Transcript Life After Breast Cancer: Survivorship Mary Helen Hackney, M.D., FACP VCU Massey Cancer Center March 2013

Life After Breast Cancer:
Survivorship
Mary Helen Hackney, M.D., FACP
VCU Massey Cancer Center
March 2013
I have no disclosures
I am employed by VCU
2008 Estimated US Cancer Deaths*
Lung & bronchus
31%
Prostate
10%
Men
294,120
Women
271,530 •26% Lung & bronchus
•15% Breast
Colon & rectum
8%
Pancreas
6%
Liver & intrahepatic
bile duct
4%
Leukemia
4%
Esophagus
4%
• 3% Non-Hodgkin
lymphoma
Urinary bladder
3%
• 3% Leukemia
Non-Hodgkin
Colon & rectum
• 6% Pancreas
• 6% Ovary
3% lymphoma
Kidney & renal pelvis
All other sites
•9%
3%
24%
•3%
Uterine corpus
• 2%
Liver & intrahepatic
bile duct
• 2% Brain/ONS
•25% All other sites
ONS=Other nervous system.
Source: American Cancer Society, 2008.
Treating Cancer: It Requires Multiple
Disciplines
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Medical Oncologist
Surgical Oncologist
Radiation Oncologist
Special surgeons: ENT,
urology, gynecology,
plastics, neurosurg.
Radiologist
Pathologist
Primary Care Physician
Genetic counselors
Other specialties:
dermatology, GI,
pulmonary,cardiology
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Oncology nurses
Clinical trial/research team
Chaplain/spiritual
Physical/occupational
therapy
Psychologist/Psych.
Social worker
Navigators/educators
Nutritionist
Palliative Care team
Cancer Numbers
• One out of two men and one out of three women
will be diagnosed with cancer during their
lifetime
• Over 10 million survivors in USA
– Over 2 million of these are breast cancer survivors
• The side effects and complications of treatment
do not always end with the treatment
• Who is responsible for the post cancer treatment
care?
Cancer Survivorship
• 2005: Institute of Medicine (National Academy of
Science) published “ From Cancer Patient to Cancer
Survivor: Lost in Transition” by M. Hewitt et al
– Lack of adequate follow up measures and symptom
management
• 2011/2012: Commission on Cancer requires the
development of survivorship care plans
• American Society of Clinical Oncology (ASCO)
– Development of treatment plans, care guidelines
– Pediatric oncology has been doing this for years
Proposed Resources
• Development of cancer survivor clinics with a
focus on long term health goals
• Revisiting Cancer Rehabilitation programs
– Expanding to include more wellness
• Developing care plans for primary care
physicians and others to utilize for long term
medical management
The Challenges of Care Plans
• There are two main types of care plans
– Outline of cancer stage and treatment received
– Guidelines for follow up testing and surveillance
after treatment is completed
• There is no evidence to confirm that
surveillance/post treatment guidelines make a
difference in patient care
• To be useful, it needs to be integrated in to
the electronic medical record
Do post treatment guidelines and care
plans make a difference?
• Hope to use the best evidence for when and
when not to perform tests
• Provide security for patients
• Provide security for primary care physicians
and others
• Provides a comprehensive care plan for all
disciplines
• ? Where is the evidence ?
Patient Name:
Medical Oncologist Name:
FOLLOW-UP CARE TEST
RECOMMENDATION
PROVIDER TO CONTACT
Medical history and physical
(H&P) examination (see below)
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 mammography
(see below)
Schedule a mammogram one year after your first mammogram that led to diagnosis,
but no earlier than six months after radiation therapy. Obtain a mammogram every
six to 12 months thereafter.
Breast self-examination
Perform a breast self-examination every month. This procedure is not a substitute for
a mammogram.
Pelvic examination
Continue to visit a gynecologist regularly. If you use tamoxifen, you have a greater
risk for developing endometrial cancer (cancer of the lining of the uterus). Women
taking tamoxifen should report any vaginal bleeding to their doctor.
Coordination of care
About a year after diagnosis, you may continue to visit your oncologist or transfer
your care to a primary care doctor. Women receiving hormone therapy should talk
with their oncologist about how often to schedule follow-up visits for re-evaluation of
their treatment.
Genetic counseling referral
Tell your doctor if there is a history of cancer in your family. The following risk factors
may indicate that breast cancer could run in the family:
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Ashkenazi Jewish heritage
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Personal or family history of ovarian cancer
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Any first-degree relative (mother, sister, daughter) diagnosed with breast
cancer before age 50
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Two or more first-degree or second-degree relatives (grandparent, aunt,
uncle) diagnosed with breast cancer
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Personal or family history of breast cancer in both breasts
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History of breast cancer in a male relative
YEARLY BREAST CANCER FOLLOW-UP & MANAGEMENT SCHEDULE
Visit Frequency for H&P Years 1-3:
Years 4-5:
3 months
6 months
6 months
12 months
(circle one)
(circle one)
Visit Frequency for Mammography:
6 months
12 months
(circle one)
VISIT FREQUENCY
HISTORY AND PHYSICAL
M AMMOGRAPHY
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3 Month (if applicable)
th
6 Month (if applicable)
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9 Month (if applicable)
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12 Month (if applicable)
Notes:
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Risk: You should continue to follow-up with your physician because the risk of breast cancer returning continues for more then
Follow up guidelines
• Yearly mammograms
– Controversial: mammogram of flap
reconstructions
• Physical exam and extensive questions by
health care provider
• No data to support yearly xrays, bone scans or
lab work
• See ASCO follow up guidelines on
www.cancer.net
Breast Imaging
• The standard of care remains mammography
• There is no data on the value of MRI in the breast
cancer survivor
– The exception is the patient with BRCA gene or
significant family history
• Ultrasound complements mammography
• Breast reconstruction
– Implant: some manufacturers suggest MRI to look for
leakage NOT cancer
– Flap reconstructions: some suggest limited
mammography
Breast Cancer Survivor Topics
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Recurrence fears
Fertility
Sexuality
Cognitive dysfunction
Fatigue
Self image/esteem
Weight control
• Menopause
management
• Cardiac complications
• Bone marrow
complications
• Pain
– Neuropathy
– Pain at surgical sites
Fear of Recurrence
• No perfect test to confirm that a patient is cancer
free
– PET scan only sensitive to 7 mm
– No ideal blood test: CA 27-29 should not be used for
asymptomatic screening
– The current approved guidelines for breast suggest
mammogram if appropriate at yearly intervals
• Different cancers have different fear levels
– Patients are increasingly educated
– Media news can cause anxiety
• Fear of abandonment (by medical staff) as years go
by
Managing Fears
• Listen to the patient
– If something persists then test but realize that “peace
of mind” testing often leads to more testing and has it
limitations
– If something does persist, tests may be appropriate
(pain, unusual headache, etc.)
• Counseling with/without appropriate
medications is suggested if patient remains
overwhelmed and unable to enjoy life
• Recurrence fears can be disabling
Survivor Guilt
• Stress can be exacerbated when other
patients develop recurrence and/or die
particularly if they have been supporting each
other (formally or informally)
• Often a challenge for support groups
• “Am I going to be next?”
• “ Why not me? Why me?”
Stress, Relationships, etc.
• Depression
– Not uncommon; use appropriate medications and
counseling
• Caregiver fatigue
• Stress on relationships
– Several small surveys report increased divorce rates in
breast cancer patients
– Partner may fear they will hurt patient
– Partner may fear losing their loved one and have their
own coping difficulties
Cognitive Changes
• It has been recognized that many patients
have cognitive changes during treatment
• The causes have not been clearly identified
– Most often associated with chemotherapy
• Recent meta analysis found statistically
significant changes for 6 + months after
chemotherapy completion
• JCO (2012:30:3578-3587)
Cognitive Changes..
• The most common deficits described are:
– Verbal memory-word finding
– Visuo-Spatial ability-getting lost, ability to multitask
• JCO (2012:30)
• What may help:
– Adequate rest and sleep
– Limit multitasking
– Time-most deficits significantly resolve after 1 year
• This area needs more research to determine who
is at risk and what potential interventions are
appropriate
Being Male
• Less than 2000 new cases of male breast
cancer in the US per year
• Treatment is the same including surgery,
chemotherapy, hormonal therapy and
radiation therapy
• Support groups are limited since the numbers
are smaller but there has been national
attention due to a national spokesperson
Being Female
• Multiple issues may affect self image and self
esteem
• Appearance
– Surgical deformities
– Loss of breast as a sexual part
– Lack of hair
– May be particularly difficult for single survivors
looking for partners
Being Female
• Loss of libido
– Due to menopause
– Due to chemotherapy
– Due to fatigue
– Due to hormonal therapies for cancer
– Due to depression and its medications
• Concerns about estrogen replacement
products and potential consequences
Sexuality and Fertility
• Fertility discussions should happen before
treatment starts
– There is usually time
• Refer to a fertility expert
• It is not possible to preserve fertility in all
women
– Fertility may be adversely impacted by surgery,
chemotherapy or hormonal manipulations
– Aging also a significant factor
Fertility and Family Planning
• Embryo cyropreservation
– Timing and costs are big barriers
– Lack of committed partner may also be barrier
• Ovary/ovum preservation
– Results are not satisfactory yet
• Continued debate regarding the use of GNRH
agonists to shut ovarian function down during
chemotherapy
Contd.
• Refer to specialist for urological or gynecologic
issues
• May need counseling to reaffirm self worth
and/or to support relationships
• Those who desire children may have other
challenges
– Many adoption agencies will not consider cancer
survivors as parents for several years after
diagnosis if at all.
Cardiac Toxicity
• Heart failure can occur any time after
treatment. May manifest years later
• Drugs putting patients at risk: doxorubicin,
epirubicin, fluoropyrimidines, trastuzumab
• Radiation to left chest wall increases risk
– Less of a problem with newer techniques and
planning
Cardiac …
• Radiation therapy to left breast, left chest wall
or to mediastinum
– Increased risk of cardiomyopathy and failure
– Increased risk of pericarditis
– Increased risk of pericardial sac fibrosis
Other Complications
• Thyroid problems: after radiation therapy to
mediastinum or neck-uncommon with breast cancer
– Check thyroid function; may develop years later
• Dental problems from radiation or chemotherapy
– Gingivitis: good hygiene, see dentist
– Xerostomia: several saliva substitutes
– Osteonecrosis: limit bisphosphonates
• Cataracts: from steroids, tamoxifen
– Ophthalmology
Secondary Cancers
• Acute leukemia or myelodysplasia
– Due to chemotherapy esp. alkylating agents
– Due to radiation therapy esp. to major marrow
– Original cancers: breast, prostate, lymphoma, others
• Breast Cancer
– Due to radiation therapy to mediastinum for childhood or
adolescent lymphoma
• Soft tissue Sarcoma
– Due to radiation therapy (usually for breast ca)
• Endometrial Cancer
– Due to tamoxifen used to treat breast cancer
Stress
• Employment, finances
– Many resources for support
and counseling
– LINC /Medical Legal
Partnership
– Often cannot qualify for
disability
• Fatigue
– May take months to recover
from treatment
– Check thyroid, blood sugars,
etc.
• Physical appearance
changes
– Hair loss (may fail to regrow)
– Breast removal with/without
reconstruction
Pain
• Neuropathy
– Side effect of many chemotherapy agents
including taxanes and vinca drugs
– May persist for years
• Post surgical pain
• Post radiation therapy pain
Pain Control
• Recognize pain
• Appropriate interventions
– Short term narcotics for postoperative pain
– Medications for neuropathic pain; often due to
chemotherapy
– Referral to symptom management specialist as
needed
• If pain is persistent or doesn’t make sense
then do appropriate imaging
Other Physical Changes
Lymphedema
• Risk increases with extent of lymph node
dissection, obesity and radiation therapy
• Refer to therapist who has had specialized
training
• Early intervention is best
– Often patient feels the difference before it is
visible
• Exercise restrictions have been lifted
What is the survivor to do?
• Exercise MOVE IT!
– Obesity especially after menopause may increase
cancer risks
– Minimum 3 hours a week; more is better
– Some drugs make it more difficult to control
weight but not impossible
– Many women gain weight during chemotherapy
• Need to exercise even during treatment
– Impact on cancer recurrence is still under study
but looks positive
Diet and Nutrition
• There is no magic anticancer diet
• Well balanced diet with fruits, vegetables, grains,
lower fat, good proteins
• No proven benefit of supplements or vitamins
• Limit alcohol consumption
– Women should consume one or less alcoholic
beverages per day
• Soy products have been controversial but more
studies suggest they are safe and okay as part of
a healthy diet
Complementary and Alternative
Medicine
• The internet and the media are full of
information and claims
• Some things make sense
– Yoga, massage, meditation for stress relief
• Some things are concerning
– Bioidentical hormones
– Drastic dietary changes
– Supplements of unknown risk/benefit
CAM..
• Ask patients what they are taking or are
considering taking
• Several major medical centers have integrative
medicine programs with a focus on CAM
– Suggest these to patients
• Memorial Sloan Kettering, MD Anderson, National
Institute of Health/NCI
• Remind patients about costs, evidence and
potential for toxicities
The Reaction to Pink
A word of warning
• She may not like pink
• She may not like (pink) ribbons
• She may lose sleep every time the words
“breast cancer” are on the news
• She may wonder where the $$$ from “pink”
goes
• She may wonder with all of the attention and
$$$, why is she not cured?
Resources
• www.cancer.net ASCO patient information site
• www.cancer.org and local chapter of
American Cancer Society
• www.cancer.gov National Cancer Institute
• www.masseycancercenter.com
• www.livestrong.com
• Several websites for survivors
VCU Massey Cancer
Breast Health Center
• New patient coordinators: (804) 828-5116
– Medical and surgical oncology appointments
• Breast Imaging: (804)237-6666 for either site
– www.breastimaging.vcu.edu
• Radiation Oncology: (804) 828-7232
– Will direct to any site
• Breast Health Nurse Navigators: (804)8285024
Thank you!
Questions???