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Follow up and survivorship issues after treatment for breast cancer
Michael Jefford
MBBS, MPH, MHlthServMt, PhD, MRACMA, FRACP
Clinical Consultant, Cancer Council VictoriaConsultant Medical Oncologist, Peter MacCallum Cancer CentreAssociate Professor of Medicine, University of [email protected]
Key points
There are a large number of breast cancer survivors – high incidence x high survival rates
Current focus of follow up / surveillance is (largely) on detection of cancer recurrence
Women with a prior experience of breast cancer have much broader survivorship issues
Key points
Women should be informed of ways to maintain their health and wellness– Survivorship care plan
– Advice and coaching regarding healthy lifestyle
Alternative models of care (rather than led by medical specialists) should be explored
Useful resources
Cancer Council resources
Cancer Council Helpline 13 11 20, and database
DVD and booklet Regional seminars Survivors Cancer
Connect Support groups – face to
face, telephone, internet
Breast cancer is the third most common cancer in Australia
(excluding non melanoma skin cancers)
1, 5 and 10 year survival from breast cancer is high
5 year survival 87%
Survival rates are improving
Unfortunately, 3rd highest cause of cancer death
(after lung, prostate cancer)
Greatest number of cancer survivors are breast cancer survivors
Available as a PDF from the Cancer Council website – www.cancervic.org.au
Breast cancer – incidence and mortality trends (Victoria)
Canstat: Cancer in Victoria 2006. The Cancer Council Victoria Epidemiology Centre 2009
Potential issues after completing treatments for (breast) cancer
Varied reactions to finishing treatment
Fear of recurrence
Ongoing treatment side effects
Relationship issues
Work / financial issues
Impact on family
Late and long-term effects of treatment– menopausal
symptoms, loss of fertility, osteoporosis, cognitive disturbance, weight changes, altered body image, sexual problems, fatigue, heart problems, risk of second cancers
Distress, anxiety, depression
The US Institute of Medicine (IOM) report
From Cancer Patient to Cancer Survivor: Lost in Transition
Landmark report Argued that the post
treatment phase is a distinct phase that requires increased attention by clinicians
17 minute video on YouTube at www.youtube.com/watch?v=7y0msS6KNAA
The US Institute of Medicine report
Recommends four components of quality survivorship care
1. prevention of recurrent and new cancers
2. surveillance for cancer recurrence as well as for medical and psychosocial late effects
3. strategies to deal with the broad consequences of cancer and its treatment
4. coordination between specialists and primary care providers
Strategies to improve outcomes for cancer survivors
Information– Survivorship care plans
Strategies to remain well
Regular surveillance– Hospital, GP, nurses?
Supports
Survivorship care plans
A key component of optimal survivorship care is the use of a survivorship care plan (SCP)
The SCP is a summary of:– Cancer diagnosis and treatments
– Plans for follow up
– Current medical, psychosocial, practical issues, and a plan for management
– Potential future issues and a plan for management
Ideally discussed with someone toward the end of potentially-curative treatment(s)
Why do we need them?
Because patients are ‘lost in transition’ (from cancer patient to cancer survivor)
Fragmented, poorly coordinated healthcare system
Patients need a coordinated plan for follow up and a plan to protect their health
Patients (and GPs) want to be informed and help ensure good survivorship outcomes
The SCP in more detail
Essential elements include details about: (i) the cancer (diagnosis and stage), all
treatments (with dates, doses, complications), and potential short and long-term consequences
(ii) the content and timing of recommended follow up (monitoring for treatment toxicity, cancer recurrence, and psychosocial / supportive care issues)
The SCP in more detail
Essential elements include details about:(iii) who will take responsibility for survivorship
care (oncologist, primary care doctor (GP), survivor, carers)
(iv) health promotional strategies (e.g. weight, exercise, diet, smoking cessation)
(v) practical information and advice (e.g. regarding employment, insurance), and
(vi) the availability of psychosocial/supportive care services
The SCP
For whom?– Person affected by cancer, GP, other treating
doctors
In what format?– Paper and electronic
– Tailored to the person’s (a) diagnosis, treatment, (b) own identified needs, and (c) to their preference for information (brief detailed)
The SCP
Completing the SCP– ? Nurse or oncologist
– Many components are ‘generic’
– Resources available: (a) ‘implementing SCP’ workshop reports are available free (next slide); (b) ASCO guidelines for follow up; (c) community-based supports
Limited implementation to date
Useful (free) resources
Health behaviours of cancer survivors
An Australian study (2007) compared health behaviours of cancer survivors to a cohort of people without cancer
968 survivors, 5808 controls
Asked about smoking, physical activity, servings of fruit and vegetables, alcohol use, skin checks
Eakin EG et al. Cancer Causes Control 2007; 18(8): 881-894.
Health behaviours of cancer survivors
More likely to have comorbidities (and more of them)
More likely to be current smokers
More likely to have regular skin checks
(not stat sig) More likely to be overweight / obese
(not stat sig) Had higher alcohol consumption
No differences regarding physical activity, fruit and vegetable consumption
Eakin EG et al. Cancer Causes Control 2007; 18(8): 881-894.
Information about staying well
Maintain a healthy weight
More fruit and vegetables
Less fat Exercise Limit or avoid alcohol Stop smoking
Weight
In women who had never smoked, those who gained between 0.5-2.0 kg/m2 had a relative risk of 1.35 of death from breast cancer, compared to those who maintained their weight
In women who had never smoked, those who gained > 2.0 kg/m2 had a relative risk of 1.64
Kroenke CH et al. J Clin Oncol 2005; 23(7): 1370-8. Epub Jan 31
Dietary change
WHEL study– Women’s Healthy Eating and Living
randomised controlled trial
– Diet very high in vegetables, fruit, fibre and low in fat
– People were able to adopt / maintain the diet
– Did not reduce breast cancer recurrence / deaths
Pierce JP et al. JAMA 2007; 298(3): 289-98
Dietary change
WINS study– Women’s Intervention Nutrition Study
randomised controlled trial
– % of calories from fat to 15% (realistic aim of 20% of calories from fat)
– 2437 women enrolled, median follow up 60 months
– Significant reduction in cancer recurrence – 9.8% vs 12.4% (HR 0.76, 24% reduction in risk of cancer recurrence)
Chlebowski RT et al. J Natl Cancer Inst 2006; 98: 1767-76
Information about staying well
Stop smoking Maintain a healthy
weight More fruit and
vegetables Less fat Exercise Limit or avoid alcohol
Views of survivors and health professionals regarding follow up and the SCP (Peter Mac) General support for the notion of a SCP
Support for core content areas
Support for information for, and involvement of GPs
Uncertainties regarding: (a) who coordinates follow up; (b) who might complete / discuss the SCP; (c) content of the SCP
Survivorship care
The SCP needs to be integrated into a more complete approach / strategy
Alternate models of follow up may include nurse-led follow up (face to face, telephone), GP follow up, survivorship clinics
Beaver K et al. BMJ 2009; Jan 14;338:a3147
GP follow up of women with early stage breast cancer
Work of Dr Eva Grunfeld (series of RCTs of GP vs specialist follow up) shows that GP follow up is associated with – Similar disease outcomes (recurrence)
– Similar quality of life
– Greater satisfaction
– Lower costs (patient, health service)
An example from our current work
We are developing a ‘comprehensive survivorship package’ including– DVD, booklet and a question prompt list
– SCP – for patient and for GP
– Nurse-led ‘end of treatment’ session
– Telephone-based follow up
Treatments
Given DVD, booklet, QPL End of treatment session
Review needs
Discuss QPL
Discuss SCP
Telephone-based follow up
GP involvement
Conclusions
There are a large number of breast cancer survivors
The current focus of follow up is (likely) inadequate and probably inefficient
There are different models of providing survivorship care – these need to be piloted and evaluated
The most appropriate model will depend on local factors
Conclusions
Tailored, survivorship care plans are part of good survivorship care
We need to determine the ideal way to develop and discuss the SCP and how this is best integrated into survivorship care (models of care)
Ideally ongoing survivorship care should screen for, and respond to unmet needs
www.cancervic.org.au
