1. Living Beyond Breast Cancer: Post Treatment Concerns
Megan Dunne RN, MA, AOCNP
Nurse Practitioner for Breast Cancer Survivorship
Memorial Sloan Kettering Cancer Center

2. Experiences of Cancer Survivors
Lance Armstrong Foundation LIVESTRONGTM Survey of 2,307 Post-Treatment Survivors
99% reported ≥ 1 problem as a result of cancer
Physical problems (86%)
Energy, concentration, sexual dysfunction, neuropathy, pain were most highly endorsed
Emotional concerns (93%)
Fear of recurrence, depression, grief/identity issues, concerns about family members risk
Practical concerns (58%)
70% of those in school reported school-related problems
40% experienced employment issues
Debt issues (33%); insurance issues (21%)
The 2006 LIVESTRONG Survey for Post-Treatment Cancer Survivors was fielded in the wake of the 2006 IOM report (Hewitt, Greenfield, & Stovall, 2006), calling for more attention to the post-treatment period of the cancer continuum. The results of the 2006 survey validated the IOM’s call to action: most post-treatment cancer survivors reported experiencing a variety of physical, emotional and practical concerns, and too often they were not receiving care for those concerns. If the 2006 survey results offered validation, the results of the 2010 survey put forth a sense of urgency. Four years after the launch of the initial survey, the landscape of post-treatment survivorship in terms of what these cancer survivors experienced remains the same—and is quite concerning.
LIVESTRONG survey 2006
LIVESTRONG Report, 2011.

3. After Effects of Breast Cancer Therapies
Long term effects
Developed during treatment
Linger and are chronic after treatment is completed
Some improve over time
Fatigue
Anemia
Permanent-
Neuropathy- nerve damage
Numbness, tingling, pain

4. After Effects of Breast Cancer Therapies
Late Effects
Delayed-can emerge months or even years after treatment
Lymphedema
Osteoporosis

5. Surgery Radiation Therapy
Late medical effects of
treatment depend
on the type of
therapy . . .
Surgery
Hormone Therapy
Radiation
Therapy
and the specific
toxicities of each therapy
Potential wide range of long-term and late effects. Risk depends on the tissue and age of patient at time of treatment Dose and modality specific (e.g., surgery, radiation, chemotherapy) Combined modality therapy can have additive risks
Surgery- Scarring at incisionTissue necrosis,Lymphedema
Limited movement or activitiesPain, Psychological effect of physical changes. Even if not visible to others
Radiation Skin changes,Sensation changes,Pain,Numbness
Chemotherapy- Fatigue,Early or premature menopause,Infertility, Neuropathy,Cognitive changes,Memory loss,Attention alteration, Osteoporosis, Skin, hair, nail changes, Secondary cancers
Hormone/Endocrine therapy-Menopausal symptoms,Hot flashes, Vaginal dryness, Sleep disorder, Osteoporosis, Arthritis , pain, Blood clots, Secondary cancers
Chemotherapy

6. Types of After Effects Physical Emotional Practical
Fatigue, Scars, Lymphedema, Osteoporosis
Emotional
Anxiety/depression
Fear of Recurrence
Practical
Employment
Health Insurance

7. Fatigue

8. Fatigue: Symptoms Prevalence in breast cancer survivors 33 to 37%.
More prevalent and prolonged in patients who’ve received chemotherapy
Symptoms reported by patients
Tired despite sleeping well at night
Difficulty performing routine activities
Irritability
Difficulty concentrating
Goedendorp et al (2007) Cancer Nov 15

9. Fatigue: Interventions
Balance activity and rest periods
Healthy lifestyle choices
High fiber, low fat diet
Exercise
Yoga
Aerobic exercise
Meta-analysis of 16 studies (n=1426)
Aerobic exercise caused significant reduction in cancer related fatigue
Further studies needed to determine effects of exercise underlying causes of fatigue
Exercise
Yoga (perhaps speak to the evidence and recommendations instead of listing them)
Systematic Review and Meta-analysis of 15 RCTs
Exercise has modest positive effect on depression
Larger effect for supervised programs
Not at home
At least 30 mins in duration
Exercise associated with reduced fatigue, pain and improved QOL
Yoga
RCT N=31 female breast cancer survivors
Randomly assigned to yoga vs. health education
Fatigue severity declined significantly over 3 months in Yoga group with “increased vigor”
Both groups had positive changes in depressive symptoms and stress
McMillan et al (2011) Appl Physiol Nutr Metab Dec;36(6)

10. Insomnia Related Fatigue
Prevalence as high as 88% cancer patients
Lasts for years after therapy is completed
Becomes chronic when maladaptive responses to the initial sleep disturbance develop
Underreported and undertreated
Contributes to:
Decreased quality of life (QOL)
Impaired function
Impaired cognition
Conducted over 6 to 10 weeks
>20 therapies developed
Used alone or in combination
Goal oriented
Behavior change through alteration of cognitive distortions
Require patient participation
Most common
Stimulus control
Sleep restriction
Sleep hygiene education
Woodward (2011) CJON 15;4Perlis et al (2008) Cog Behav Tr Insomnia: session by session guide ONS (2008) PEP: Sleep wake Disturbances

11. Cognitive Changes

12. Cognitive Changes: Symptoms
Prevalence up to 40% cancer patients
Difficulty concentrating, attention deficit, easily distracted
Short term memory loss
Inability to perform routine tasks
Checkbook, multi-tasking, recall names/dates
American Cancer Society (2008)Jansen et al (2005) ONF 32: Stewart et al (2008) PsychoOncology 17:2Ahles et al (2002) JCO 20:

13. Cognitive Changes: Interventions
Exercise- improves brain oxygenation
Acupuncture
Antioxidant foods- fruits and vegetables high in vit C and E can mediate effects of oxidative stress
Increased fluid intake- prevents dehydration, flushes toxins
Inform family and friends- generate support and understanding
Nelson et al (2007)Palliative and Supp Care 5:3 p
Barton and Loprinzi (2002) Clin Breast Ca 3 (suppl 3) s

14. Cognitive Changes: Interventions
Sleep habits
Make lists
Mental exercises-
Crosswords, Sudoku puzzles
Relaxation activities
Music, hobbies, nature
Cognitive therapy
MSKCC Trial- Memory Training
Pharmacologic Interventions: Effectiveness Not Established
MSKCC Trial with Intervention “CogMed Memory Training”
5 week Computer based training with exercises to improve cognitive function
30 mins per day 5 days/week
Wilson et al (2002) J Amer Geriatrics Soc 50:12 p

15. Lymphedema

16. Lymphedema: Symptoms Prevalence is estimated at 21% to 49%
Includes self- reported symptoms
Swelling of arm or trunk
Jewelry and clothing feel “tight”
Fullness or discomfort of arm
Loss of flexibility of hand, wrist, fingers
Infections that recur in same area
Cellulitis
Skin changes and feels “tight”
Smoot et al (2010) J Cancer Surv; Jun 4:2 p167-78
2010 LIVESTRONG survey, Petrek et al (2001) Cancer 92:

17. Lymphedema: Interventions
Multimodality Therapy
Lymphedema specialist
Occupational Therapy
Compression garment or “sleeve”
Manual lymphatic drainage with massage
Health diet, healthy weight
Adequate fluid hydration
Shah and Vicini (2011) Int J Rad Onc Biol Phys. 81:4 p

18. Chemotherapy Induced Peripheral Neuropathy (CIPN)
Common side-effect of Taxane therapy
25% incidence of severe neurotoxicity even 6 to 12 months after therapy completed
Incidence is increase with multi-drug therapy

19. CIPN : Symptoms Incidence is greatest in patients treated with taxanes
Paclitaxel 57%-83%overall; 2%-33% severe
Docetaxel 11%-64% overall; 3%-14% severe
Numbness
Hands or feet most common
Pain
Burning, shooting pain
Sensitivity to temperature
Loss of reflexes and reduced function of extremities
Ataxia- gait changes
Quastoff and Hartung. (2002) J Neurol 249 (1): 9-17

20. CIPN: Interventions No proven evidence based interventions
Control contributing conditions
Diabetes mellitus
Thyroid dysfunction
Physical and Occupational Therapy
Exercise
Acupuncture
Studies of pharmacologic and non-pharmacologic interventions with adequate sample sizes, rigorous study design, and standardized well established measurements of CIPN are still necessary.
Pharmacologic interventions with some weak supportive evidence include:
Chemo-protectants- Amifostine
Vitamin E
Calcium and magnesium infusions
Tricyclic antidepressants- Nortriptyline
Anticonvulsants- carbamazepine
Acetyl-L-carnitine
Glutamine
Glutathione
Visovsky et al. (2007) CJON 11;6 p
ONS PEP: Evidence Based Interventions for CIPN

21. CIPN: Education Maintain Safety Proper foot care and foot wear
Visual input to compensate for sensation loss
Risk of ischemic and thermal injury
Protect skin from hot and cold extremes
Proper foot care and foot wear
Dangle legs prior to standing
High fiber diet and adequate fluid intake
Armstrong et al. (2005) ONF. 32:
Marrs and Newton. (2003) CJON, 7:

22. Bone Health

23. Osteoporosis Primary Osteoporosis
Major public health issue in general population
Particularly post-menopausal women
Baseline Bone Mineral Density
age 50
Wickham (2011) CJON 15:6

24. Osteoporosis
Secondary osteoporosis related to cancer therapies is common in Breast Cancer Survivors
Premature ovarian failure
Chemotherapy
Elective ovarian ablation
Impaired gonadal function
Gonadotropin and Androgen blockade
Estrogen blockade
Tamoxifen
Negative effect in pre-menopausal women only
Aromatase inhibitors
Abdel –Razeq and Awidi: J of Ca Res and Ther 7:3

25. Osteoporosis: Symptoms
Silent disease
Can exist for years without symptoms
Loss of height
Stooped posture
Spinal curve or “hump”

26. Osteoporosis: Assessment
Bone Mineral Density Testing
T-score
NTX ( serum and urine)
bone turnover rate
FRAX ® World Health Organization Fracture Risk Assessment Tool
Algorithm
Estimates 10 year fracture risk
Stratifies gender, age, co-morbidities

27. Osteoporosis: Non-pharmacologic Interventions
Limit alcohol and stop smoking
Weight bearing activities
Maintain a healthy weight
Strength training
Safety- falls prevention
Nutritional considerations
Calcium and Vit D

28. Osteoporosis: Pharmacologic Interventions
Bisphosphonates
Alendronate (Actonel®)
Ibandronate (Boniva®)
Risedronate IV
Zoledronic Acid IV
Other agents
Denosumab
Calcitonin
Wickham, R (2011) CJON 15:6 p E90-E104
Drake et al (2008) Mayo Clin Proceedings 83:

29. Chronic Pain
Who is at risk? Any patient who has surgery and this increased with XRT to the breast, chest wall. Pain can be related to musculoskeletal changes and nerve fibers regenerating after damage from surgery/XRT. Pain is usually described as “fleeting” lasting only a few seconds to mins at a time. Most women do not require pain meds and breast pain is not usually associated with a recurrence.

30. Chronic Pain: Interventions
Talk to your medical team
Multidisciplinary approach
Stretching, exercise
Complementary therapies
Acupuncture
Take medication as directed
May require frequent monitoring and changes
Pain specialist consult

31. Sexual Dysfunction Under reported and under- addressed.
Can have a sustained negative effect on QOL which is why I plan to spend some time on this today.

32. Sexual Dysfunction: Symptoms
Decreased libido (desire)
Difficulty reaching climax (orgasm)
Vaginal dryness
Painful intercourse
Painful touching
Tightness

33. Sexual Dysfunction: Interventions
Consult with GYN who specialized in women’s issues
Kegel exercises
Vaginal dilator
Psychologic support
Depression
Anxiety
Self- esteem, body images issues

34. Vaginal Moisturizers Apply at bedtime 2 to 5 times weekly
Vitamin E capsules
Puncture a vitamin E capsule with a pin. Insert the capsule into your vagina. You can also empty the capsule onto a finger. Wipe the vitamin E inside your vagina.
Replens®
This vaginal moisturizer comes with an applicator and is inserted into the vagina.
K-Y® Brand LIQUIBEADS™
This is a vaginal bead (OVULE™) suppository placed into the vagina. It also comes with disposable applicators.
Non-hormonal OTC Products for overall vaginal health regardless of sexual activity
Goal is to hydrate and improve moisture
Carter et al (2011) J Sexual Med 8:

35. Vaginal Lubricants Eros® women formula. Astroglide®. KY® Jelly.
Pjur® Woman Bodyglide (a silicone-based lubricant).
Avoid colors, flavors, spermicides, and warming liquids
Liquid or gel to supplement woman’s own lubrication-
Applied to clitoris and labia minora and inside the vaginal entrance
May require several applications during sexual activity
Carter et al (2011) J Sexual Med 8:

36. Vaginal Hormone Replacement
Discuss safety with your medical team
Opinions vary
Vagifem® is contained in an applicator. Insert it into your vagina every night for 14 days. Then insert it twice a week, at bedtime.
Estring® comes as a vaginal ring. Insert the ring into the vagina and push it as far back as possible. Remove it after 90 days.

37. Emotional After Effects

38. Depression and Anxiety
Common in cancer survivors
Fear of recurrence
Body changes
Support Services
Community support groups
Family, friends
Psychologist, Psychiatrist

39. Journey Forward: Supporting Survivors and Providers
SCPB – available thru CDs and on website
Provide supporting materials like sample care plans, demo, tech support

40. ASCO Breast Cancer Adjuvant Treatment Plan and Summary

41. Treatment Summary and Care Plan
Diagnosis and treatment history
Co-morbid conditions
Medications
Family history
Genetics consult
Screening recommendations
Health Promotion Counseling
Care plans should quickly summarize patient’s diagnosis and treatment history and the follow-up plan.
This should be communicated from the cancer specialist to the patient and their PCP and/or GYN

42. Routine Screening Annual mammogram at age 40
Annual clinical breast exam
Self breast awareness
Notify your NP/MD of changes
Colonoscopy baseline at age 50
PAP smear with gynecologist
Skin cancer screening as indicated

43. Promote Healthy Life Choices to Prevent Cancer
If you smoke- STOP
Limit alcohol
Exercise
Eat a balanced low-fat, high-fiber diet
Reduce stress
Health maintenance with Primary Care Provider