Julie R. Gralow, M.D.Julie R. Gralow, M.D.

Director, Breast Medical Oncology, Seattle Cancer Care AllianceDirector, Breast Medical Oncology, Seattle Cancer Care Alliance

Professor, Medical Oncology, University of Washington School of Professor, Medical Oncology, University of Washington School of MedicineMedicine

Member, Clinical Division, Fred Hutchinson Cancer Research CenterMember, Clinical Division, Fred Hutchinson Cancer Research Center

Long-term Follow-up of Long-term Follow-up of Breast Cancer PatientsBreast Cancer Patients

The Cancer Care The Cancer Care ContinuumContinuum

Detection Treatment SurvivorshipDetection Treatment Survivorship

& Diagnosis& Diagnosis

Optimal care of an individual person differs Optimal care of an individual person differs along the continuum along the continuum

Institute of Medicine 2005 Report Institute of Medicine 2005 Report From Cancer Patient to Cancer Survivor: From Cancer Patient to Cancer Survivor:

Lost in TransitionLost in TransitionHewitt M, Greenfield S, and Stovall E, eds. Hewitt M, Greenfield S, and Stovall E, eds.

http://www.cancer.net/patient/Survivorship/IOM_Executive_Summary.pdhttp://www.cancer.net/patient/Survivorship/IOM_Executive_Summary.pdff

• Transition from active treatment to post-treatment care Transition from active treatment to post-treatment care critical to long-term healthcritical to long-term health

• Routine follow-up visits are opportunities to promote Routine follow-up visits are opportunities to promote healthy lifestyle, check for cancer recurrence, manage healthy lifestyle, check for cancer recurrence, manage lasting effects of the cancer experiencelasting effects of the cancer experience

• Cancer survivors are a heterogeneous population, some Cancer survivors are a heterogeneous population, some having few late effects of cancer and its treatment, and having few late effects of cancer and its treatment, and others suffering permanent and disabling symptomsothers suffering permanent and disabling symptoms

• The good news is that there is much that can be be done The good news is that there is much that can be be done to avoid, ameliorate, or arrest the late effects of cancerto avoid, ameliorate, or arrest the late effects of cancer

IOM IOM Report: All Report: All

Patients Patients Should Should

Receive a Receive a Cancer Cancer

Treatment Treatment SummarySummary

SCCA SCCA Breast Breast Cancer Cancer

Treatment Treatment SummarySummary

(modified from (modified from asco.org)asco.org)

Patient Name: UW/SCCA medical record number:

Date of Birth:

Cancer Diagnosis: Date of Diagnosis:Age at Diagnosis:

Tumor Stage: Tumor Size (T) , Nodes (N) , Metastases (M) Tumor grade:

Hormone receptors: Estrogen receptor (ER) , Progesterone receptor (PR)

HER-2:IHC, FISH

Oncotype DX (if done): Family History of Cancer: BRCA1/2 testing (if done):

Significant Past Medical History and Medications:

Cancer TreatmentSurgery

Breast Surgery: Procedure, date Lymph Node Surgery: Procedure, date

Reconstruction: Procedure, date

Systemic TherapyChemotherapy: Route Dose Schedule Number of

cyclesCumulative Anthracycline Dose Administered:Doxorubicin____ mg/m2 Epirubicin___ mg/m2

HER-2 Targeted Therapy: Drug, start date, stop date

Endocrine (Hormonal Therapy): Drug, start date, stop date

Bisphosphonate Therapy for Breast Cancer Indication: Drug, start date, stop date

Enrolled in Clinical Trials?

Radiation TherapyDate Start Date Stop Total Dose (cGy)

Fields included:

Complications of therapy:

ProvidersPrimary Care Provider: Surgeon:Radiation Oncologist: Medical Oncologist:

Breast Cancer Follow-Up Breast Cancer Follow-Up Includes Three Major Includes Three Major

Goals:Goals:

• Surveillance for cancer Surveillance for cancer recurrencerecurrence

• Monitoring for toxicities Monitoring for toxicities related to therapyrelated to therapy

• Maximizing overall health and Maximizing overall health and quality of lifequality of life

Breast Cancer Survivorship Care Plan Breast Cancer Survivorship Care Plan (modified from asco.org)(modified from asco.org)

FOLLOW-UP CARE FOLLOW-UP CARE TESTTEST

RECOMMENDATIONRECOMMENDATION

Medical history and Medical history and physicalphysical

Visit your doctor every three to six months for the first three years after the first Visit your doctor every three to six months for the first three years after the first treatment, every six to 12 months for years four and five, and every year thereafter.treatment, every six to 12 months for years four and five, and every year thereafter.

Post-treatment breast Post-treatment breast imagingimaging

The SCCA recommends a mammogram of the affected breast every 6 months for The SCCA recommends a mammogram of the affected breast every 6 months for up to 3 years from cancer diagnosis, and annual mammography of the opposite up to 3 years from cancer diagnosis, and annual mammography of the opposite breast. In some selected patients, a periodic breast MRI or ultrasound may be breast. In some selected patients, a periodic breast MRI or ultrasound may be recommended.recommended.

Breast self-examinationBreast self-examination..

Perform a breast self-examination every month. This procedure is not a substitute Perform a breast self-examination every month. This procedure is not a substitute for a mammogram.for a mammogram.Inspection and palpation of irradiated skin and soft tissues every year. Report any Inspection and palpation of irradiated skin and soft tissues every year. Report any unusual symptoms to your medical provider.unusual symptoms to your medical provider.

Pelvic examinationPelvic examination Continue to visit a gynecologist regularly. Women taking tamoxifen should report Continue to visit a gynecologist regularly. Women taking tamoxifen should report any irregular vaginal bleeding to their doctor. any irregular vaginal bleeding to their doctor.

Laboratory testsLaboratory tests Your oncologist will determine which blood tests are recommended in your case. Your oncologist will determine which blood tests are recommended in your case. This may include a periodic complete blood count (CBC), chemistry panel, liver This may include a periodic complete blood count (CBC), chemistry panel, liver and kidney tests, and tumor markers. and kidney tests, and tumor markers.

Radiology testsRadiology tests Your oncologist will determine which radiology tests are recommended in your Your oncologist will determine which radiology tests are recommended in your case. While a regular chest xray is sometimes indicated annually in higher-risk case. While a regular chest xray is sometimes indicated annually in higher-risk patients, it is uncommon to routinely recommend bone scans, CT scans, PET patients, it is uncommon to routinely recommend bone scans, CT scans, PET scans or MRIs in asymptomatic patients. Every few years a DEXA scan to evaluate scans or MRIs in asymptomatic patients. Every few years a DEXA scan to evaluate bone density is indicated in postmenopausal breast cancer patients.bone density is indicated in postmenopausal breast cancer patients.

Coordination of careCoordination of care Most patients diagnosed with invasive breast cancer continue to be followed by Most patients diagnosed with invasive breast cancer continue to be followed by their medical oncologists for at least 5 years from diagnosis. It is important to also their medical oncologists for at least 5 years from diagnosis. It is important to also have a primary care doctor, to manage non-cancer related health issues. have a primary care doctor, to manage non-cancer related health issues.

Surveillance for Breast Surveillance for Breast Cancer RecurrenceCancer Recurrence

• Local/Regional RecurrenceLocal/Regional Recurrence

• Distant RecurrenceDistant Recurrence

• Assessment of risk of cancer recurrence Assessment of risk of cancer recurrence and second cancersand second cancers

• Interventions to further reduce risk of Interventions to further reduce risk of cancer cancer

• Early detection of recurrence and second Early detection of recurrence and second cancerscancers

Assessing Risk of Cancer RecurrenceAssessing Risk of Cancer RecurrenceRecurrence Hazard Rates for Recurrence Hazard Rates for

Breast Cancer After Primary TherapyBreast Cancer After Primary Therapy Saphner et al, J Clin Oncol 14:2738, 1996Saphner et al, J Clin Oncol 14:2738, 1996

Years

Re

cu

rren

ce

ha

zard

ra

te

0

0.1

0.2

0.3

0 1 2 3 4 5 6 7 8 9 10 11 12

Assessing Risk of Second Cancers Assessing Risk of Second Cancers How Much Breast Cancer Is How Much Breast Cancer Is

Hereditary?Hereditary?

Sporadic

Hereditary

FamilyClusters

15-20%

5-10%

70-80%

Cancer Screening: Looking for Cancer Cancer Screening: Looking for Cancer Recurrence and Second CancersRecurrence and Second Cancers

• MammographyMammography• Health Professional’s ExamHealth Professional’s Exam• Self-ExamSelf-Exam• Breast MRI in some very high Breast MRI in some very high

risk?risk?

Monitoring for Toxicities Related to Monitoring for Toxicities Related to TherapyTherapy

• Assessing risk of toxicitiesAssessing risk of toxicities

• Interventions to reduce risk of toxicityInterventions to reduce risk of toxicity

• Detection and treatment of side effectsDetection and treatment of side effects

Side Effects of ChemotherapySide Effects of ChemotherapyCardiac Events vs. Cumulative Cardiac Events vs. Cumulative

Chemotherapy DoseChemotherapy Dose

Doxorubicin

450 mg/m2

Cumulative anthracycline dose (mg/m2)

00

0

100100 200200 300300 400400 500500 600600 700700 800800 900900 10001000

100

80

60

40

20

Car

diac

eve

nts

(%)

Side Effects of ChemotherapySide Effects of ChemotherapyChemotherapy-induced Chemotherapy-induced

Menopause in Breast CancerMenopause in Breast Cancer• Ovarian damage is a significant long-term consequence of Ovarian damage is a significant long-term consequence of

adjuvant chemotherapy in premenopausal breast cancer adjuvant chemotherapy in premenopausal breast cancer patientspatients– All are affected by resultant menopausal effectsAll are affected by resultant menopausal effects– Infertility seriously affects some Infertility seriously affects some

• For women who retain ovarian function after breast cancer, For women who retain ovarian function after breast cancer, pregnancy is possible post-chemopregnancy is possible post-chemo– Limited data do not show a worse outcome for women Limited data do not show a worse outcome for women

who become pregnant after breast cancerwho become pregnant after breast cancer

• New techniques for preserving ovarian function and New techniques for preserving ovarian function and achieving fertility are under studyachieving fertility are under study

Side Effects of Endocrine TherapySide Effects of Endocrine TherapyAdjuvant Hormonal Treatment of Adjuvant Hormonal Treatment of Breast Cancer: Weighing the Side Breast Cancer: Weighing the Side

EffectsEffects

Arthralgia/myalgia Arthralgia/myalgia Neurocognition?Neurocognition? DVT, CVADVT, CVA

HyperlipidemiaHyperlipidemia Sexual function?Sexual function? Uterine CAUterine CA

Osteoporosis risk Osteoporosis risk Cardiovascular Dz?Cardiovascular Dz? Hot flashesHot flashes

TamoxifenTamoxifen Aromatase Aromatase

InhibitorsInhibitors

Assessing Risk of Side EffectsAssessing Risk of Side EffectsWomen Cancer Patients Are at Women Cancer Patients Are at

Increased Risk for OsteoporosisIncreased Risk for Osteoporosis• Lack of estrogenLack of estrogen

– Estrogen prevents bone breakdown (resorption) Estrogen prevents bone breakdown (resorption) and preserves bone densityand preserves bone density

– Estrogen may also help maintain normal levels of Estrogen may also help maintain normal levels of vitamin D, an important nutrient in bone protectionvitamin D, an important nutrient in bone protection

• Premenopausal womenPremenopausal women

– Chemotherapy-induced menopauseChemotherapy-induced menopause

– Ovarian suppressionOvarian suppression

• Postmenopausal womenPostmenopausal women

– Aromatase inhibitorsAromatase inhibitors

Maximizing Overall Health and Quality of Life Maximizing Overall Health and Quality of Life

The Effects of Breast Cancer Treatment on The Effects of Breast Cancer Treatment on Emotional and Physical Well-BeingEmotional and Physical Well-Being

• Fatigue/decreased energyFatigue/decreased energy• Nausea/vomitingNausea/vomiting• Alopecia (hair loss)Alopecia (hair loss)• MenopauseMenopause• InfertilityInfertility• Sexuality/body imageSexuality/body image• LymphedemaLymphedema• Depression, anxietyDepression, anxiety• PainPain• Fear of recurrenceFear of recurrence• Etc….Etc….

Managing MenopauseManaging Menopause

Prevalence of Menopausal Prevalence of Menopausal Symptoms in Women with a Symptoms in Women with a

History of Breast CancerHistory of Breast CancerCouzi et al, JCO 1998Couzi et al, JCO 1998

•Hot flashes 65%Hot flashes 65%•Night sweats 44%Night sweats 44%•Vaginal dryness 48%Vaginal dryness 48%•Pain with intercourse 26%Pain with intercourse 26%•Insomnia 44%Insomnia 44%•Depression 44%Depression 44%

Exercise, Physical Activity and Exercise, Physical Activity and CancerCancer

Team Survivor NorthwestTeam Survivor Northwest Mt. Baker August 2008Mt. Baker August 2008

Exercise Decreases Side Effects During Exercise Decreases Side Effects During TreatmentTreatment

Fatigue and QOL Outcomes of Fatigue and QOL Outcomes of Exercise During Cancer TreatmentExercise During Cancer Treatment

Mock V et al, Cancer Pract 9: 119-127 2001Mock V et al, Cancer Pract 9: 119-127 2001

• PatientsPatients: 52 breast cancer patients randomized : 52 breast cancer patients randomized to home-based walking program or usual care to home-based walking program or usual care during chemotherapy or radiation therapyduring chemotherapy or radiation therapy

• ResultsResults: Women who exercised > 90 minutes : Women who exercised > 90 minutes per week (divided over 3 or more days) per week (divided over 3 or more days) reported significantlyreported significantly– Less fatigueLess fatigue– Less emotional distressLess emotional distress– Higher functional abilityHigher functional ability– Better QOLBetter QOL

Physical Activity Can Impact Breast Cancer Survival Physical Activity Can Impact Breast Cancer Survival

Exercise and Survival After Breast Cancer Exercise and Survival After Breast Cancer DiagnosisDiagnosis (Nurses Health Study)(Nurses Health Study)

Holmes MD et al, JAMA 2005Holmes MD et al, JAMA 2005

PatientsPatients: 2,987 nurses with early stage breast cancer: 2,987 nurses with early stage breast cancer

Physical activity categories:Physical activity categories:

– LOWLOW

– MEDIUMMEDIUM

– HIGHHIGH

• ResultsResults: Compared to women with LOW physical activity, : Compared to women with LOW physical activity, risk of dying of breast cancerrisk of dying of breast cancer was: was:

– 20% less for MEDIUM exercise (at least 3 hours per week 20% less for MEDIUM exercise (at least 3 hours per week walking at average pace)walking at average pace)

– 40-50% less for HIGH exercise40-50% less for HIGH exercise

What About Lymphedema?What About Lymphedema?

Carefully Monitored Exercise Does Not Carefully Monitored Exercise Does Not Increase LymphedemaIncrease Lymphedema

Weight Training and Lymphedema in Weight Training and Lymphedema in Breast Cancer SurvivorsBreast Cancer Survivors

Ahmed RL et al, J Clin Oncol 2005Ahmed RL et al, J Clin Oncol 2005

• PatientsPatients: 45 breast cancer survivors s/p axillary lymph node : 45 breast cancer survivors s/p axillary lymph node dissectiondissection

• StudyStudy: Randomized to weight training program or not: Randomized to weight training program or not– Weight training sessions 2x per week for 6 monthsWeight training sessions 2x per week for 6 months– For upper body, initially used no weights or only wrist For upper body, initially used no weights or only wrist

weights, weight gradually increased if no symptoms of weights, weight gradually increased if no symptoms of lymphedema developedlymphedema developed

• ResultsResults::– None of the women in the weight training program None of the women in the weight training program

experienced a noticeable change in arm circumference (> experienced a noticeable change in arm circumference (> 2 cm)2 cm)

– Frequency of new lymphedema, or worsening of existing Frequency of new lymphedema, or worsening of existing lymphedema, was similar in both groupslymphedema, was similar in both groups

Nutrition, Body Weight and Nutrition, Body Weight and Breast CancerBreast Cancer

--Maintain good Maintain good body weightbody weight

-Low fat diet-Low fat diet

-High fiber-High fiber

-Increase fruits -Increase fruits and vegetablesand vegetables

-Limit alcohol-Limit alcohol

Nutrition Can Impact Breast Cancer Survival Nutrition Can Impact Breast Cancer Survival Women’s Intervention Nutrition Study Women’s Intervention Nutrition Study

(WINS)(WINS)Chlebowski R et al, 2006Chlebowski R et al, 2006

• PatientsPatients: 2,437 postmenopausal women with early stage : 2,437 postmenopausal women with early stage breast cancer breast cancer

• InterventionIntervention: Randomized within 1 year of surgery to:: Randomized within 1 year of surgery to:

– dietary intervention (8 biweekly counseling sessions by dietary intervention (8 biweekly counseling sessions by nutritionists and support throughout)nutritionists and support throughout)

– vs. controlvs. control

• ResultsResults::

– At 1 year: Intervention group 1/3 less fat intake per dayAt 1 year: Intervention group 1/3 less fat intake per day

– At 5 years: 24% reduction in breast cancer recurrenceAt 5 years: 24% reduction in breast cancer recurrence

Conclusion: Nutrition interventions can decrease Conclusion: Nutrition interventions can decrease recurrences in breast cancer patientsrecurrences in breast cancer patients

• Weight gain during adulthood has been Weight gain during adulthood has been found to be a consistent and strong predictor found to be a consistent and strong predictor of breast cancer riskof breast cancer risk

• Overweight women (BMI > 25) are 1.3 – 2.1 Overweight women (BMI > 25) are 1.3 – 2.1 times more likely to die from breast cancer times more likely to die from breast cancer compared to women with normal weight (BMI compared to women with normal weight (BMI = 18.45 – 24.9)= 18.45 – 24.9)

Weight Can Impact Breast Cancer Survival Weight Can Impact Breast Cancer Survival Body Weight and Breast CancerBody Weight and Breast Cancer

Cognitive FunctionCognitive Function

Urogenital AtrophyUrogenital Atrophy

PremenopausalPremenopausal PostmenopausalPostmenopausal

Sexuality and Body ImageSexuality and Body Image

Strategies for Providing Patient SupportStrategies for Providing Patient SupportSeattle Cancer Care AllianceSeattle Cancer Care Alliance

University of WashingtonUniversity of Washington

Women’s Wellness Follow-up ClinicWomen’s Wellness Follow-up Clinic• Screening for cancersScreening for cancers• Management of menopausal Management of menopausal

symptomssymptoms• Screening for osteoporosis, Screening for osteoporosis,

cardiac risk factorscardiac risk factors• Physical therapyPhysical therapy• NutritionNutrition• Psychology and social Psychology and social

servicesservices• Reconstructive surgeryReconstructive surgery• Genetic counselingGenetic counseling• Education (newsletter, Education (newsletter,

lectures, retreats)lectures, retreats)

OVERALL HEALTH AND WELLNESS RECOMMEDATIONSOVERALL HEALTH AND WELLNESS RECOMMEDATIONSHealth MaintenanceHealth Maintenance Make sure you keep up to date on vaccinations and routine health maintenance screening Make sure you keep up to date on vaccinations and routine health maintenance screening

(cholesterol, blood pressure, skin checks, pelvic exams, colonoscopy, etc).(cholesterol, blood pressure, skin checks, pelvic exams, colonoscopy, etc).

Exercise and Physical Exercise and Physical ActivityActivity

The SCCA encourages breast cancer survivors to adopt a physically active lifestyle. Try to engage The SCCA encourages breast cancer survivors to adopt a physically active lifestyle. Try to engage in at least 30 minutes of moderate to vigorous physical activity 4-5 days of the week. Request a in at least 30 minutes of moderate to vigorous physical activity 4-5 days of the week. Request a referral to physical therapy for help in setting goals, and/or aid in dealing with physical limitations.referral to physical therapy for help in setting goals, and/or aid in dealing with physical limitations.

LymphedemaLymphedema Review lymphedema prevention education. Consider a referral to physical therapy for Review lymphedema prevention education. Consider a referral to physical therapy for lymphedema, range of motion, or general exercise recommendations if indicated. lymphedema, range of motion, or general exercise recommendations if indicated.

NutritionNutrition The SCCA supports the nutrition guidelines of the American Cancer Society to optimize health and The SCCA supports the nutrition guidelines of the American Cancer Society to optimize health and reduce cancer risk. These include a diet high in fruits, vegetables and whole grains, and low in fat. reduce cancer risk. These include a diet high in fruits, vegetables and whole grains, and low in fat. Choose foods and drinks in amounts that help achieve and maintain a healthy weight, and limit Choose foods and drinks in amounts that help achieve and maintain a healthy weight, and limit alcohol. Request a referral to our nutrition department if you’d like help in setting nutrition goals. alcohol. Request a referral to our nutrition department if you’d like help in setting nutrition goals.

Genetic counseling and Genetic counseling and testingtesting

If there is a history of cancer in your family, or if you were diagnosed with breast cancer at a very If there is a history of cancer in your family, or if you were diagnosed with breast cancer at a very young age, consider genetic counseling and testing. young age, consider genetic counseling and testing.

Fear of RecurrenceFear of Recurrence Develop and strengthen coping skills. Talk to friends and family. Request a referral to a therapist Develop and strengthen coping skills. Talk to friends and family. Request a referral to a therapist and information on community resources as needed.and information on community resources as needed.

Heart HealthHeart Health Low fat diet, regular aerobic exercise and maintaining weight and blood pressure. Know what your Low fat diet, regular aerobic exercise and maintaining weight and blood pressure. Know what your cholesterol level is. Symptoms that should be reported are SOB, dizziness, and chest pain and cholesterol level is. Symptoms that should be reported are SOB, dizziness, and chest pain and new onset or worsening of fatigue. new onset or worsening of fatigue.

Bone HealthBone Health Regular weight bearing exercise. Daily Calcium and vitamin D, limit ETOH and no smoking. Regular weight bearing exercise. Daily Calcium and vitamin D, limit ETOH and no smoking.

PainPain Regular exercise both aerobic and resistance training, stretching, yoga, acupuncture and Regular exercise both aerobic and resistance training, stretching, yoga, acupuncture and massage can decrease pain. massage can decrease pain.

Fatigue Fatigue Adequate sleep, regular exercise and good nutrition will facilitate recovery and reduce fatigue Adequate sleep, regular exercise and good nutrition will facilitate recovery and reduce fatigue after treatment.after treatment.

Sexual Health/Body Sexual Health/Body ImageImage

Communicate with your partner. Suggest vaginal lubricants/moisturizers and plan time for Communicate with your partner. Suggest vaginal lubricants/moisturizers and plan time for intimacy. Consider a referral to a therapist to address body image issues, or a gynecologist for intimacy. Consider a referral to a therapist to address body image issues, or a gynecologist for help with vaginal atrophy and other physical issues. help with vaginal atrophy and other physical issues.

Memory/ cognitive Memory/ cognitive concernsconcerns

Look into organizational strategies such as establishing a routine and keeping a planner, taking Look into organizational strategies such as establishing a routine and keeping a planner, taking notes, etc. Focus on addressing anxiety and depression symptoms, if present, and optimizing notes, etc. Focus on addressing anxiety and depression symptoms, if present, and optimizing sleep and nutrition.sleep and nutrition.

Strategies for Providing Patient SupportStrategies for Providing Patient Support

Team Survivor NorthwestTeam Survivor NorthwestAn Exercise and Fitness Program for All Women An Exercise and Fitness Program for All Women Affected by Affected by

Cancer Founded 1995Cancer Founded 1995

• Weekly workoutsWeekly workouts

• Twice weekly walksTwice weekly walks

• RunningRunning

• HikingHiking

• BikingBiking

• Yoga and tai chiYoga and tai chi

• Dragon boatingDragon boating

• SwimmingSwimming

• Annual fitness retreatAnnual fitness retreat

Optimizing Health and Wellness Optimizing Health and Wellness After a Diagnosis of CancerAfter a Diagnosis of Cancer

• The majority of cancer patients The majority of cancer patients can look forward to a long life can look forward to a long life after diagnosis and treatmentafter diagnosis and treatment

•Clinicians must work with Clinicians must work with patients on all aspects of health patients on all aspects of health and well-being:and well-being:

•regular exerciseregular exercise•weight controlweight control•healthy diethealthy diet•smoking avoidancesmoking avoidance•sunscreensunscreen•stress reductionstress reduction•controlling co-morbidities: hypertension, diabetes, controlling co-morbidities: hypertension, diabetes, hyperlipidemia, osteoporosishyperlipidemia, osteoporosis

Team Survivor Northwest Team Survivor Northwest Dragon Boat TeamDragon Boat Team