CANCER

SURVIVORSHIPEXAMPLE: BREAST CANCER

Issam Makhoul, MD

March 14, 2018

Disclosure

• Company Nature of relationship

• Genentech/Roche - Grant/Clinical Trial Research Support

• New Link – Grant/Clinical Trial Research Support

Definition of a Cancer Survivor(National Coalition for cancer survivorship)

Anyone with a history of cancer,

from the time of diagnosis and for

the remainder of life, whether that is

days or decades.

1. Rowland JH et al. J Clin Oncol. 2006;24:5101-5104. 2. Clark EJ. You have the right

to be hopeful. 2004. ttp://www.canceradvocacy.org/resources/publications/hopeful.pdf.

The US population in

2040:

380 millions

1/15

Focus on Survivorship – Males

American Cancer

Society, 2014a

2014 Prostate

Colorectal

Melanoma

UrinaryBladder

NH*Lymphoma

Testis

Kidney

2024Prostate

Colorectal

Melanoma

UrinaryBladder

NH*Lymphoma

Kidney

Testis

OralCavity/Pharynx

*Non-Hodgkin

2014 Breast

UterineCorpus

Colorectal

Melanoma

Thyroid

NH*Lymphoma

UterineCervix

Lung/Bronchus

Ovary

Kidney

2024 Breast

Colorectal

UterineCorpus

Melanoma

Thyroid

NH*Lymphoma

Lung/Bronchus

UterineCervix

Ovary

Kidney

Focus on Survivorship – Females

*Non-Hodgkin

American Cancer

Society, 2014a

Impacts of Cancer Treatment

Individual Effects/Risks

Surgical Side Effects

Chemotherapy Side Effects

Radiation Side Effects

Hormonal Therapy Side

Effects

Non-Treatment-Specific Side

Effects

Psychological Well-Being

Spiritual Well-Being

• Control

• Anxiety• Depression• Fear of recurrence

• Cognition/attentionQuality of Life

Physical Well-Being

• Functional status

• Fatigue and sleep• Overall physical health• Fertility

• Pain

Social Well-Being

• Family distress

• Roles and relationships• Affection/sexual function• Appearance

• Isolation• Finances/employment

• Meaning of illness

• Religiosity• Transcendence• Hope

• Uncertainty• Inner strength

Cancer Survivor Needs

Cancer Survivorship Care Guidelines:

Key Areas

Long-term and Late Effects

• Long-term effects are medical problems that develop

during active treatment and persist after the completion of

treatment

• Late effects are medical problems that develop or

become apparent months or years after treatment is

completed

Risk Factors for Physical Effects

Potential Effects of Surgery

long-term effects

• Lack of skin sensitivity

• Body image issues

• Sexual dysfunction

• Numbness

• Pain

• Limited ROM

• Weakness

• Poor cosmesis outcome

LATE EFFects

• Lymphedema

• Neuropathy

Potential Effects of Radiation Therapy

Long-Term

Effects

Fatigue Poor cosmetic

outcome

Pneumonitis

Skin

sensitivity/pain

Breast

atrophy/asymmetri

cal breast volume

Sexual

dysfunction

Lymphedema

Pain Numbness or

weakness of

upper extremities

Potential Effects of Radiation Therapy

Late effects

Skin discoloration Lymphedema Numbness or

weakness of the UE

Breast may remain

smaller and firmer

than non-irradiated

breast

Shortness or breath

(lung pneumonitis or

fibrosis)

Secondary cancers

(i.e. soft tissue

sarcomas; lung

cancer)

Skin sensitivity/pain Cardiovascular

disease (i.e.

pericardial effusion,

pericarditis)

Teleangiectasia

Sexual dysfunction

Chemotherapy

•Alkylating Agents

•Anthracyclines

•Taxanes

•Platinum Agents

•Targeted therapy

Potential Effects of Chemotherapy

Long-Term Effects

Cognitive

impairment

Infertility Hair loss

Fatigue Weight gain

Ovarian failure

with or w/o

menopausal

symptoms

Obesity

Sexual

dysfunction

Neuropathy

Potential Effects of Chemotherapy

Late Effects

Osteoporosis/osteopenia

cardiovascular disease with anthracyclines-based

chemotherapy

Leukemia and myelodysplastic syndrome with

alkylating agents and anthracyclines

Long-term Effects: Trastuzumab

Cardiac dysfunction

Potential Effects of Hormonal Therapy

Long-Term Effects

Tamoxifen Aromatase Inhibitors

Hot flashes Vaginal dryness

Changes in

menstruation

Decreased libido

Increased

triglycerides

MSK symptoms/pain

Mood changes Cholesterol elevation

Potential Effects of Hormonal Therapy

Late Effects

Tamoxifen Aromatase Inhibitors

Increased risk of

stroke

Increased risk osteoporosis

Increased risk of

endometrial

cancer

Increased risk of fractures

Increased risk of

blood clots

Osteopenia in

pre-menopausal

women

Cancer Survivorship Care Guidelines:

Key Areas

First 3 years

• Every 3-6 months

Years 4-5

• Every 6-12 months

5+ years

• Annually

History and Physical Exam

• Annual mammography

MRI of the breast only if lifetime risk of

secondary breast cancer is more than 20%

• Should NOT offer routine laboratory tests or imaging for detection of recurrence in the absence of symptoms

• Should educate and counsel about signs and symptoms of recurrence

• Should counsel patients to adhere to adjuvant endocrine therapy

Risk Evaluation and Genetic Counseling

• At least 1 grandparent of Ashkenazi Jewish heritage

• Younger than age 50 at diagnosis (younger than age 60 if

triple negative)

• History of ovarian cancer at any age or in first-degree or

second-degree relative

• First-degree relative who had breast cancer before age 50

• 2+ first- or second-degree relatives diagnosed with breast

cancer at any age

• Diagnosis of bilateral breast cancer

• History of breast cancer in male relative

Cancer Survivorship Care Guidelines:

Key Areas

Screening for Second Primary Cancers

(Average Risk Patient)

• Should screen for other cancers similarly to general

population

• Should provide an annual gynecological assessment for

post-menopausal women on selective estrogen receptor

modulator therapies (SERMs), such as tamoxifen

• In absence of abnormal vaginal spotting or

bleeding, periodic imaging is NOT of value

Cancer Survivorship Care Guidelines:

Key Areas

Physical and Psychosocial

Long-term and Late Effects • Body imaging concerns

• Lymphedema

• Cardiotoxicity

• Cognitive impairment

• Distress, depression, anxiety

• Fatigue

• Bone health

• Musculoskeletal health

• Infertility

• Sexual health

• Premature menopause and hot flashes

• CINP

Body Image Concerns

• 31-67% of breast cancer survivors

• Concerns are caused by:- Loss of breast - Scarring and/or lymphedema

- Hair loss - Skin changes

- Sexual dysfunction - Weight gain

- Chemotherapy-related menopause

• Offer option for adaptive devices (e.g. breast prostheses, wigs) and/or surgery

• Refer to psychosocial care as indicated

Lymphedema

• Over 40% of breast cancer survivors

• Risk related to breast surgery and/or radiation

• Axillary lymph node dissection > sentinel lymph node

biopsy

• ARM: Axillary Reverse Mapping

• Immediate or delayed

• Limited ROM

• Mild discomfort, pain

• Body image concerns

Lymphedema

• Take good care of skin and nails

• Maintain optimal body weight

• Avoid injury of area at risk

• Avoid tight underwear, clothing, watches and

jewelry

• Wear compression garments, if prescribed

• Undertake exercise/movement and limb elevation

Lymphedema

• Should counsel survivors on how to

prevent/reduce risk of lymphedema, including

weight loss for those overweight or obese.

• http://www.lymphnet.org/pdfDocs/nlnriskreduction.pdf

• Should refer patient with clinical symptoms or

swelling suggestive of lymphedema to a therapist

knowledgeable about diagnosis and treatment of

lymphedema.

Cardiotoxicity

• Radiation, chemotherapy or endocrine therapy with

aromatase inhibitors

• Epirubicin; doxorubicin; trastuzumab

• Aromatase inhibitors can raise cholesterol

• Post-menopausal

• Weight gain (HTN and insulin resistance)

• Monitor lipid levels and provide CV monitoring as indicated

• Educate breast cancer survivors on healthy lifestyle

modifications, potential cardiac risk factors , and when to report

relevant symptoms (shortness of breath and fatigue)

Cognitive Impairment

• Multifactorial (fatigue, insomnia, and depression)

• Problems with concentration, executive function, and

memory

• 75% of breast cancer patients in treatment and 35% after

treatment

• Older adults and/or those with lower cognitive reserves

may be more susceptible

Cognitive Impairment

• Screen for cognitive problems

• Mini Mental State Assessment (MMSE)

• Functional Assessment for Cancer Therapy Cognitive

(FACT-Cog)

• Refer survivors with signs of cognitive impairment for

neurocognitive assessment and rehabilitation

Potential Psychosocial Effects

Distress Thermometer

Our Three Question-Screening

• Are you having concerns with sadness, worry, family or

support, how you function at home, or financial issues?

• Are you having problems sleeping?

• Would you like to speak to someone about your

concerns?

Fatigue

28-91% of breast cancer survivors

▪ Treat any causative factors (anemia, thyroid

dysfunction, and cardiac dysfunction)

▪ Offer treatment or referral for factors that may impact

fatigue (e.g., mood disorders, sleep disturbance,

pain)

▪ Counsel to engage in regular physical activity

▪ Refer for cognitive behavioral therapy as appropriate

Bone Health

• Estimated up to 80% of breast cancer survivors

• Postmenopausal

• Women on an aromatase inhibitor

• Premenopausal women on tamoxifen and/or

gonadotropic-releasing hormone (GnRH) agonists

• Women who have chemotherapy-induced premature

menopause

The Bikini Test

10- 20 minutes without

sun screen, daily!!!

Bone Health

DEXA

VIT D

Normal vitamin D level is 30 – 100 ng/ml

Bone Health-Universal Recs

▪Elemental calcium 1000-1200 mg/day

▪VIT D 1000 - 2000 International units/day

▪Weight-bearing/muscle- strengthening exercises

▪Avoid tobacco

▪Limit alcohol

▪Limit caffeine

Musculoskeletal Health

• Assess for MSK symptoms, including pain

• Aromatase inhibitors

• Acupunture, physical activity, referral for physical therapy

or rehabilitation

Infertility

Refer survivors of childbearing age who

experience infertility to a specialist in

reproductive endocrinology and infertility as

soon as possible

Sexual Health

• Aromatase inhibitor can lead to vaginal dryness,

dyspareunia, menopausal symptoms, and loss of libido

• Radiation/surgery can lead to skin fibrosis, loss of sexual

sensitivity to the skin

Sexual Health

• Assess for reversible contributing factors

• Offer non-hormonal water-based lubricants and moisturizers for vaginal dryness

• Low dose estrogen vaginal tablets (not recommended on aromatase inhibitors)

• Refer to psychoeducational support, group therapy sexual counseling, marital counseling, or intensive psycho-therapy when appropriate

What is my Husband PSA?

•What is my husband’s Possibility for

Sexual Activity

•Male sexual dysfunction is the reason

in 20% of the cases

Premature Menopause and Hot Flashes

• Serotonin and norepinephrine reuptake inhibitors (SNRIs)

• Selective serotonin reuptake inhibitors (SSRIs)

• Gabapentin

• Clonidine

* Some SSRIs are CYP2D6 inhibitors

Premature Menopause and Hot Flashes

• Acupuncture

• Lifestyle modifications (e.g, rhythmic breathing, exercise,

avoiding spicy food, caffeine and alcohol)

• Enviromental modifications (e.g. cool rooms , dressing in

layers)

Chemotherapy induced neuropathic pain

• Platinum: cisplatin, carboplatin, and oxaliplatin

• Taxanes: paclitaxel, docetaxel, and cabazitaxel.

• Epothilones: ixabepilone

• Plant alkaloids: vinblastine, vincristine, vinorelbine,

and etoposide.

• Thalidomide, lenalidomide, and pomalidomide.

• Bortezomib and carfilzomib.

• Eribulin .

Chemotherapy-Induced Peripheral

Neuropathy • Signs and symptoms develop and worsen 2-6 months

post treatment

• Paresthesia

• Pins & needles sensation

• Pressure

• Tingling

• Cold

• Numbness

• Warmth

• Sensory ataxia

• Pain

• Severe numbness

Neuropathy

Cancer Survivorship Care Guidelines:

Key Areas

Health Promotion

Achieve and

maintain a healthy weight

Avoid inactivity

Engage in regular aerobic exercise

and strength training

Achieve a diet high in vegetables, fruits and

whole grains

Avoid/limit alcohol

Physical Activity

• Aim for at least 150 minutes of moderate or 75 minutes of

vigorous exercise per week

• Include strength training at least 2 days per week

Cancer Survivorship Care Guidelines:

Key Areas

PCP’s Role on the Care Team

ASCO Treatment Plan and Summary

Reproduced with permission from the American Society of Clinical Oncology.

Breast Cancer Adjuvant Treatment Plan and Summary. http://www.asco.org/ASCOv2/Practice+%26+Guidelines/

Quality+Care/Quality+Measurement+%26+Improvement/Chemotherapy+Treatment+Plan+and+Summary. Accessed

June 10, 2009.

◼ Name, age, contact information

◼ Breast cancer diagnosis

◼ Surgery (type/dates)

◼ Patient history, including comorbid conditions

◼ Overview of page 2 (not shown)

– Hormonal therapy (agent, duration, date to be

initiated)

– Trastuzumab (dates, ejection fraction)

– Provider contacts (including referrals)

– Pre- and posttreatment comments (eg, baseline

assessments, patient counseling, follow-up

recommendations)

◼ Adjuvant chemotherapy/radiation therapy (planned

and received)

– Details on agents/doses prescribed (dates

initiated/completed)

– Toxicities (anticipated, experienced)

ASCO Survivorship Care PlanFollow-Up Care Providers to Contact

Medical history and physical

examination

• First 5 years

• Year 6+

Posttreatment

mammography

• First 5 years

• Year 6+

Breast self-examination • N/A

Pelvic examination Ob/gyn

Coordination of care • First 5 years

• Year 6+

Genetic counseling If indicated, based on risk

factors

Follow-Up Care Visit Frequency

Medical history and physical

examination

• Years 1 to 3: every 3 or 6

months (including key notes for

1st-year visits)

• Years 4 to 5: every 6 or 12

months

Mammography • Every 6 or 12 months as

indicated

Notes • May include any relevant

patient notes and/or

recommendations

N/A=not applicable. Breast Cancer Survivorship Care Plan. v1.0 09/07.

http://www.asco.org/ASCO/Downloads/Cancer%20Policy%20and%20

Clinical%20Affairs/Quality%20of%20Care/

Breast%20Cancer%20Survivorship%20Plan%209.07.doc. Accessed

May 27, 2009.

Thank You!!!

Questions?