducation (newsletter, lectures, retreats)
29OVERALL HEALTH AND WELLNESS RECOMMEDATIONS Health MaintenanceMake 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 ActivityThe 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.LymphedemaReview lymphedema prevention education. Consider a referral to physical therapy for lymphedema, range of motion, or general exercise recommendations if indicated.NutritionThe 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 testingIf 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 RecurrenceDevelop and strengthen coping skills. Talk to friends and family. Request a referral to a therapist and information on community resources as needed.Heart HealthLow 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 HealthRegular weight bearing exercise. Daily Calcium and vitamin D, limit ETOH and no smoking.PainRegular exercise both aerobic and resistance training, stretching, yoga, acupuncture and massage can decrease pain.FatigueAdequate sleep, regular exercise and good nutrition will facilitate recovery and reduce fatigue after treatment.Sexual Health/Body ImageCommunicate 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 concernsLook 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.
30Strategies for Providing Patient Support Team Survivor Northwest An Exercise and Fitness Program for All Women Affected by Cancer Founded 1995Weekly workoutsTwice weekly walksRunningHikingBikingYoga and tai chiDragon boatingSwimmingAnnual fitness retreat
31Optimizing Health and Wellness After a Diagnosis of Cancer Team Survivor Northwest Dragon Boat TeamThe majority of cancer patients can look forward to a long life after diagnosis and treatmentClinicians must work with patients on all aspects of health and well-being:regular exerciseweight controlhealthy dietsmoking avoidancesunscreenstress reductioncontrolling co-morbidities: hypertension, diabetes, hyperlipidemia, osteoporosis