Young Survivors Breast Cancer Conferencebreastcanceroptions.org/Follow Up - young...

Young SurvivorsBreast Cancer Conference

Saturday November 8th, 2014

Follow-up: Screening Protocols, Genetic Risk Assessment

Diana L. Silverman, D.O.Breast Surgical Oncologist

Herb & Sue Ann Redl Center for Cancer Care

The Latest Statistics…

Approximately 12.3 percent of women will be diagnosed with breast cancer at some point

during their lifetime, based on 2009-2011 data.

SEER: Surveillance, Epidemiology and End Results Program 1973-2011

The Latest Statistics…

In 2011, there were an estimated 2,899,726 women living with breast cancer in the United States.

SEER: Surveillance, Epidemiology and End Results Program 1973-2011

The Latest Statistics…

SEER: Surveillance, Epidemiology and End Results Program 1973-2011

SEER: Surveillance, Epidemiology and End Results Program 1973-2011

The Latest Statistics…

The Latest Statistics…

Women who are diagnosed at a younger age may be less likely than older women to die of the disease.

SEER: Surveilland, Epidemiology and End Results Program 1973-2011

Follow-up Care for the Young Survivors

Survivorship

The process of living with, through

and beyond cancer.

• Begins at diagnosis …

• Includes those who continue to receive treatment to either reduce the risk of cancer coming back or to manage chronic disease.

Goals of follow-up care

• Detection and management of loco-regional breast cancer recurrences

• Detection and management of second primary breast cancers and

• Detection and management of side effects of treatment

• Recognition of genetic cancer syndromes• Promotion of healthy behaviors• Provide information to survivors and their families on

the treatments they received and what they should expect during the months and years after treatment

Recommendations for follow-up care

• H&P

• Breast imaging

• ? genetic counseling

• Regular pelvic examinations by OB/GYN

• Lifestyle counseling: smoking cessation, alcohol use, diet and exercise

• Social services/counseling/support groups

History and Physical Examination

Every 4 to 6 months for 5 years, then annually

• Medical History

– A careful history for symptoms of recurrence

– Evaluation for any side-effects of treatment

– Women should be counseled on how to perform monthly breast self-examination

History and Physical Examination

Every 4 to 6 months for 5 years, then annually

• Physical Examination– Careful examination of lymph nodes

– Examination of breasts in upright and supine position for changing symmetry, skin changes, new dominant masses, or scar/incision nodularity

– Cardiovascular and Pulmonary examination

– Examination of abdomen for evidence of hepatomegaly or RUQ tenderness

– Extremities evaluated for lymphedema

Mammography

Annually

• Women who had breast-conserving therapy should have their 1st mammogram of the

treated breast approximately 6 months after completion of radiation therapy

Referral for genetic counselingAn affected individual with one or more of the following:

• A known genetic mutation within the family

• Early-age-onset breast cancer (<50)

• Triple negative breast CA

• Two breast CA primaries in a single individual

• Breast CA at any age, and

≥1 close relative with breast CA <50 or

≥ 1 close relative with ovarian CA at any age or

≥ 2 close relatives with breast CA and/or pancreatic cancer at any age

From a population at increased risk (Ashkenazi Jewish)

• ≥1 family member on same side with combination of breast CA and pancreatic

CA, prostate CA, sarcoma, adrenocortical CA, brain tumors, endometrial CA,

leukemia/lymphoma, thyroid CA, macrocephaly, gastric CA

• Ovarian CA

• Male Breast CA

Referral for genetic counseling

An UNaffected individual with a FAMILY HISTORY of one or more of the following:• A known genetic mutation within the family• ≥ 2 breast CA primaries in a single individual• ≥ 2 individuals with breast primaries on the same side of the family

• ≥ 1 ovarian cancer on the same side of the family

• 1st or second degree relative with breast CA ≤ 45y

• ≥1 family member on same side with combination of breast CA and pancreatic CA/prostate CA, sarcoma, adrenocortical CA, brain tumors, endometrial CA, leukemia/lymphoma, thyroid CA, macrocephaly, gastric CA

• Male Breast CA

Pelvic examination

• Regular gynecologic care is recommended.

Women on tamoxifen should have annual gynecological exam

Report any postmenopausal bleeding

• Despite the increase in risk of endometrial cancer in women treated with tamoxifen, endometrial ultrasound and biopsies are not indicated in asymptomatic patients on tamoxifen

Monitoring of bone health

• Women who have premature menopause due to chemotherapy

• Women on aromatase inhibitors

Arimidex, Aromasin, Femara

• Baseline bone mineral density

• Periodically thereafter (2-15 yrs)

Lifestyle counseling

Evidence suggests that active lifestyle and achieving and maintaining an ideal body weight (20-25 BMI) may lead optimal breast cancer outcome

• Diet

• Exercise

• Strategies for weight loss

• Smoking cessation

• Awareness of screening guidelines for other CA’s (colorectal, gynecological, skin, etc)

Referral to appropriate specialists

• Physical therapy

lymphedema

• Registered dieticians

• Psychotherapists

• Sex therapists

• Fertility specialists

• Financial counselors

Additional tests

• More intensive monitoring with laboratory and radiographic tests vs. regular examinations and mammography– No survival benefit or difference in disease-free

• Routine laboratory studies in asymptomatic patients, including hepatic transaminases, alkaline phosphatase, tumor markers, and bone scans– Do not improve disease-free survival, overall survival, or quality

of life

• Often leads to additional imaging and invasive procedures • Increases patient and family anxiety • Increases costs of care with no proven benefit• Not recommended

Survivorship Care Plans

• Studies have shown that most patients are dissatisfied with the quantity and quality of information.

• Patients should be provided a treatment summary and survivor care plan at the conclusion of multimodality therapy

Survivorship Care Plans

Treatment SummaryDate of diagnosisAge at diagnosisAffected breast(s)Menopausal status at diagnosisTumor characteristicsStageHistologic subtypeHormone receptor statusHistologic gradeHER2 statusAngiolymphatic invasionTreatmentsLocoregional therapySurgeryDate(s) of surgerySurgery performedSentinel lymph node/axillary lymph node dissectionType of reconstruction if applicableComplications

References

• Hayes DF. Clinical practice. Follow-up of patients with early breast cancer. N Engl J Med. 2007;356:2505-2513

• NCCN Guidelines Version 3.2014 Invasive Breast Cancer

• Oeffinger KC, McCabe MS. Models for delivering survivorship care. J Clin Oncol. 2006;24:5117-5124.

• Rojas MP, Telaro E, Russo A, et al. Follow-up strategies for women treated for early breast cancer. Cochrane Database Syst Rev. 2005:CD001768.

• SEER: Surveillance, Epidemiology and End Results Program 1973-2011

THANK YOU!

Diana L. Silverman, D.O.Breast Surgical Oncologist

Herb & Sue Ann Redl Center for Cancer Care