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Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance

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.

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Julie R. Gralow, M.D. Director, Breast Medical Oncology, Seattle Cancer Care Alliance

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  1. 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

  2. The Cancer Care Continuum Detection Treatment Survivorship & Diagnosis Optimal care of an individual person differs along the continuum

  3. Institute of Medicine 2005 Report From Cancer Patient to Cancer Survivor: Lost in TransitionHewitt 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

  4. IOM Report: All Patients Should Receive a Cancer Treatment SummarySCCA Breast Cancer Treatment Summary(modified from asco.org)

  5. 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

  6. Breast Cancer Survivorship Care Plan (modified from asco.org)

  7. 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

  8. Assessing Risk of Cancer RecurrenceRecurrence Hazard Rates for Breast Cancer After Primary TherapySaphner et al, J ClinOncol 14:2738, 1996 0.3 0.2 Recurrence hazard rate 0.1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Years

  9. Assessing Risk of Second Cancers How Much Breast Cancer Is Hereditary? 15-20% 5-10% 70-80%

  10. Cancer Screening: Looking for Cancer Recurrence and Second Cancers • Mammography • Health Professional’s Exam • Self-Exam • Breast MRI in some very high risk?

  11. Monitoring for Toxicities Related to Therapy • Assessing risk of toxicities • Interventions to reduce risk of toxicity • Detection and treatment of side effects

  12. Side Effects of ChemotherapyCardiac Events vs. Cumulative Chemotherapy Dose 100 80 Doxorubicin 60 Cardiac events (%) 40 450 mg/m2 20 0 100 100 200 200 300 300 400 400 500 500 600 600 700 700 800 800 900 900 1000 1000 0 0 Cumulative anthracycline dose (mg/m2)

  13. Side Effects of ChemotherapyChemotherapy-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

  14. Side Effects of Endocrine TherapyAdjuvant Hormonal Treatment of Breast Cancer: Weighing the Side Effects Arthralgia/myalgiaNeurocognition? DVT, CVA Hyperlipidemia Sexual function? Uterine CA Osteoporosis risk Cardiovascular Dz? Hot flashes Tamoxifen Aromatase Inhibitors

  15. Assessing Risk of Side EffectsWomen 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

  16. Maximizing Overall Health and Quality of Life The Effects of Breast Cancer Treatment on Emotional and Physical Well-Being • Fatigue/decreased energy • Nausea/vomiting • Alopecia (hair loss) • Menopause • Infertility • Sexuality/body image • Lymphedema • Depression, anxiety • Pain • Fear of recurrence • Etc….

  17. Managing Menopause • Prevalence of Menopausal Symptoms in Women with a History of Breast CancerCouzi et al, JCO 1998 • Hot flashes 65% • Night sweats 44% • Vaginal dryness 48% • Pain with intercourse 26% • Insomnia 44% • Depression 44%

  18. Exercise, Physical Activity and Cancer Team Survivor Northwest Mt. Baker August 2008

  19. Exercise Decreases Side Effects During TreatmentFatigue and QOL Outcomes of Exercise During Cancer TreatmentMock 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

  20. 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

  21. What About Lymphedema?

  22. Carefully Monitored Exercise Does Not Increase LymphedemaWeight Training and Lymphedema in Breast Cancer SurvivorsAhmed RL et al, J ClinOncol 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

  23. Nutrition, Body Weight and Breast Cancer -Maintain good body weight -Low fat diet -High fiber -Increase fruits and vegetables -Limit alcohol

  24. 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

  25. 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)

  26. Cognitive Function Urogenital Atrophy Premenopausal Postmenopausal

  27. Sexuality and Body Image

  28. Strategies for Providing Patient SupportSeattle Cancer Care AllianceUniversity of WashingtonWomen’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)

  29. Strategies for Providing Patient SupportTeam Survivor NorthwestAn Exercise and Fitness Program for All Women Affected by Cancer Founded 1995 • Weekly workouts • Twice weekly walks • Running • Hiking • Biking • Yoga and tai chi • Dragon boating • Swimming • Annual fitness retreat

  30. Optimizing Health and Wellness After a Diagnosis of Cancer Team Survivor Northwest Dragon Boat Team • The majority of cancer patients can look forward to a long life after diagnosis and treatment • 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

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