1. Supportive Care During and After Treatment
Julie R. Gralow, M.D.
Director, Breast Medical Oncology
Jill Bennett Endowed Professor of Breast Cancer
Professor, Global Health
University of Washington School of Medicine
Fred Hutchinson Cancer Research Center
Seattle Cancer Care Alliance

2. Breast Health Global Initiative (BHGI) 5th Global Summit (2012) Supportive Care and Quality of Life
3 resource-stratified guidelines:
Long-term Follow-up Care and Survivorship
Treatment-related Supportive Care
Pain and Palliative Care

3. Supportive Care During Treatment for Breast Cancer Cardoso F et al: The Breast 22: 593-605, 2013
Providing supportive care during treatment can help:
Manage treatment-related toxicities and symptoms
Improve adherence to treatment recommendations
Address psychological and spiritual needs of patients

4. Supportive Care During Treatment for Breast Cancer Example: Gastrointestinal Toxicities Cardoso F et al: The Breast 22: , 2013
Basic:
Oral and/or IV hydration
Basic anti-emetics (nausea drugs)
Basic anti-diarrheals, stool softeners, laxatives
Mucositis (mouth inflammation) support: ice chips
Limited:
Stomach acid blockers (5HT3 blockers, H2 antagonists, antacids)
Stimulant laxatives
Topical agents for mucositis
Enhanced:
Enhanced anti-emetics (NK-1 antagonists)
Enhanced stomach acid blockers (PPIs)
Opioid analgesics for severe mucositis

5. Supportive Care During Treatment for Breast Cancer Example: Hematologic Toxicity and Infection Cardoso F et al: The Breast 22: , 2013
Basic:
Broad spectrum antibiotics
Limited:
Antifungals
Red blood cell transfusion
Enhanced:
Granulocyte (white blood cell) growth factors
Platelet transfusion
Iron therapy

6. Supportive Care During Treatment for Breast Cancer: Psychosocial Support
Psychosocial supportive care should be available soon after diagnosis and during treatment
Majority of disease and treatment-related psychosocial issues occur at this time
Major impact on roles at home, work and in community

7. Supportive Care During Treatment for Breast Cancer Cardoso F et al: The Breast 22: 593-605, 2013
Summary:
Treatment-related toxicities may be overlooked in LMICs
Health systems implementing supportive care programs should devote resources to:
Educating professionals, patients and communities about supportive care services
Provide resources to support monitoring of treatment-related toxicities
Provide psychosocial support

8. Breast Health Global Initiative (BHGI) 5th Global Summit (2012) Supportive Care and Quality of Life
3 resource-stratified guidelines:
Long-term Follow-up Care and Survivorship
Treatment-related Supportive Care
Pain and Palliative Care

9. U.S. National Cancer Institute Office of Cancer Survivorship Established in
Recognition of increasing number of individuals surviving cancer for long periods of time
Dedicated to enhancing length and quality of life of cancer survivors
Supports research that addresses long- and short-term effects of cancer and its treatment

10. Long-term Effects of Breast Cancer on Emotional and Physical Well-Being
Fatigue/decreased energy
Reproductive hormone effects: estrogen depletion (menopausal symptoms)
Infertility
Sexuality/body image, sexual function
Lymphedema
Depression, anxiety, fear of recurrence
Cognitive dysfunction
Pain/neuropathy
Relationships, employment
Etc….

11. IOM 2005 Report on Cancer Survivorship: Essential Components of Survivorship Care
Recurrence, second cancers, and assessing medical and psychosocial late effects
Recurrence, new cancers, late effects
Hewitt 2006, p2,
para 7- Box ES-1
Prevention
Surveillance
Treating the consequences
of cancer and its treatments
Intervention
Coordination
Interdisciplinary
coordination between specialists and primary care providers
Quality cancer survivorship should include 4 essential components within a delivery system that enables access to comprehensive and coordinated care:
Prevention of recurrent or secondary cancers, and of other late effects due to the cancer or therapy
Surveillance for cancer spread, recurrence, or second cancers; as well as vigilance for medical and psychosocial late effects
Intervention and management of symptoms and consequences of cancer and any effects related to cancer treatment. For example, medical problems such as sexual dysfunction or lymphedema that may arise after certain therapies
Coordination and teamwork among specialists and primary care providers to ensure that all the cancer survivor’s needs are being met
Reference:
Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition.
Washington DC; The National Academies Press; 2005.
Hewitt 2006, p2,
para 7- Box ES-1
Hewitt M, et al. eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington DC; The National Academies Press; 2005

12. BHGI: Supportive Care After Curative Treatment for Breast Cancer (Survivorship Care) Ganz PA et al, The Breast 22: , 2013
Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications
In LMICs supportive care services are frequently limited
Survivorship care is a distinct aspect of cancer treatment that should be integrated into all breast cancer care programs

13. Healthy Lifestyle Choices After a Breast Cancer Diagnosis Can…
Reduce risk of cancer recurrence and second cancers
Help manage early and late side effects of treatment
Improve overall health and well-being

14. Team Survivor Northwest An Exercise and Fitness Program for Women Affected by Cancer Seattle, Washington, USA Established 1995
Weekly workouts
Twice weekly walks
Running
Hiking
Biking
Yoga and tai chi
Dragon boating
Swimming
Annual fitness retreat

15. A Model for Providing Survivorship Care Seattle Cancer Care Alliance Women’s Wellness Follow-up Clinic
Patient population: breast and gynecologic cancer survivors more than 5 years from diagnosis and without recurrence
Providers: Nurse Practitioners
Services provided:
Screening for cancers
Physical therapy
Nutrition
Psychology and social services
Reconstructive surgery
Genetic counseling
Management of menopausal symptoms
Screening for osteoporosis, cardiac risk factors
Education (newsletter, lectures, retreats)

16. BHGI: Supportive Care After Curative Treatment for Breast Cancer (Survivorship Care) Ganz PA et al, The Breast 22: , 2013
Summary:
Survivorship care is intended to maximize health and well-being, while monitoring for recurrence and late-effects of treatments
Health professionals must be prepared to educate women about issues they are likely to experience, and to address specific problems in order to enhance recovery, improve functioning, and maximize adherence to medications
The most effective way to expand survivorship care in LMICs is through involvement of primary care networks and community-based programs

17. Supportive Care During and After Cancer Treatment Partnering with Patient Advocates