Breast Cancer Surveillance Guidelines & Wellness Recommendations

1. 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

2. 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

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

4. Breast conservationHow 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

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

7. 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

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

9. 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

10. 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

11. 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

12. 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

14. 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

15. 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

16. 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

17. 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

18. 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

20. 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!!

21. 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

22. 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 %

23. 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

24. 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…..

25. 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

26. 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!!!!!!

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

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

29. 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

30. 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

31. 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

32. 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!!!!

33. 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

34. 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.