Transcript 12.Long term Follow up of Breast Cancer Patients

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
The Cancer Care
Continuum
Detection
& Diagnosis
Treatment
Survivorship
Optimal care of an individual person differs
along the continuum
Institute of Medicine 2005 Report
From Cancer Patient to Cancer Survivor:
Lost in Transition
Hewitt M, Greenfield S, and Stovall E, eds.
http://www.cancer.net/patient/Survivorship/IOM_Executive_Summary.pdf
• 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
IOM
Report: All
Patients
Should
Receive a
Cancer
Treatment
Summary
SCCA
Breast
Cancer
Treatment
Summary
(modified from
asco.org)
Patient Name:
UW/SCCA medical record number:
Cancer Diagnosis:
Date of Birth:
Tumor Stage: Tumor Size (T) , Nodes (N) , Metastases (M)
Hormone receptors:
Estrogen receptor (ER) , Progesterone receptor (PR)
Oncotype DX (if done):
Family History of Cancer:
Date of Diagnosis:
Age at Diagnosis:
Tumor grade:
HER-2:
IHC, FISH
BRCA1/2 testing (if done):
Significant Past Medical History and Medications:
Breast Surgery: Procedure, date
Cancer Treatment
Surgery
Lymph Node Surgery: Procedure, date
Reconstruction: Procedure, date
Chemotherapy:
Systemic Therapy
Dose
Route
Schedule
Cumulative Anthracycline Dose Administered:
Doxorubicin____ mg/m2
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:
Radiation Oncologist:
Surgeon:
Medical Oncologist:
Number of
cycles
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
Breast Cancer Survivorship Care Plan
(modified from asco.org)
FOLLOW-UP CARE TEST
Medical history and
physical
Post-treatment breast
imaging
Breast self-examination
.
Pelvic examination
Laboratory tests
Radiology tests
Coordination of care
RECOMMENDATION
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.
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.
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.
Continue to visit a gynecologist regularly. Women taking tamoxifen should report
any irregular vaginal bleeding to their doctor.
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.
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.
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.
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
Assessing Risk of Cancer Recurrence
Recurrence Hazard Rates for
Breast Cancer After Primary Therapy
Recurrence hazard rate
Saphner et al, J Clin Oncol 14:2738, 1996
0.3
0.2
0.1
0
0
1
2
3
4
5
6
Years
7
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12
Assessing Risk of Second Cancers
How Much Breast Cancer Is
Hereditary?
Family 15-20%
Clusters
Hereditary
5-10%
Sporadic
70-80%
Cancer Screening: Looking for Cancer
Recurrence and Second Cancers
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Mammography
Health Professional’s Exam
Self-Exam
Breast MRI in some very high
risk?
Monitoring for Toxicities Related to
Therapy
• Assessing risk of toxicities
• Interventions to reduce risk of toxicity
• Detection and treatment of side effects
Side Effects of Chemotherapy
Cardiac Events vs. Cumulative
Chemotherapy Dose
Cardiac events (%)
100
80
Doxorubicin
60
40
450 mg/m2
20
0
0
100
200
300
400
500
600
700
800
Cumulative anthracycline dose (mg/m2)
900
1000
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
Side Effects of Endocrine Therapy
Adjuvant Hormonal Treatment of
Breast Cancer: Weighing the Side
Effects
Arthralgia/myalgia
Hyperlipidemia
Osteoporosis risk
Tamoxifen
Neurocognition?
Sexual function?
Cardiovascular Dz?
DVT, CVA
Uterine CA
Hot flashes
Aromatase
Inhibitors
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
Maximizing Overall Health and Quality of Life
The Effects of Breast Cancer Treatment on
Emotional and Physical Well-Being
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Fatigue/decreased energy
Nausea/vomiting
Alopecia (hair loss)
Menopause
Infertility
Sexuality/body image
Lymphedema
Depression, anxiety
Pain
Fear of recurrence
Etc….
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%
Exercise, Physical Activity and
Cancer
Team Survivor Northwest
Mt. Baker August 2008
Exercise Decreases Side Effects During
Treatment
Fatigue and QOL Outcomes of
Exercise During Cancer Treatment
Mock V et al, Cancer Pract 9: 119-127 2001
• 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
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
What About Lymphedema?
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
Nutrition, Body Weight and
Breast Cancer
-Maintain good
body weight
-Low fat diet
-High fiber
-Increase fruits
and vegetables
-Limit alcohol
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
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
= 18.45 – 24.9)
Cognitive Function
Urogenital Atrophy
Premenopausal
Postmenopausal
Sexuality and Body Image
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)
OVERALL HEALTH AND WELLNESS RECOMMEDATIONS
Health Maintenance
Exercise and Physical
Activity
Lymphedema
Nutrition
Genetic counseling and
testing
Fear of Recurrence
Heart Health
Bone Health
Pain
Fatigue
Sexual Health/Body
Image
Memory/ cognitive
concerns
Make sure you keep up to date on vaccinations and routine health maintenance screening
(cholesterol, blood pressure, skin checks, pelvic exams, colonoscopy, etc).
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.
Review lymphedema prevention education. Consider a referral to physical therapy for
lymphedema, range of motion, or general exercise recommendations if indicated.
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.
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.
Develop and strengthen coping skills. Talk to friends and family. Request a referral to a therapist
and information on community resources as needed.
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.
Regular weight bearing exercise. Daily Calcium and vitamin D, limit ETOH and no smoking.
Regular exercise both aerobic and resistance training, stretching, yoga, acupuncture and
massage can decrease pain.
Adequate sleep, regular exercise and good nutrition will facilitate recovery and reduce fatigue
after treatment.
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.
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.
Strategies for Providing Patient Support
Team Survivor Northwest
An Exercise and Fitness Program for All Women Affected by
Cancer Founded 1995
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Weekly workouts
Twice weekly walks
Running
Hiking
Biking
Yoga and tai chi
Dragon boating
Swimming
Annual fitness retreat
Optimizing Health and Wellness
After a Diagnosis of Cancer
• The majority of cancer patients
can look forward to a long life
after diagnosis and treatment
Team Survivor Northwest
Dragon Boat Team
•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