2. Breast Cancer Surveillance Guidelines & Wellness Recommendations Lynne P Clark MD F.A.C.S. Tacoma, Washington March 13, 2012 Fourth Annual Pierce County Cancer Survivorship Conference

3. Objectives Review recommendations for surveillance type of surgery/ stage of your cancer Review opportunities for wellness to help prevent recurrence of breast cancer Survivorship goals Prevention tips

4. Surveillance How it was found Type of surgery performed What stage your cancer is Type of adjuvant therapy Chemotherapy Hormonal therapy

5. Breast conservation How was your cancer found? Screening mammogram Continue diagnostic mammograms every six months for the first two years and then diagnostic mammograms annual for five years Self found breast mass/not found on mammogram More difficult situation, continue with diagnostic mammograms but may additional studies Tomosynthesis, MRI, BSSI Self breast exams monthly report changes

6. After mastectomy NO reconstruction Typically no need for mammograms Monthly self chest exams critical

8. After reconstruction Implants -- saline Implants -- silicone need MRI to look at integrity of silicone implants every three years Flap ? need periodic MRI to look behind the flaps -- not standard of care to offer this

9. Breast imaging MRI of the breast Breast specific sestabimi – BSSI Tomosynthesis Whole breast ultrasound Thermography ???

10. Stage of cancer Stage 1 - limited to breast Stage 2 – larger tumors or involved nodes may require additional studies annually PET, CXR, BONE SCANS, MRI, CT scans, LABS Stage 3 additional metastatic studies annually Stage 4 additional metastatic studies annually

11. What treatment you had Breast conservation with radiation Follow up q 6 months with surgeon and radiation oncologist Mastectomy/reconstruction Breast surgeon for surveillance q 6 months to annually Chemotherapy Oncologist follow q 3 months first few years and then q 6 months labs to follow your blood levels

12. Type of adjuvant therapy Chemotherapy Check labs serially DEXA scans Hormonal therapy Tamoxifen Gynecological exams yearly Monitor for abnormal bleeding DVT prevention Aromatase Inhibitor DEXA scan baseline and yearly

13. Need for physical therapy After surgery ? Range of motion of upper body After radiation ? Range of motion of upper body Breast Edema Arm edema Prevention of lymphedema Physical therapist Lymphedema therapist GOAL is to get back to original level of functioning

15. Vitamin D supplementation Minimal replacement of 2000 IU daily Check vitamin D 25OH level in blood but many insurances companies won’t pay for it Vitamin D makes breast cells more resistent to toxins, decrease ability for breast cancer cells to grow and boosts immune system

16. Opportunities for wellness Dietary recommendations ( Tricia Sinek talks) Exercise Body weight (Body Mass Index) Social habits – tobacco and alcohol ingestion Sleep habits Stress Family issues Intimacy issues

17. Dietary recommendations Vegetables variety at each meal Phytochemicals/phytoestrogens Each color is a potent natural medicine Eat the rainbow daily Fills you up, adds elimination, remove toxins 5-8 servings a day Cruciferous vegetables most powerful(40% reduction) Fruits 3-4 servings a day Berries, grapes, apples antioxidants

18. Red meats no more than 18 oz a week rich in saturated fats, hormones Fish 2-3 times a week Omega 3 fatty acids Healthiest type of fat Lowers risk of metastases

19. Legumes - one serving daily inhibits reproduction of cancer cells anti angiogenesis properties Whole grains- 3 or more servings a day fiber, antioxidants, phenols 25 gm/day (54% reduction) Nuts and seeds – one serving daily Omega 3 fatty acids,, phytoestrogen

21. Exercise 30 minutes five days a week aerobic activity reduces risk of recurrence of breast cancer by 30-50 % Strength training a few days a week Start slow, listen to your body, make it part of your day 15 minutes a day then add 5 minutes every couple of weeks, add weights Join gym Get friends to commit with you Even during chemotherapy can be helpful!!

22. Body Weight Maintain or strive for BMI of under 25 Body fat produces estrogens and proteins that cause inflammation and increase blood insulin levels which encourages cancer cell growth Find a program that will help YOU Hospital based programs with dieticians Weight watchers Spark people online programs. Overweight women higher risk of recurrence and of dying from breast cancer

23. Body habits Tobacco now associated with breast cancer Avoid second hand smoke Alcohol moderation 1-2 times a week 1 drink increases risk 11% 2 drinks increase risk by 22 %

24. Sleep Habits Natural rhythm of nature Go to bed before 10 pm Get up before 6 am Hormonal fluctuations will be optimal Melatonin levels will be highest Avoid light in your bedroom

25. Stress reduction Family, job, changes in your body form, hormonal changes in your body Find out what you can do to alleviate your stress Counseling/communicate with family members Remove stressors!!! Change job Separation / abusive relationships Meditation/exercise/music/dancing…..

26. Family situation How is the rest of your family dealing with your disease Is it a topic discussed or avoided? Women can be the dominant figure in the family and fear of loss of the woman can bring a lot of negative interactions with other family members out of FEAR Make sure you communicate with each other Have people take responsibility for chores in the house Make family time This has to be agreed upon and maintained by all Individual or family counseling

27. Intimacy issues Change in your body form/deformity Is it your problem or your partner’s problem??? Weight gain – work with lifestyle coach Vaginal dryness – estrace cream can be prescribed Loss of libido – short course of testosterone ???estrogen replacement QUALITY OF LIFE!!!!!!

28. Survivorship goals Write down your own goals Prioritize them Change one thing a month Revisit it semiannually Visit with professionals that can help you

29. YOUR SUVIVORSHIP PLAN DIAGNOSIS: WORKUP: SURGERY: CHEMOTHERAPY: RADIATION: PHYSICAL THERAPY: ANTI ESTROGEN TREATMENT: VITAMIN D THERAPY RECOMMENDED: DEXA SCAN EVALUATION:

30. Survivorship plan -2 MAMMOGRAM FOLLOWUP SCHEDULE MRI NEEDED IF HAD BIOPSY? LYMPHEDEMA PREVENTION IF NODES REMOVED CURRENT BMI GOAL < 25 EXERCISE: CURRENT? GOAL 30 MINUTES 5 DAYS A WEEK

31. Survivorship plan 3 HEALTHY EATING: ALCOHOL INTAKE ONLY ONE OR TWO DRINKS A WEEK ABSENCE FROM TOBACCO OR SECOND HAND SMOKE WEIGHT REDUCTION PREVENTION OF OSTEOPOROSIS STRESS REDUCTION FAMILY SITUATION FEMININITY OR INTIMACY ISSUES/VAGINAL DRYNESS COUNSELING SPIRITUAL PERSONAL NEEDS /SATISFACTION

32. Dr. Clark’s TIPS for Prevention P - plants foods daily R - reduce alcohol intake E - exercise 30 minutes five days a week V - vitamin D 2000 IU or more daily E - examine your breasts monthly N - No tobacco or secondary smoke T - take care of yourself first /be an example to others I - ideal body weight less than 25 O- olive oil in your diet (mediterranean diet) decreases mammographic density suppress HER2 N - eat the RAINBOW

33. Our community is very rich in organizations dedicated or involved in breast cancer and prevention Seek out these programs Wellness programs Support groups Hospital based programs Be a warrior goddess!!!!

34. SPARKPEOPLE.COM AMERICAN CANCER SOCIETY SUSAN G KOMEN ORGANIZATIONBREAST CANCER RESOURCE CENTER PERSONAL TRAINING FHS ONCOLOGY DIETICIAN MULTICARE DIETCIAN, NATIONAL COALITION FOR CANCER SURVIVORSHIP Waking the Warrior Goddess by Christine Horner MD

35. Final thoughts We cannot do everything at once but we can do something at once! A vision must be followed by a venture. It is not enough to stare up the steps we Must step up the stairs.