1. Long-term Follow-up of Breast Cancer Patients
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

2. The Cancer Care Continuum
Detection Treatment Survivorship
& 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 health
Routine 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 symptoms
The good news is that there is much that can be be done to avoid, ameliorate, or arrest the late effects of cancer

4. Complications 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, 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:
Route
Dose
Schedule
Number of cycles
Cumulative Anthracycline Dose Administered:
Doxorubicin____ mg/m Epirubicin___ mg/m2
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 Start
Date Stop
Total Dose (cGy)
Fields included:
Complications of therapy:
Providers
Primary 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)

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

6. Breast Cancer Survivorship Care Plan (modified from asco.org)
Follow-Up Care Test
Recommendation
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 Recurrence
Distant Recurrence
Assessment of risk of cancer recurrence and second cancers
Interventions to further reduce risk of cancer
Early detection of recurrence and second cancers

8. Recurrence hazard rate
Assessing Risk of Cancer Recurrence Recurrence Hazard Rates for Breast Cancer After Primary Therapy Saphner et al, J Clin Oncol 14:2738, 1996
0.3
0.2
Recurrence hazard rate
0.1
Saphner 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. 1 2 3 4 5 6 7 8 9 10 11 12
Years

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
Mammography
Health Professional’s Exam
Self-Exam
Breast MRI in some very high risk?

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

12. Side Effects of Chemotherapy Cardiac Events vs
Side Effects of Chemotherapy Cardiac Events vs. Cumulative Chemotherapy Dose
100 80
Doxorubicin 60
Cardiac events (%) 40
This 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/m2 20
100
100
200
200
300
300
400
400
500
500
600
600
700
700
800
800
900
900
1000
1000
Cumulative anthracycline dose (mg/m2)

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 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-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 study

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

15. Assessing Risk of Side Effects Women Cancer Patients Are at Increased Risk for Osteoporosis
Lack 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 women
Chemotherapy-induced menopause
Ovarian suppression
Postmenopausal 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 energy
Nausea/vomiting
Alopecia (hair loss)
Menopause
Infertility
Sexuality/body image
Lymphedema
Depression, anxiety
Pain
Fear of recurrence
Etc….

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

18. Exercise, Physical Activity and Cancer
Team Survivor Northwest
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 therapy
Results: 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:
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 dissection
Study: 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:
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 cancer
Intervention: Randomized within 1 year of surgery to:
dietary intervention (8 biweekly counseling sessions by nutritionists and support throughout)
vs. control
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 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 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)

26. Cognitive Function Urogenital Atrophy
Premenopausal
Postmenopausal

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 cancers
Management of menopausal symptoms
Screening for osteoporosis, cardiac risk factors
Physical therapy
Nutrition
Psychology and social services
Reconstructive surgery
Genetic counseling
Education (newsletter, lectures, retreats)

29. 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 workouts
Twice weekly walks
Running
Hiking
Biking
Yoga and tai chi
Dragon boating
Swimming
Annual fitness retreat

31. Optimizing Health and Wellness After a Diagnosis of Cancer
Team Survivor Northwest Dragon Boat Team
The 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:
regular exercise
weight control
healthy diet
smoking avoidance
sunscreen
stress reduction
controlling co-morbidities: hypertension, diabetes, hyperlipidemia, osteoporosis