5/28/2013

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Health Issues in Breast Cancer Survivors

Michelle Melisko MD

Associate Clinical Professor of Medicine

UCSF Helen Diller Family Cancer Center

Cancer Survivors 2012 (U.S.)

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Trends in 5-Year Relative Survival Rates by Year of Diagnosis, All

Cancers, United States

5054

66

0

10

20

30

40

50

60

70

1975 to 1977 1984 to 1986 1996 to 2003

National Cancer Institute. SEER Cancer Statistics Review 2000-2004. http://seer.cancer.gov/csr/1975_2004/results_merged/topic_survival.pdf

Pat

ien

ts S

urv

ivin

g M

ore

Th

an 5

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rs

Aft

er a

Can

cer

Dia

gn

osi

s (%

)

High Rates of Long-term Survival Among Breast Cancer Survivors

Horner MJ et al (eds). National Cancer Institute. http://seer.cancer.gov/csr/1975_2006. Accessed July 21, 2009.

9081

74

0

20

40

60

80

100

5 10 15

Pat

ien

ts A

live

(%

)

There are an estimated 2.5 million breast cancer survivors in the United States

Years After Diagnosis

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Survivorship Issues

• What is the impact on health of being a long-term cancer survivor?

• What is the cost of being a survivor—physically, emotionally, spiritually and financially?

• Is our healthcare system prepared to handle the growing number of people diagnosed with cancer, and the treatment and follow up needed for quality of life?

Differences in cancer follow up care - A world perspective

• In many countries, access to subspecialists is limited

• Primary care physicians and other “physician extenders” play a bigger role in health care in general

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GREAT BRITAIN• In a randomized trial of 296 women with a

history of breast cancer, transfer of routine oncology follow-up care to a family physician did not result in an increase in the time to diagnosis of recurrence

– Patient satisfaction was greater

– Health service costs were less

– Anxiety and health related quality of life were unaffected

Grunfeld E, Mant D, Yudkin P, et al. Routine follow up of breast cancer in primary care: randomised trial. BMJ 1996;313(7058):665-9.

CANADA

• 968 early-stage breast cancer patients who had completed adjuvant treatment were randomized to follow up in a cancer center or with their own family physician– No differences in number of recurrences, deaths,

recurrence related serious clinical events

– No difference in patient reported health-related quality of life

Grunfeld E, Levine MN, Julian JA, et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol 2006;24(6):848-55.

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2005 Institutes of Medicine Guidelines on Survivorship

Key Recommendations: 1.All cancer stakeholders should work to raise

awareness of cancer survivorship and to establish this as a distinct phase of cancer treatment

2.Each patient should be given a Survivorship Care Plan reimbursed by insurers

3.Plan components should be developed and refined using evidence-based clinical practice guidelines and assessment tools

Hewitt M et al. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington DC: The National Academies Press; 2005.

ASCO Treatment Plan and Summary

Reproduced with permission from the American Society of Clinical Oncology.

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)

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ASCO Survivorship Care PlanFollow-Up Care Providers to Contact

Medical history and physical examination

• First 5 years

• Year 6+

Posttreatmentmammography

• 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

Breast Cancer Survivorship Care Plan. v1.0 09/07.

http://www.asco.org/ASCO/Downloads/Cancer/Survivorship%20Plan%209.07.doc. Accessed May 27, 2009.

Hewitt M, et al. eds. From Cancer Patient to Cancer Survivor: Lost in Transition.Washington DC; The National Academies Press; 2005.

Essential Components of Survivorship Care

Treating the consequences of cancer and its

treatments

Recurrence, new cancers, late effects

Recurrence, second cancers, and assessing medical and psychosocial late effects

Interdisciplinary coordination between PCPs and specialists

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Optimizing Survivorship Care: Practice Considerations and Barriers in the Community

1.Fragmented system of care

2.Lack of training

3.Absence of agreed-upon standards of care

4.Reimbursement

5.Communication

Hewitt M, et al. From Cancer Patient to Cancer Survivor: Lost in Transition.Washington DC: The National Academies Press; 2005.

• 56 year old postmenopausal woman is diagnosed with a Stage I invasive ductal carcinoma

– 1.5 cm grade 2 IDC

– ER positive, PR positive, HER2 negative

– She is treated with a lumpectomy, SLND, and radiation to the breast

– She has recently started on an aromatase inhibitor

She comes to see her primary care MD for routine health care and is extremely worried about breast cancer recurrence. She wants to have lab tests and scans to “make sure her cancer hasn’t come back”.

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What are the chances that this patient will die of breast cancer

in the next 10 years?

1. < 5%2. 5-10% 3. 10-20%

Should you order any lab tests or scans to follow up on her cancer?

Breast Cancer Follow Up:What to do and What NOT to do

• American Society of Clinical Oncology 2013 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting (JCO March 1 2013)– Routine labs, CT scans, bone scans are not

necessary or indicated

• American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor Markers in Breast (JCO Nov 20 2007: 5287-5312)– TUMOR MARKERS ARE NOT RECOMMENDED

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Breast Imaging Recommendations• NCCN, ACSO, and ACS guidelines recommend follow up

mammograms every 6-12 months for affected breast in the setting of breast conserving surgery

• Breast MRI only indicated for the following:– Pts with equivocal mammographic and/or US at primary diagnosis– Pts presenting with malignant axillary adenopathy and unknown site of

primary tumor– Patient with extensive or locally advanced cancer undergoing

chemotherapy– Screening of women at increased ( 20% to 25%) lifetime risk

• Known BRCA1 or BRCA2 gene mutation carrier• Pt with first-degree relative with a BRCA1 or BRCA2 gene mutation who

has not had genetic testing themselves • Radiation therapy to the chest between the ages of 10-30 yo• Genetic disease such as Li-Fraumeni or Cowden syndrome or one of

these syndromes in first-degree relatives

Orel S, JCO Feb 2008

Critical Issues in Cancer Survivorship

• Cancer survivors are at risk for a range of late physical effects and emotional and practical issues due to their primary treatment

ASCO. Cancer Advances Information from the Experts: Cancer Survivorship—Increasing Survival, Improving Lives. December 2004.

Physical Effects Emotional Issues Practical Issues

Fatigue Chronic pain or neuropathy Organ damage Cognitive dysfunction Sexual dysfunction Premature menopause or

infertility Osteoporosis Lymphedema

Increased concerns about the future and health

Sadness, depression, and sense of loss

Coping with stopping treatment Relationship issues

Financial issues and insurance coverage

Employment/workplace discrimination

Obtaining future medical or life insurance

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Spectrum of Potential Side Effects

Hayes DF. N Engl J Med. 2007;356:2505-2513.

Hot flashes/night sweats

Arthralgia/joint symptoms

Sexual dysfunction

Cognitivedysfunction

Depression

Genitourinary symptoms

Other 2nd-malignancy(ie, endometrial cancer)

Chronic fatigue

Cardiovascular effects

Osteoporosis/bone fractures

Early breast cancertreatments including:

Radiation therapyChemotherapy

Monoclonal antibodyHormonal therapy

Weight gain

Symptom/Side-Effect Management

Cardiovascular and Thrombotic Effects in Breast Cancer Survivors

Hormonal Therapy

Potential Cardiovascular or ThromboticAdverse Effects

Anthracycline-Based Chemotherapy

TrastuzumabRadiation Therapy

1. Carver JR, et al. J Clin Oncol. 2007;25:1-18. 2. Mrozek MD, Shapiro CL. Clin Adv Hematol Oncol. 2005;3:211-222. 3. Hayes DF. N Engl J Med. 2007;356:2505-2513.

• Many early breast cancer survivors receive a combination of treatments associated with cardiovascular and/or thromboticside effects1-3

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Thrombotic Effects of Cancer Treatment

• Tamoxifen increases the risk of thromboembolic events and cerebrovascular disease by approximately threefold1,2

• A meta-analysis indicated a 29% increase in risk of stroke in women randomized to tamoxifen vs placebo or other therapies3

• Concurrent combination of chemotherapy and tamoxifenhas been associated with a further increased risk of thromboembolism4

1. Hayes DF. N Engl J Med. 2007;356:2505-2513. 2. Mrozek MD, Shapiro CL. Clin Adv Hematol Oncol. 2005;3:211-222. 3. Bushnell CD, Goldstein LB. Neurology. 2004;63:1230-1233. 4. Pritchard KI, et al. J Clin Oncol. 1996;14:2731-2737.

Cardiotoxicity Overview

• Extensive data regarding anthracycline mechanism for cardiac injury, but little data regarding treatment

• Over 50% of children with cancer will be exposed to anthracycline based therapy

• Tyrosine Kinase inhibitors (Sunitinib, Imatinib, Dasatinib, etc) have been in use <10 yrs

– Extensive number of TKI trials ongoing

– >50% of these trials have pathways that are shared in cardiac signaling

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Frequency of Deaths by Different Causes in the Childhood Cancer Survivor Study

Total DeathsNo. 2,534 %

Recurrence/progressive disease 1,469 58.0

Medical Causes of Death 879 34.7

- Subsequent neoplasm 470 18.5

- Diseases of the circulatory system 176 6.9

- Diseases of the respiratory system 67 2.6

Armstrong GT et al. JCO.2009;27:2328-2338

Late Mortality Among 5 Year Survivors of Childhood Cancer (CCSS)

Tukenova M et al. JCO.2010;28:1308-1315

Role of Cancer Treatment in Long-Term Overall and Cardiovascular Mortality After Childhood Cancer

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Doxorubicin: Dose-Relationships

• Retrospective review of 4018 patients who received doxorubicin

• Definition of doxorubicin-induced CHF: Clinical signs/symptoms of CHF believed to be secondary to doxorubicin by the clinician

• Findings:

– Overall incidence: 2.2% (n=88).

– ‘Inflection point’ at 550 mg/m2

(7%)

Adapted from Von Hoff et al. Ann Int Med. 1979;91:710-7.

A More Recent Look at the Data…

• Analysis of the placebo-arms of three dexrazoxane trials

• In all trials: Normal LVEF at start• MUGA performed at baseline & after

every 50 mg/m2 of doxorubicin

• Examined rate of significant EF drop or symptomatic HF

• Almost identical data later shown in post-anthracycline echos in breast cancer patients in B-31 & N-9831 trials

Adapted from Swain et al. Cancer. 2003;97:2869-79.

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• 703 patients (216 males)

• Age 47±12 years

• Treated with HDC for poor prognosis malignancies

• Follow-up = 48 months

• MACE (Major Adverse Cardiac Event) incidence

Tn I serum determination: Baseline = before HDC Early = soon after HDC (0,12,24,36,72 hours) Late = 1 month after HDC

Circulation 2004

Results

TnI +/-n = 145 pts (21%)

TnI +/+n = 63 pts (9%)

TnI -/-n = 495 pts (70%)

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Left ventricular ejection fraction

TnI +/+

TnI -/-

(%)

40

45

50

55

60

65

0 1 3 6 12 18 48 months

TnI +/-

Cardinale et al. Circulation 2004

§

*§

* = p<0.01 vs. TnI -/-; = p<0.01 vs. TnI +/-.

* **

*

** *

*§ §

Cardiac Events3.5 year-follow-up

Sudden death

Cardiac death

Acute pulmonary edema

Heart failureAsymptomatic LVEF >25%

Life-threatening arrhythmias

Conduction disturbancesrequiring PM implantation

PersistentTnI +

NegativeTnI

TransientTnI +

Circulation 2004

1%

*= p<0.001 vs. TnI -

37%*

#= p<0.001 vs. TnI +-

84%* #

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Circulation 2006

Pat

ient

s(%

)

ACEI group

0

20

40

0%

43%

p<0.001

Controls

50

30

10

(n=0) (n=25)

Primary end-point:LVEF decrease >10 percent units + <50%

Troponin I Early Positivity

Enalapril

n = 56 pts

Controls

n = 58 pts

physical examination, ECG, ECHO: b,1,3,6,12 months

started 1 month after HDC continued for 1 year

443 ptsHigh-dose CT

TnI + = 114 pts (24%)

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Secondary end-pointsfollow-up 12 months

Sudden death 0 (0%) 0 (0%) 0 (0%) NSCardiac death 2 (2%) 0 (0%) 2 (3%) NSAcute pulmonary edema 4 (2%) 0 (0%) 4 (3%) NSHeart failure 14 (12%) 0 (0%) 14 (22%) <0.001Life-threatening arrhythmias 11 (10%) 1 (2%) 10 (16%) 0.01

CUMULATIVE EVENTS 31 (28%) 1 (2%) 30 (52%) 0.001

Totaln=112 PACEI

n=54Controls

n=58

Cardinale et al. Circulation 2006

Cancer 2005; 104:2492-8

Valsartan for Prevention of Cardiotoxicity•40 patients with NHL randomized to receive CHOP with or without 80 mg/day of valsartan

•Acute cardiotoxicity evaluated before and on days 3, 5, and 7 after CHOP

•CHOP induced transient increases in the LVEDD on ECHO, the QTc interval and QTc dispersion on EKG, and in the plasma BNP. All these changes returned to nearly normal levels within a week after CHOP (P < 0.001)

•Valsartan significantly prevented all these changes except for the elevation in BNP(P < 0.05).

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Protective Effects of Carvedilol Against

Anthracycline-Induced Cardiomyopathy

Kalay et al. JACC. Dec 2006. 48:2258-62Data expressed as mean values.

•25 pts in whom ANT therapy was planned were randomized to carvedilol or control. Carvedilol was given 12.5 mg qd for 6 months during chemo

•Pts were evaluated with ECHO before and after chemotherapy.

•At the end of 6 months of follow-up, 1 patient in the carvedilol group and 4 in the control group had died

•Control EF was below 50% in 1 patient in the carvedilol group and in 5 in the control group.

•Mean EF of the carvedilol group was similar at baseline and fupl echocardiography (70.5 vs. 69.7, respectively; p = 0.3), but in the control group the mean EF at fup ECHO was significantly lower (68.9 vs. 52.3; p < 0.001)

Efficiency of Atorvastatin in the Protection of Anthracycline Induced Cardiomyopathy

JACC Vol 58:2011 Randomized to Lipitor 40mg or Placebo

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High Mortality Rates Associated with Withdrawal of Beta Blockers and Ace Inhibitors in Chemotherapy-

Induced Heart Failure

Circulation. 2008;118:S_797

DRUG HYPERTENSION (%)

Bevacizumab (Avastin) Hypertension (23% to 34%)

Sunitinib (Sutent) Hypertension (>15%)

Alemtuzumab (Campath) Hypertension ( 11%)

Gemtuzumab (Mylotarg) Hypertension ( >5%)

Infliximab (Remicade) Hypertension (10%)

Muromanoab-CD3 (Orthoclone® OKT 3)

Hypertension ( < 1%)

Rituximab (Rituxan) Hypertension (6%)

Drug-Induced Hypertension with FDA

Approved Cancer Therapies

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Drug-Induced HF of FDA Approved Targeted Cancer Therapies

Sorafenib (Nexavar) 2007 VEGF1,2,3/PDGF 1%

Dasatinib (BMS-354825) 2006 BCR-ABL/SRC C-Kit,PDGF

4%

Sunitinib (Sutent) 2006 VEGF/PDGF/

C-KIT

3-14%

Bevacizumab (Avastin) 2004 VEGF 2-14%

Trastuzumab (Herceptin) 2000 ErbB-2/TKI 3-27%

Imatinib (Gleevec) 2001 C-ABL, C-Kit 1%

Drug Approval Action CHF

Chemotherapy-induced Neuropathy: Natural History, Prevention, and Treatment

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Persistent Peripheral Neuropathy in Breast Cancer Survivors Treated With Taxane Chemotherapy

• Study design:

– 35 pts receiving adjuvant paclitaxel for breast cancer followed for a median of 14 months following taxane therapy.

– Quantitative sensory testing, FACT-Tax and Neuropathic Pain Scale assessments, and serum levels of nerve growth factor were evaluated.

• Results:

– Overall, significant peripheral neuropathy (> 60%) was seen a year or more after taxane therapy completion

Patients With Neuropathy (%)

Patients With Moderate-to-Severe

Neuropathy (%)

Numbness in Hands 66% 34%

Numbness in Feet 64% 36%

Pain in Hands 68% 41%

Pain in Feet 65% 44%

Crew, SABCS 2007, Abstract 6089

Many cancer drugs cause neuropathy

• Paclitaxel

• Docetaxel

• Abraxane

• Ixabepilone

• Vinorelbine

• Oxaliplatin

• Eribulin

• Velcade (proteosome inhibitor)

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Patients scheduled to receive IV paclitaxel at one of 2 dose/schedules175+ mg/m2 Q 3 wks70-90 mg/m2 weekly

Patient questionnaires looking at the incidence and severity of paclitaxel-associated acute pain and sensory neuropathy.

Paclitaxel-Associated Acute Pain Syndrome: Natural History Study N08C1

Daily Mean Pain Scores (Q 3 Week)

Mea

n P

-AP

S P

ain

2 3 4 5 6 7 *2 3 4 5 6 7 2 3 4 5 6 7

*Cycle 4, day 2

Cycle 1 Cycle 2 Cycle 3

Day Day Day

0

1-4

5-6

7-10

5

0

2

3

4

1

6

7

8

9

10

5/28/2013

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0

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12

EORTC CIPN-20 Data (Weekly)

Cycles

Bas

elin

e va

lues

(%

)

40

0

n= 100 99 95 98 98 96 95 95 93 93 93 91 94n= 100 99 98 98 96 95 94 93 91 90 90 89 88n= 100 98 96 94 92 90 87 85 83 80 80 77 76

Sensory

AutonomicMotor90

70

50

P< 0.0001

100

0

40

50

60

70

0 2 3 4 5 6 7 8 9 10 11 12

80

90

1

EORTC CIPN-20 Tingling, Numbness and Pain Scores – Hands (Weekly)

n= 91 85 83 80 87 87 84 84 77 79 70 66 58n= 91 85 83 80 87 87 83 84 77 79 70 66 57n= 91 85 83 80 87 87 84 84 77 79 70 66 58

Cycles

Numbness

Pain

Tingling

CIP

N-2

0 S

core

s

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Selected CIPN Clinical Trials

• Gabapentin

• Scrambler therapy

• Photon Simulator (Near Infared Light)

CP1347589-47

Gabapentin Study Schema

R

6 wk6 wkGabapentinGabapentin2700 mg/day2700 mg/day

PlaceboPlacebo

6 wk6 wk PlaceboPlaceboGabapentinGabapentin2700 mg/day2700 mg/day

2 wk2 wk WashoutWashout

Chemotherapy-induced neuropathyChemotherapy-induced neuropathy

CP1347589-48Cancer 110(9):2110, 2007Cancer 110(9):2110, 2007

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0

2

4

6

8

10

0 2 4 6 8 10 12 14

Placebo

Gabapentin

Meanpain

intensity

Meanpain

intensity

WeekWeek

P=0.21P=0.21 P=0.37P=0.37

First periodFirst periodWash-

outWash-

out Second periodSecond period

Mean Pain Intensity

CP1347589-49

Placebo

Gabapentin

Cancer 110(9):2110, 2007Cancer 110(9):2110, 2007

Pilot trial of a Patient-specific Cutaneous Electro-stimulation Device (MC5-A Calmare®)

for Chemotherapy Induced Peripheral Neuropathy

Thomas J. Smith MD, Patrick J. Coyne RN MSN, Patricia Dodson BSN MA, , Gwendolyn Parker RN MSN, V. Ramakrishnan, PhD

Massey Cancer Center of Virginia Commonwealth University

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MC5-A Calmare™• Patient-specific cutaneous electro-stimulation similar to

spinal cord stimulation, but non-invasive

• Creates "non pain" information in packets of rapidly varying impulses, given non-invasively using the patients own nerves

• 30 minute long sessions using EKG pads. Above and below pain, on dermatomes.

• Stinging, then tingling; adjust to tolerance.

• US FDA approved Feb 09.

0

1

2

3

4

5

6

7

1 2 3 4 5 6 7 8 9 10

Days of therapy

CIP

N P

ain

Sco

re 0

-10

CIPN Mean

Unadjusted CIPN "pain now" scores

Results

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Characterization and Treatment of Chemotherapy Neuropathy (CIN)

Recruiting patients with (n=400) and without (n=200) chemo-induced neuropathy (CIN) whom received taxanes, platinum-based, or both classes of CTX agents and completed therapy

Pts will come to the CRS at Mt Zion once for an interview, neurological testing, and a blood collection for a candidate gene analysis

Characterization and Treatment of Chemotherapy Neuropathy:

Intervention Arm Pts with CIN in their feet may enroll in a RCT of the

photon stimulator, a device that delivers near-infrared light

The LED diode wavelength for this study is 870 nanometers– When activated, the photon stimulator is preset to deliver

1800 Joules in a 7 minute treatment period.

– Patients will receive a total of 8 treatments, to both feet simultaneously, within a 14 day period

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What medications breast cancer patients might be taking

And what to worry about with these medications…

Tamoxifen

• Tamoxifen has been shown to decrease disease recurrence and increase overall survival

• Remains the standard of care for pre-menopausal breast cancer patients

• CYP2D6 pharmacogenetics varies and results in different levels of therapeutic efficacy– Certain antidepressants should be avoided in patients

on tamoxifen

• Tamoxifen use has been associated with endometrial cancer and thromboembolism

EBCTG. Lancet. 1998;351:1451-1467 (A); Johnston et al. Nat Rev Cancer. 2003;3:821-831(B); Knox et al. Presented at: American Society of Clinical Oncology Annual Meeting; June 2-6, 2006; Atlanta, Ga (A).

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Acute effects of tamoxifen and AIs on menopausal symptoms in breast cancer

patients• Prospective study of 181 consecutive

postmenopausal women starting hormonal therapy

• Both first line tamoxifen and AIs increased occurrence and severity of hot flashes

• Musculoskeletal pain and dyspareunia significantly increased with AIs

• Sexual interest decreased significantly with tamoxifen

• Younger age was associated with more hot flashes and vaginal dryness

Morales et al, Anti-Cancer Drugs 2004

Changes in menopausal symptomsSymptom AI

(Baseline)

AI

(3 mo)

TAM

(Baseline)

TAM

(3 mo)

Hot flashes 54/46/0 23/69/8 52/44/4 13/64/23

Musculoskeletal

Pain

36/57/7 18/46/36 56/40/4 40/53/6

Vaginal Dryness 67/32/0 50/46/4 65/27/8 53/32/15

Dyspareunia 68/21/11 37/37/25 74/18/8 50/38/12

Decreased sexual interest

63/21/16 31/37/31 53/37/10 21/32/47

Emotional disturbance

45/50/5 53/47/0 35/56/8 27/64/9

(no symptom or mild/mod-severe/intolerable)

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Aromatase Inhibitors

• AIs have been shown to decrease disease recurrence compared with tamoxifen

• Several regimens have been shown to be more effective than 5 yrs of tamoxifen alone – 5 yrs of adjuvant AI therapy

– 2 to 3 yrs of tamoxifen, followed by 2 to 3 yrs of an AI

– 5 yrs of tamoxifen, followed by 5 yrs of AI

Winer et al. J Clin Oncol. 2005;23:619-629 (A).

Your breast cancer patient comes in to see you three months later and is complaining of pain in her right hip and also stiffness in her

hands. She says she has tried acetominophen without relief. What should

you do?

1. Reassure patient that joint pains are a common side effect of the aromatase inhibitors.

2. Order plain films of her hands and/or hip

3. Order a bone scan

4. Suggest she try NSAIDS and exercise

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Musculoskeletal Events: Bone Health

• During treatment, aromatase inhibitors (AIs):

– Reduce estrogen

– Are associated with a decline in BMD and an increased risk of fracture

– Exacerbate the normal progressive loss of BMD in postmenopausal women

• In contrast, tamoxifen may preserve BMD• Osteoporosis/increased fracture risk are serious health issues for

breast cancer survivors• Patients with osteopenia/osteoporosis prior to initiation of AI

therapy may be at the greatest risk

BMD=bone mineral density.Chien AJ, Goss PE. J Clin Oncol. 2006;24:5305-5312; Gralow JR. J Clin Oncol. 25:1-4; Hilner BE et al. J Clin Oncol. 2003;21:4042-4057; Grey AB, et al. Am J Med. 1995;99:636-641; Marttunen MB, et al. J Clin Endocrinol Metab. 1998;83:1158-1162; Eastell R, et al. J Clin Oncol. 2008;26:1051-1058.

Monitoring of bone density while on an aromatase inhibitor

• Most patients should have a bone density tested within one year of starting an AI

• Recommend patients with normal BMD at baseline to take calcium, vit D, and pursue weight bearing exercise

• Patients with osteopenia should have BMD rechecked one year later to assess change

• Patients with osteoporosis at baseline or during follow up should consider bisphosphonate therapy

• Osteoporosis is not a contraindication to taking an aromatase inhibitor

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Aromatase Inhibitors and Bone LossIV bisphosphonates may decrease AI-associated bone loss

Z-FAST study evaluated 36-month safety and efficacy of upfront vs delayed IV ZA in decreasing AI-associated bone loss in postmenopausal

women with early breast cancer

Brufsky et al. J Clin Oncol 25:829-836

Musculoskeletal Events: Joint Symptoms

• AIs are associated with significantly higher rates of joint symptoms/arthralgias vs tamoxifen1

– Typical onset within 2 months of treatment initiation1

– Symptoms may resolve over time2

– The true etiology and the optimal treatment is not known1

1. Burstein HJ. Breast. 2007;16:223-234. 2. Buzdar AU, for the ATAC Trialists’ Group. Presented at: 42nd Annual Meeting of the American Society of Clinical Oncology; June 2-6, 2006; Atlanta, GA. Abstract 551.

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ATAC Substudy: Risk Factors for Developing Joint Symptoms

Sestak I, et al. SABCS 2007. Abstract 2071.

Risk FactorJoint Symptoms, n

(%)Multivariate OR (95%

CI)P Value

Anastrozole 1040 (37.2) 1.31 (1.16-1.47) < .001

Previous HRT 840 (42.3) 1.52 (1.35-1.72) < .001

Chemotherapy 485 (38.9) 1.20 (1.04-1.38) .01

HR negative 130 (27.7) 0.76 (0.61-0.85) .02

Region of origin (vs rest of world)

• UK 563 (30.2) 1.19 (1.01-1.37) .04

• North America 803 (47.7) 2.1 (1.81-2.43) < .001

BMI > 30 kg/m2 (vs < 25)

555 (39.3) 1.36 (1.17-1.57) < .001

• Use of previous HRT led to greater difference in joint symptoms between patients on anastrozole vs tamoxifen

Estrogen Deprivation:Vasomotor Symptoms

• Chemotherapy can induce ovarian failure

• Hormone therapy can exacerbate vasomotor symptoms

• Hot flashes and sleep disturbances are common

• May lead to additional physical and psychosocial symptoms including mood lability

1. Hayes DF. N Engl J Med. 2007;356:2505-2513; 2. Barton DL, et al. Supportive Cancer Therapy. 2006;3:91-7. 3. Mrozek MD, Shapiro CL. Clin Adv Hematol Oncol. 2005;3:211-222.

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Management of hot flashes in breast cancer

• Placebo effect– Several placebo controlled studies have

shown that placebo can decrease hot flashes by 25% over 3-4 week period

– 10% of women may >75% reduction

– 10% will have a 50-75% reduction

Loprinzi et al, Lancet Oncol 2001

Phyto-estrogens

• NCCTG found no evidence of efficacy or toxicity from soy phyto-estrogen equivalent of 3 glasses of soy milk

• Small placebo controlled randomized trial found 50 mg of soy isoflavone equivalent to reduce hot flashes by 45% (c/w 25% in control arm)

• Larger randomized trial of soy preparation found statistically significant decrease in hot flashes at 6 weeks (p=0.03) but not at 12 wks

Quella et al, JCO 2000; Scambia et al, Menopause 2000; Upmalis et al, Menopause 2000

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Progestational Agents

• Megestrol acetate (Megace) tested in placebo controlled, double-blinded, randomized crossover trial in men and women– Megace reduced hot flashes by 75-80% c/w 20% with

placebo– Women on tamoxifen had transient increase in hot

flashes, resolving in 2-3 wks– Well tolerated but many pts d/c’d treatment due to

perceived side effects (weight gain)

• Attractive option in metastatic breast cancer pts due to anti-cancer effects of Megace

Loprinzi et al, NEJM 1994; Quella et al, Cancer 1998; Burch et al, JCO 1999

Other “Safe”Options• Vitamin E

– Double blind placebo controlled trial in breast cancer survivors

– 800 IU/day was slightly more effective than placebo, decreased hot flash frequency by one per day

• Black Cohash– Herb, Cimicifuga racemosa, approved in Germany for

menopausal symptoms– Ongoing trials in US and Europe with mixed results

• Bellergal– Several small studies showed decrease in hot flash

frequency (at 2 wks only) and severity (retrospective)

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Mean Hot Flash Score Reduction Randomized Studies

0

20

40

60

80

100

0 1 2 3 4 5 6

Week

% R

edu

ctio

n (

Mea

n) Placebo (n=420)

Soy (n=78)

Clonidine (n=75)

Megestrol (n=74)

Fluoxetine (n=36)

Venlafaxine (n=48)

Vitamin E (n=53)

Black Cohosh (n=58)

Ven (vs MPA) (n=94)

MPA 400 mg (n=94)

0

20

40

60

80

100

Baseline 1 2 3 4 5 6Weeks

Ho

t fl

ash

sco

re

(per

cen

t o

f b

asel

ine)

Placebo

Venlafaxine 37.5 mg/d

Venlafaxine 150 mg/dVenlafaxine 75 mg/d

Loprinzi et al, Lancet 2000

Venlafaxine for Hot Flashes

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Gabapentin for Hot Flashes

Placebo

Gabapentin 300 mg

0

-10

-6

Week 4

Change from baseline in hot flash severity

Baseline

-8

-4

-2

Week 8

Gabapentin 900 mg

-12

-14

Pandya KJ et al. Lancet 2005;366:818–824.

• 40% to 100% of cancer survivors report some form of sexual dysfunction (ie, vaginal dryness, painful intercourse)1

• Multiple dimensions2:

– Psychological/body image

– Hormonal treatment effects

• After primary treatment with mastectomy and chemotherapy3:

– 34% of women lacked sexual interest

– ~25% of women report difficulty with arousal, orgasm, or lubrication

Estrogen Deprivation: Sexual Dysfunction Symptoms

1. Krychman ML, et al. Oncology. 2006;71:18-25. 2. Hayes DF. N Engl J Med. 2007;356:2505-2513. 3. Ganz PA, et al. J Natl Cancer Inst. 2004;96:376-387. 4. Ganz PA. J Clin Oncol. 2006;24:5105-5111.

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Vaginal Dryness

• Non-estrogenic vaginal lubricants (Replens)

• Vaginal estrogens (ESTRING or Vagifem )

• Vaginal Testosterone Cream or DHEA

Loprinzi et al JCO 15, 969-973; 1997

Replens

PlaceboReplens

Placebo

Replens for vaginal dryness

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Are vaginal estrogens safe in breast cancer patients?

The jury is still out…

Vagifem - Controversial• Prospectively measured the serum E

levels in 6 women on adjuvant AI therapy for early breast cancer using Vagifem

• All were prescribed Vagifem 25 mcg tablets administered qd for 2 wks then twice wkly

• Serum was analyzed for E, FSH and LH at baseline then 2, 4, 7–10 and 12 weeks since commencement of vaginal estradiol

• Serum E levels rose from baseline levels ≤5 pmol/l consistent with AI therapy to a mean 72 pmol/l at 2 weeks. By 4 weeks this had decreased to <35 pmol/l in the majority (median 16 pmol/l) although significant further rises were seen in two women

Kendall et al, Annals of Oncology 17: 584–587, 2006

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Transdermal Testosterone in Female Cancer Survivors with Decreased Libido –

NCCTG N02C3

R

4 weeks

Testosterone*10 mg/day

Placebo**

4 weeks

Placebo**

Testosterone*10 mg/day

*In Vanicream** Vanicream JCO 24:469S, 2006 ASCO abstract #8507

-1

0

1

2

1stperiod

2ndPeriod

placebotestosterone

Mean Change from baseline:

Free testosterone concentrations

ng/dl

P<.0001

(Norms: 0.3-1.9 ng/dl)

Testosterone

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Libido Change from Baseline

0

1

2

3

4

5

6

7

8

9

1st Period 2nd Period

placebotestosterone

P=0.58 P=0.71

What other long term health and QOL issues may be in store for

your breast cancer patient?

• Weight gain

• Unfavorable lipid profiles?

• Persistent cognitive complaints?

• Chronic fatigue?

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What Are the Most Essential Aspects Required to Optimize Survivorship Care?

a)Monitoring for recurrenceb)Managing treatment-related side effectsc)Adherence to therapyd)Overall wellness promotione)Emotional healthf) Coordination of careg)Monitoring late effects of treatmenth)Patient/caregiver counseling/education about

recurrence riski) Referralsj) Other

Breast Cancer Survivorship Alliance. Health Care Professional Survey: Assessment of Survivorship Awareness and Educational Needs. Conducted at: 30th Annual San Antonio Breast Cancer Symposium; December 13-17, 2007; San Antonio, TX.

Potential Impact of Lifestyle Factors on Survivorship

Diet and Weight

• Weight and weight gain may be associated with higher rates of breast cancer recurrence and mortality

• One study suggests that a low fat diet high may be associated with a decreased risk of recurrence2

Exercise

• Regular moderate exercise may improve survival, particularly in women with hormone receptor–positive tumors3

Alcohol• Limited alcohol consumption is recommended by the

NCCN to promote a healthy lifestyle4

1. Kroenke CH et al. J Clin Oncol. 2005;23:1370-1378 2. Chlebowski RT et al. J Natl Cancer Inst. 2006;98:1767-1775 3. Holmes MD et al. JAMA. 2009;293:2479-2486. 4. National Comprehensive Cancer Network. Breast Cancer Risk Reduction-v.2.2009. http://www.nccn.org/professionals/physician_gls/PDF/breast_risk.pdf. Accessed September 15, 2009.

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Takeaway Messages for HCPs of Breast Cancer Survivors

• Cancer patients face many long term complications and symptoms from their treatment

• Many cancer patients will be cured of their disease– Not every symptom is a recurrence of cancer!!

– Before you order a scan or test, consider contacting patient’s treating oncologist to discuss what test would be best and what the implications will be