Survivorship Issues of the Metastatic, Recurrent and Intractable Breast Cancer

Yaelim Lee, PhD, MSN, RNRed Cross College of Nursing, Chung-Ang University

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Breast cancer, a common cancer in women• In the U.S. • Every 2 minutes a woman is diagnosed with

breast cancer • Every 13 minutes a woman die of breast cancer

• In Korea • The 2nd most common cancer in women• The 6th most common cause of death in women

with cancer

Backgrounds

(National Breast Cancer Foundation (NBCF), 2016; Korean Breast Cancer Society (KBCS), 2016)

Relatively high survival rate (5-year survival) • Prostate cancer 99%• Thyroid cancer 98%• Testis cancer 95%• Melanoma of skin 92%• Breast cancer (female) 89%• …• Cervical cancer 68%• …• Colon & rectum cancer 65%• …• Ovarian cancer 46%• …• Stomach cancer 29%• …• Pancreas cancer 7%

Backgrounds

(American Cancer Society (ACS), 2016)

Backgrounds

(ACS, 2016)

Backgrounds

(KBCS, 2016)

Who are the breast cancer survivors?

Backgrounds

(American Society of Clinical Oncology (ASCO), 2016)

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Cancer survivorship• Living with, through, and beyond cancer• Phases• Acute survivorship

• Begins at cancer diagnosis ~ end of cancer treatment

• Extended survivorship• End of cancer treatment ~ months after

• Permanent survivorship• Later period: Years have passed since cancer

treatment, recurrence less likely

Backgrounds

(American Society of Clinical Oncology (ASCO), 2016)

Survivorship issues• What if…• my cancer goes aggressive

(progressions)• my family gets tired of me

• How should I …• cope with numerous side-effects• keep up with multiple health

appointments

Backgrounds

Image: http://www.trcc.org/survivorship/

(National Cancer Institute (NCI), 2016)

Resources• An integrated literature review using • Multiple databases • Publications of official health parties

• Korean Breast Cancer Society, American Cancer Society, U.S. National Cancer Institute, and etc.

Steps• Three themes on survivorship issues• Five directions for patient encounter & care

based on the discussion of these issues

Methods

Three themes

Survivorship Issues

1.• Suffering from the lingering

symptoms of cancer treatment

2.• Managing conditions acquired from

the treatment

3.• Experiencing complex emotions

Vasomotor symptoms• Hot flashes: warmth, sweating, redness• Often belittled: “Ah.. another flash, open the

window” Sudden & Intense: “Once you have one, there’s no mistaking it” Negatively impact daily livings, sleep, compliance to medication

Survivorship Issues

1.• Suffering from the lingering

symptoms of cancer treatment

Image: http://accesstelehealth.org/understanding-and-dealing-with-hot-flashes/

Survivorship Issues

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Low estrogen levels

Deregulation of

hypothalamus

Symptoms

Survivorship Issues

Chemotherapy, hormonal therapy• Interrupting ovarian function• Decreasing estrogen concentration• Decreasing sensitivity of tissues to estrogen

‘Body’s thermostat’: “Too hot!” Heat-releasing mechanism• Increased heart rate• Dilated vessels (near skin), sweat glands

• Palpitation (nausea, dizziness, anxiety)

• Flash (heat, redness)• Sweating (soaking)

Neuromusculoskeletal pain• Arthralgia, neuropathy

• Impairing activities of daily livings• Chemotherapy, Hormonal therapy (aromatase inhibitor;

AI)• Neurotoxicity• Rapid drop in estrogen release of cytokines which

hasten bone loss and aging of joints • Risk of social isolation• Chronic pain leading to depression

Survivorship Issues

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Fatigue• Persistent feeling of exhaustion• Cancer treatment in general• Neurotoxicity, hormonal change, chronic stress,

anemia• Comprehensive assessment• Hypothyroidism, cardiomyopathy, depression

Survivorship Issues

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Anemia

Pain

Emotional Distress

Sleep Problems

Medication

Poor Nutrition

Lack of Exercise

Other Problems

Survivorship Issues

(ACS, 2016)

Cancer-relatedFatigue

Bone marrow suppression

Depression & Anxiety

Pain killer, anti-depressants, antiemetic

Infections, cardiomyopathy,hypothyroidism, depression

Poor appetite, increased energy needs

Pain, “obsessive resting”

Fatigue• Rest, but not too much• 30 minutes or less• “obsessive resting”

• Stay active• Save your energy• Prioritize

• Get help• “Learning to let others help you”

• Eat well• Reduce stress

Survivorship Issues

(ACS, 2016)

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Impaired sexuality• Surgery, radiation

• Changing body appearance and sensation• Chemotherapy, hormonal therapy (AI>tamoxifen)

• Early menopause, sexual dysfunction• Decreased libido, dyspareunia, anorgasmy

• Less discussed• Uncomfortable (health care providers patients)• Few standard tool screening for sexual dysfunction in

survivors of cancer• Female Sexual Function Index (FSFI)

Survivorship Issues

Cardiac toxicity• Cardiomyopathy

• Breathlessness, swelling of extremities, fatigue• Chemotherapy (anthracycline-based; doxorubicin,

epirubicin)• Special eyes on accumulation dose

• Irreversible Reversible• Early intervention with angiotensin-converting

enzyme inhibitors (ACEI), beta-blockers

Survivorship Issues

2.• Managing conditions acquired from

the treatment

Weight gain• Average weight gain: 2.5-6.2 kg• Sarcopenic obesity• Treatment in general• Lipoprotein lipase (LPL) activity

• LPL: Fat into fat cells and makes it fatter• Estrogen supposed to suppress LPL

• Decreased estrogen

• Decreased physical activity

Survivorship Issues

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Weight gain• Strong evidence: • Physical exercise – reducing recurrence and

death• American Cancer Society• Moderate-intensity aerobic activity: 150 minutes

per week• Strength training: 2 days per week

Survivorship Issues

Image: http://gymflow100.com/the-importance-of-exercise-while-fighting-cancer/

Cognitive changes• Problems with attention, concentration,

executive function, memory• Chemotherapy > Hormonal therapy • Poorly studied• Slow recovery• Cognitive behavioral training

Survivorship Issues

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Increased risk of osteoporosis • Chemotherapy, Hormonal therapy (AIs)• Premature menopause

• Estrogen• Decreases the osteoclasts stimulates osteoblast

• Modifiable risk factors• Weight-bearing physical activity, calcium / vit. D

supplements, smoke cessation Increased risk of other cancers• Leukemia (chemotherapy), lung cancer, uterine

cancer (tamoxifen)

Survivorship Issues

Fears• Disease progression, pain, death, and uncertainty• Obsession in life styles

Anger• “Life is not fair”

Sadness, hopelessness• Thoughts of death

Self-consciousness• Social isolation

Guilty feelings• “I did something wrong” (cancer-causing potential)• To their family members, caregivers

Survivorship Issues

3. • Experiencing complex emotions

Thankfulness• Positive life changes: ‘post-traumatic growth’• Healthier life styles, new perspectives

• Supports and love from family and friend• Stronger spirituality

Motivation• A second chance• Complete one’s will or life plans

Survivorship Issues

Survivorship Issues

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1.• Provide individualized treatment and a follow-up

plan

2.• Provide evidence-based health education and

preventing follow-up loss

3.• Deliver collaborative care with multi-providers

4.• Implement a comprehensive interdisciplinary team

approach

5.• Emphasize the necessity of further efforts

Proposed Directions

1.• Provide individualized treatment and a

follow-up plan

Proposed Directions

Decision sharing, planning together• Valuing each person’s concerns, life priority

Importance of follow-up care• Maintain good health• Manage symptoms (side-effects)• Find signs of progression• Screening for other types of cancers

2.• Provide evidence-based health

education and preventing follow-up loss

Proposed Directions

Too much information• Friends, family, support group, mass media

(internet, television, magazines) Importance of continuity of care• “Learning to let others help you”• “You are not alone”• Support group

3.• Deliver collaborative care with multi-

providers

Proposed Directions

Collaboration with multi-providers• Oncologist, surgeon, gynecologist,

cardiologist, psychiatrist…• ‘Patchwork’

• Multiple outpatient visits, repetitive testing

• Medication• Repetitive drugs, drug-drug

interactions• ‘Prescribing cascade’

Collaboration!! Patient education!!

Image: http://edtansrant.blogspot.kr/2015/11/prescribing-cascade.html

4.• Implement a comprehensive

interdisciplinary team approach

Proposed Directions

Interdisciplinary team approach• Multi-providers + pathologist, radiologist, pharmacist,

nutritionist, physical therapist… Benefits

• Decision making• Balanced care plan through objective second opinions• Up-to-date management plan Optimal management plan among many options

• Supportive care• Integral part of breast cancer management• Compliance

• Managing side-effects from cancer treatment• Empowering

Image: https://n415son11.wordpress.com/interdisciplinary-practice-nurses-as-full-partners-in-care/

5.• Emphasize the necessity of further

efforts

Proposed Directions

Qualitative nursing research• Breast cancer survivors’ experiences• In-depth understanding

Utilizing health informatics• Web-based tools (education, decision making

supports)• Integrated data registry• Genomics: response to drugs, disease prognosis

Image: http://ehealth4everyone.com/did-you-know-health-informatics-trivia/

Breast cancer survivors confront complex changes from cancer and its treatments

Understanding breast cancer survivors’ issues and priority concerns contribute in… • Enhancing communication with the survivors• Providing adequate care• Improving their quality of life

Conclusion

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https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatment-and-survivorship-facts-and-figures/cancer-treatment-and-survivorship-facts-and-figures-2016-2017.pdf

https://www.cancer.gov/about-cancer/coping/survivorship

http://www.cancer.net/survivorship/about-survivorship

https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/fatigue.html

http://www.kbcs.or.kr/journal/file/2016_Breast_Cancer_Facts_and_Figures.pdf

References