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Megan Dunne RN, MA, AOCNP Nurse Practitioner for Breast Cancer Survivorship Memorial Sloan Kettering Cancer Center

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Experiences of Cancer Survivors Lance Armstrong Foundation LIVESTRONG TM Survey of 2,307 Post-Treatment Survivors 99% reported 1 problem as a result of cancer Physical problems (86%) Energy, concentration, sexual dysfunction, neuropathy, pain were most highly endorsed Emotional concerns (93%) Fear of recurrence, depression, grief/identity issues, concerns about family members risk Practical concerns (58%) 70% of those in school reported school-related problems 40% experienced employment issues Debt issues (33%); insurance issues (21%) LIVESTRONG Report, 2011. LIVESTRONG survey 2006

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After Effects of Breast Cancer Therapies Long term effects Developed during treatment Linger and are chronic after treatment is completed Some improve over time Fatigue Anemia Permanent- Neuropathy- nerve damage Numbness, tingling, pain

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After Effects of Breast Cancer Therapies Late Effects Delayed-can emerge months or even years after treatment Lymphedema Osteoporosis

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Late medical effects of treatment depend on the type of therapy... and the specific toxicities of each therapy Radiation Therapy Surgery Chemotherapy Hormone Therapy

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Types of After Effects Physical Fatigue, Scars, Lymphedema, Osteoporosis Emotional Anxiety/depression Fear of Recurrence Practical Employment Health Insurance

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Fatigue: Symptoms Prevalence in breast cancer survivors 33 to 37%. More prevalent and prolonged in patients whove received chemotherapy Symptoms reported by patients Tired despite sleeping well at night Difficulty performing routine activities Irritability Difficulty concentrating Goedendorp et al (2007) Cancer Nov 15

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Fatigue: Interventions Balance activity and rest periods Healthy lifestyle choices High fiber, low fat diet Exercise Yoga Aerobic exercise McMillan et al (2011) Appl Physiol Nutr Metab Dec;36(6) 892-903

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Insomnia Related Fatigue Prevalence as high as 88% cancer patients Lasts for years after therapy is completed Becomes chronic when maladaptive responses to the initial sleep disturbance develop Underreported and undertreated Contributes to: Decreased quality of life (QOL) Impaired function Impaired cognition Woodward (2011) CJON 15;4Perlis et al (2008) Cog Behav Tr Insomnia: session by session guide ONS (2008) PEP: Sleep wake Disturbances

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Cognitive Changes: Symptoms Prevalence up to 40% cancer patients Difficulty concentrating, attention deficit, easily distracted Short term memory loss Inability to perform routine tasks Checkbook, multi-tasking, recall names/dates American Cancer Society (2008)Jansen et al (2005) ONF 32: 6 1151-63. Stewart et al (2008) PsychoOncology 17:2Ahles et al (2002) JCO 20:485-493

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Cognitive Changes: Interventions Exercise- improves brain oxygenation Acupuncture Antioxidant foods- fruits and vegetables high in vit C and E can mediate effects of oxidative stress Increased fluid intake- prevents dehydration, flushes toxins Inform family and friends- generate support and understanding Nelson et al (2007)Palliative and Supp Care 5:3 p 273-80 Barton and Loprinzi (2002) Clin Breast Ca 3 (suppl 3) s121-127

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Cognitive Changes: Interventions Sleep habits Make lists Mental exercises- Crosswords, Sudoku puzzles Relaxation activities Music, hobbies, nature Cognitive therapy MSKCC Trial- Memory Training Pharmacologic Interventions: Effectiveness Not Established Wilson et al (2002) J Amer Geriatrics Soc 50:12 p 2041-56

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Lymphedema: Symptoms Prevalence is estimated at 21% to 49% Includes self- reported symptoms Swelling of arm or trunk Jewelry and clothing feel tight Fullness or discomfort of arm Loss of flexibility of hand, wrist, fingers Infections that recur in same area Cellulitis Skin changes and feels tight Smoot et al (2010) J Cancer Surv; Jun 4:2 p167-78 2010 LIVESTRONG survey, Petrek et al (2001) Cancer 92: 1368-77.

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Lymphedema: Interventions Multimodality Therapy Lymphedema specialist Occupational Therapy Compression garment or sleeve Manual lymphatic drainage with massage Health diet, healthy weight Adequate fluid hydration Shah and Vicini (2011) Int J Rad Onc Biol Phys. 81:4 p907-914

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CIPN : Symptoms Incidence is greatest in patients treated with taxanes Paclitaxel 57%-83%overall; 2%-33% severe Docetaxel 11%-64% overall; 3%-14% severe Numbness Hands or feet most common Pain Burning, shooting pain Sensitivity to temperature Loss of reflexes and reduced function of extremities Ataxia- gait changes Quastoff and Hartung. (2002) J Neurol 249 (1): 9-17

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CIPN: Interventions No proven evidence based interventions Control contributing conditions Diabetes mellitus Thyroid dysfunction Physical and Occupational Therapy Exercise Acupuncture Visovsky et al. (2007) CJON 11;6 p.901-913 ONS PEP: Evidence Based Interventions for CIPN

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CIPN: Education Maintain Safety Visual input to compensate for sensation loss Risk of ischemic and thermal injury Protect skin from hot and cold extremes Proper foot care and foot wear Dangle legs prior to standing High fiber diet and adequate fluid intake Armstrong et al. (2005) ONF. 32:305-311 Marrs and Newton. (2003) CJON, 7:299-303

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Osteoporosis Primary Osteoporosis Major public health issue in general population Particularly post-menopausal women Baseline Bone Mineral Density age 50 Wickham (2011) CJON 15:6

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Osteoporosis Secondary osteoporosis related to cancer therapies is common in Breast Cancer Survivors Premature ovarian failure Chemotherapy Elective ovarian ablation Impaired gonadal function Gonadotropin and Androgen blockade Estrogen blockade Tamoxifen Negative effect in pre-menopausal women only Aromatase inhibitors Abdel Razeq and Awidi: 2011. J of Ca Res and Ther 7:3

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Osteoporosis: Symptoms Silent disease Can exist for years without symptoms Loss of height Stooped posture Spinal curve or hump

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Osteoporosis: Assessment Bone Mineral Density Testing T-score NTX ( serum and urine) bone turnover rate FRAX World Health Organization Fracture Risk Assessment Tool Algorithm Estimates 10 year fracture risk Stratifies gender, age, co-morbidities

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Osteoporosis: Non-pharmacologic Interventions Limit alcohol and stop smoking Weight bearing activities Maintain a healthy weight Strength training Safety- falls prevention Nutritional considerations Calcium and Vit D

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Osteoporosis: Pharmacologic Interventions Bisphosphonates Alendronate (Actonel) Ibandronate (Boniva) Risedronate IV Zoledronic Acid IV Other agents Denosumab Calcitonin Wickham, R (2011) CJON 15:6 p E90-E104 Drake et al (2008) Mayo Clin Proceedings 83:1032-45

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Chronic Pain: Interventions Talk to your medical team Multidisciplinary approach Stretching, exercise Complementary therapies Acupuncture Take medication as directed May require frequent monitoring and changes Pain specialist consult

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Sexual Dysfunction: Symptoms Decreased libido (desire) Difficulty reaching climax (orgasm) Vaginal dryness Painful intercourse Painful touching Tightness

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Sexual Dysfunction: Interventions Consult with GYN who specialized in womens issues Kegel exercises Vaginal dilator Psychologic support Depression Anxiety Self- esteem, body images issues

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Vaginal Moisturizers Apply at bedtime 2 to 5 times weekly Vitamin E capsules Puncture a vitamin E capsule with a pin. Insert the capsule into your vagina. You can also empty the capsule onto a finger. Wipe the vitamin E inside your vagina. Replens This vaginal moisturizer comes with an applicator and is inserted into the vagina. K-Y Brand LIQUIBEADS This is a vaginal bead (OVULE) suppository placed into the vagina. It also comes with disposable applicators. Carter et al (2011) J Sexual Med 8:549-559

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Vaginal Lubricants Eros women formula. Astroglide. KY Jelly. Pjur Woman Bodyglide (a silicone-based lubricant). Avoid colors, flavors, spermicides, and warming liquids Carter et al (2011) J Sexual Med 8:549-559

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Vaginal Hormone Replacement Discuss safety with your medical team Opinions vary Vagifem is contained in an applicator. Insert it into your vagina every night for 14 days. Then insert it twice a week, at bedtime. Estring comes as a vaginal ring. Insert the ring into the vagina and push it as far back as possible. Remove it after 90 days.

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Depression and Anxiety Common in cancer survivors Fear of recurrence Body changes Support Services Community support groups Family, friends Psychologist, Psychiatrist

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Journey Forward: Supporting Survivors and Providers

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ASCO Breast Cancer Adjuvant Treatment Plan and Summary

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Treatment Summary and Care Plan Diagnosis and treatment history Co-morbid conditions Medications Family history Genetics consult Screening recommendations Health Promotion Counseling

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Routine Screening Annual mammogram at age 40 Annual clinical breast exam Self breast awareness Notify your NP/MD of changes Colonoscopy baseline at age 50 PAP smear with gynecologist Skin cancer screening as indicated

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Promote Healthy Life Choices to Prevent Cancer If you smoke- STOP Limit alcohol Exercise Eat a balanced low-fat, high-fiber diet Reduce stress Health maintenance with Primary Care Provider