Breast Cancer Follow-Up Care: What to do beyond a...

GenevieveChaput,BA,MD,MAHealthProfessionsEduca<on,CAC(PC)CancerSurvivorshipProgram

CedarsCancerCentre,[email protected]

BreastCancerFollow-UpCare:WhattodobeyondaMammogram

DisclosureStatement

§  Faculty:GenevieveChaput

§  NoDisclosuresorconflictsofinterest

Presenta@onoutline

§  CancerSurvivorshipDefini<on§  OverviewofBreastCancerSurvivors§  ShiKingRoleofPrimaryCareProviders

§  Follow-upofBreastCancerSurvivors:4ComponentModel

CancerSurvivorshipDefini@on

“Anindividualisconsideredacancersurvivorfromthe<meofdiagnosis,throughthebalanceofhisorherlife.Familymembers,friends,andcaregiversarealsoimpacted,andthusareincludedinthedefini<on.”

Lost in Transition, 2005

OverviewofBreastCancerSurvivors

§  About1in107Canadianwomenarelivingwithadiagnosisofbreastcancermadeinthepastdecade

§  About93%arediagnosedwithstageItoIIIcancerandaretreatedforcure,mostcommonlywiththesequenceof:⎻  Surgery⎻  Postopera<vechemotherapy⎻  Radia<ontherapy⎻  Oralan<estrogenmedica<ons

CanadianCancerSociety,2015

OverviewofBreastCancerSurvivors

§  Increasingnumberofwomenaresurvivingbreastcancer

88% 82%

0

20

40

60

80

100

5yearsurvivalrate 10yearsurvivalrate

CanadianCancerSociety,2015

ShiEingRoleofPrimaryCareProviders

§  IncreaseinBCS=shiKingofsurvivorshipcaretoPCPs⎻  LevelIevidenceofeffec<venessofPCPfollow-up⎻  PCPwillingnesstotakeonfollow-upcarerole⎻  Needforspecialty/ter<arycareresourcestofocusoncomplex/advancedcare

Grunfeld,2006Grunfeld,1996Sussman,2012

Chaput,2016DelGiudice,2009

CurrentPrac@cesforBreastCancerSurvivorFollow-upCare

§  Inarecentsurvey,2/3ofbreastcancersurvivorsinearlyfollow-upnamedaFamilyPhysicianornurseprac<<onerasoneofthemainprovidersoftheirfollow-upcare

⎻  MostcommonarrangementwastheFamilyPhysicianac<ngasthesolemedicalprovideroffollow-up

Sisler,2016

BreastCancerSurvivorFollow-upCareisaGoodFitforPrimaryCare

§  Managementofsurvivorshipphaseviewedassimilartomanagementofchronicdiseases

§  Scopeofsurvivorshipcarehasbroadenedfromcancerrecurrencetoalsoinclude:-  Managementofpsychosocialandphysicaleffects-  Promo<onofhealthylifestyles-  Carecoordina<on,par<cularlybetweenspecialistsandprimaryproviders

Sisler,Chaputetal,2016

SurvivorshipCareRecommenda@ons

§  Familyphysiciansfacechallengesinsurvivorshipcareandareabletorou<nelyimplementonlyabouthalfofthekeycarerecommenda<ons

⎻  However,overtes<ngandundertes<ngareconcerns

§  Familyphysiciansplaceahighvalueonguidelinestohelpguidetheirworkincancersurvivorship.

§  Hence,theneedforrelevantevidence-basedsurvivorshipcarerecommenda<ons

DelGiudice,2009Lucktar-Flude,2015

Follow-upofBreastCancerSurvivors:4ComponentModel

Follow-upofBreastCancerSurvivors:4ComponentModel

§  4components:

1.  Surveillanceandscreening

2.  Managementoflong-termeffects

3.  Healthpromo<on

4.  Carecoordina<on

§  ProvidesPrimaryProviderswithausefulframeworktoapproachthisimportantwork

Sisler,Chaputetal,2016

Component1:SurveillanceandScreening

SurveillanceandScreeningOneoftopconcernsinBCS:fearofrecurrence

Recommenda@on:§  Carefulinquiryandexamina<onforcommonsignsand

symptomsoflocalanddistancerecurrence

However:§  Nowelldesignedstudieshaveevaluatedthebenefitsofmorevslessfrequentclinicvisits

§  Approx.60%ofregionalrecurrencesaresymptoma<candpresentoutsideofscheduledfollow-upvisits

SimardS,2013DeBockGH,2004KhatcheressianJL,2012

RunowiczCD,2016GradisharWJ,2015

SurveillanceandScreening

BreastCancerFollow-uptes<ngisstraighjorward

Recommenda@on:§  Annuallybutatleast6monthsaKerRTcomple<on;can

performevery6monthsinselectcases

However:§  Thisrecommenda<onlackslevelIevidenceofbenefit

Khatcheressian,2013


NOTrecommended:

§  Rou<neMRI§  Othertests:

-  CompleteBloodCount-  LiverFunc<onTests-  Rou<neimagingofchest,abdomen,orbone-  TumorMarkers

(levelIevidence)

Khatcheressian,2013Morrow,2011

Saslow,2007Gradishar,2015


WhatAboutBreastExamina<ons?

Recommenda@ons:§  Regularclinicalbreastexamina<on§  Monthlyself-examina<oninasymptoma<cbreast

cancersurvivors (LevelIIIevidence)

Khatcheressian,2013


Follow-upofMetasta<cBreastCancerPa<ents

Recommenda@ons:§  Aggressivepursuitofasymptoma<cmetasta<cdiseasewithbloodtestsandimagingdoesNOTresultinanybenefittopa<entsurvival

Challengesinclinicalprac@ce:§  “Minimalist”approachdifficultfrompa<ent’sperspec<ve

RojasMP,2005


OtherCancerScreening

Recommenda@ons:§  Mostbreastcancersurvivors’shouldbescreenedforothermalignanciesinthesamefashionasthoseataverageriskingeneralpopula<on

-  colorectal-  cervicalcancers

SummarySurveillanceandScreening

Component2:AssessmentandManagementofLong-termEffectsofBreastCanceranditsTreatments

§  Bodyimageandappearanceconcerns:

-  31%to67%

§  Cogni<veimpairment

-  upto75%posttreatment

§  Depressionandanxiety-  22%(range,13%to56%)

Long-termEffectsofBreastCanceranditsTreatments

FalkDahl,2010Zainal,2013

Stan,2013Janelsins,2011

Long-termEffectsofBreastCanceranditsTreatments

CommonLong-termEffectsandIssues

Cardiovascularhealth PainandCIPN

Cogni<vedysfunc<on Sexualhealth

Distress,depression,anxiety Prematuremenopause,menopausalsymptoms

Fa<gue Lymphedema

Referralforgene<ccounseling Infer<lity

Osteoporosis Bodyimageconcerns

AssessmentandManagementofLong-termEffectsofBreastCanceranditsTreatments

Fearofrecurrence

§  70%reporthighlevelsoffearofcancerrecurrence,whichcancausedistress

§  Maycausetoavoidfollow-uptestsandappointments

§  Incidenceofcompletedsuicideamongpa<entswithcancerandsurvivorsisapproximatelytwicethatofthegeneralpopula<on

NCCN Clinical Practice Guidelines, Survivorship, 2016


Fearofrecurrence

§  CommonevenmanyyearsaKertreatment

§  Lowintensityinmostcases(80%)

§  Morecommoninyoungersurvivors

§  Maybeburdensomeregardlessofintensity

§  Maybeassociatedwithbothposi<ve&nega<veoutcomes


DistressScreeningandManagementInTheOffice

Evidenceforprac@ce:

§  Earlierdiagnosisofdistressthroughstandardizedscreeninghasbeenassociatedwithimprovementindistressoutcomes

§  Seriateddistressscreening(ESAS-R,DT)

CarlsonLE,2012

BurgessC,2005MaunsellE,1992MehnertA,2008

Distress,Anxiety,DepressionRecommenda@ons:

§  Normalize+educate§  Keepinmindriskfactorsforincreaseddistress:

-  Previoushistoryofmooddisorder(anxiety,depression)-  Livingcondi<ons/maritalstatus-  Youngerage,female-  Medicalcondi<ons-  Acutestressors

§  Offercounseling,pharmacotherapyorrefertomentalhealthresourcesasindicated(levelIevidence)


CPAC,CAPO,2015

hups://www.capo.ca/wpcontent/uploads/2015/11/FINAL_Distress_Guideline1.pdf


Cogni<veDysfunc<on

§  Mostcommonwithchemotherapy,butalsoduetoradia<ontreatments,andothercancertherapies

§  40%increaseinthelikelihoodofmemoryproblems

§  Planningandorganizing,learningandmemory,auen<on,andthinkingspeedarecommonlyaffected

§  MostsymptomsimproveorstopaKer1year,andsomehavelong-termsymptoms



Cogni<veDysfunc<on

Prac@cal@psfortheoffice:§  Normalize§  Educate§  Offerself-managementsugges<ons:relaxa<ontechniques,regularphysicalexercise(levelIIIevidence)


Cogni<veDysfunc<onRecommenda@ons:

§  Assessreversiblecontribu<ngfactorsandop<mallytreatwhenpossible:

-  Mooddisorder,sleepdisturbances

§  Referforneurocogni<veassessmentandrehabilita<onwhenappropriate

(levelIevidence)


Cancer-relatedFa<gue

§  Defini<on:distressing,persistent,subjec<vesenseofphysical,emo<onal,and/orcogni<ve<rednessorexhaus<onrelatedtocancerorcancertreatmentthatisnotpropor<onaltorecentac<vityandinterfereswithusualfunc<oning.

§  Fa<gueisexperiencedbymorethan80%ofthosewhoreceivecancertreatment.

§  Normal:Mildtomoderatelevelsoffa<guethatpersistfor6-12monthsaKertherapywithoutothersymptomspresent.




Prac@cal@psfortheoffice:

§  Valida<onofpa<ent’sexperience§  Helptosetrealis<cexpecta<ons§  Educa<on+addressassump<onsandbeliefs



Recommenda@ons:

§  Offertreatmentorreferralforfactorsaffec<ngfa<gue(mooddisorders,sleepdisturbance,pain,etc)

§  Encourageregularphysicalac<vity,referforCBTifindicated

§  Preliminaryevidencesuggeststhatyogaislikelytoimprovefa<gue

(levelIevidence)


Chemotherapy-inducedPeripheralNeuropathy(CIPN)

§  Neuropathy,includingnumbness,<ngling,burningpaincanpresentaKertreatmentwithtaxane-basedorpla<num-basedchemotherapies

§  30to40%ofpa<ents§  Canleadto:

-  Decreasedphysicalfunc<on,difficul<esinADL,reducedQOL

Runowicz,2016Pachman,2011



Recommenda@ons:§  Suggestregularphysicalac<vity(levelIevidence)§  Suggestduloxe<ne(SNRI)

Ini<aldose:30mg/dayx1week,thenincreaseto 60mg/day(levelIevidence)

*Dosesupto120mg/daystudiedinclinicaltrials=noaddi9onalbenefit



Notrecommended/lessevidence:

§  Studiesoftricyclican<depressantsandan<convulsivantshavenotdemonstratedconsistentsignificantimprovementsinCIPNsymptoms

Runowicz,2016



Recommenda@ons:

§  Emergingevidenceforacupunctureaseffec<vetreatmentforCIPN


HormonalTherapy

§  Endocrinetherapy(tamoxifen,aromataseinhibitors,orovariansuppressiontherapy)usedasadjuvantsystemictherapyreducesriskofrecurrence/secondprimarybreastcancer

Runowicz,2016


HormonalTherapy

§  Adherencetoendocrinetherapyisnecessarytoachievebenefits

§  Adherencereported=50%to92%partlybecauseofadverseeffects(menopausalsymptoms)

§  Foryoungerwomenonendocrinetherapies50to70%willlikelyhavehotflashesontamoxifen

Ruddy,2009


CommonAdverseEffectsofHormonalTherapy

ManagementofHotFlashes/VasomotorSymptoms


§  Regularlyassessadherencetotreatment

§  Inquireaboutsideeffects-  Frequency,severity,effectonQOL

§  Discussself-careop<ons§  OfferSNRIs,SSRIs,orgabapen<nandlifestylemodifica<onstohelpvasomotorsymptomsofprematuremenopause



Recommenda@ons:

§  SNRI=Venlafaxine StartSR37.5mg/dayx1week,thenincreaseto75mg/day

§  Gabapen<n(an<convulsivant) Start100mgTID,<trateupto300mgTID

(level1evidence)

Kaplan,2014Kaplan,2011Rada,2010Bordeleau,2010



RxSideEffectProfile

Venlafaxine Gabapen<n

Lossofappe<te Increaseddizziness

Nausea Increasedappe<te

Cons<pa<on LesswelltoleratedthanVenlafaxine

LessmoodchangesthanGabapen<n

Kaplan,2014Kaplan,2011Rada,2010Bordeleau,2010

OtherRecommenda@ons:

§  Clonidine=effec<venesslesswellestablished§  SSRI=CitalopramRTC=Hotflashesscoresfrombaselinevsplacebo 10mg/daydose.Noeffectwith20and 30mg/daydoses

§  Concern:SSRIsinhibitCYP2D6pathway=mayconversionoftamoxifentoac<vemetabolites

Clayden,1974Burstein,2010Gradishar,2015Jin,2005




OtherRecommenda@ons:

Jointpain/MSKs<ffness:§  Acetaminophen/NSAIDS(levelIevidence)§  Acupuncture(levelIevidence)

Emergingevidence:

§  Behavioralinterven<ons(CBT,exercise)§  Placeboeffect

Chiu,2015Presant,2007Peppone,2015Mewes,2015


Component3:HealthPromo@on

HealthPromo@on

§  InvolvementofPCPiscrucialtoop<malsurvivorshipcaredelivery

§  StudieshaveshownthatsurvivorswhovisittheirPCPinaddi<ontospecialistsaremorelikelytoreceive:

-  Recommendedpreventa<vecare

-  Higher-qualitycarefortheirothermedicalcondi<ons

SnyderCF,2015EarleCC,2003SnyderCF,2009SnyderCF,2009

HealthPromo@on

Prac@calTipforTheOffice:

Approachabreastcancersurvivorlikeapa<entrecentlydiagnosedwithanACS:assomeonewhowillstronglybenefitfromandlikelyberecep<vetocounselingaboutlifestylemodifica<ontoop<mizetheirhealth

Sisler,2016

HealthPromo@on

4maincategories:

1.  Weightmanagement

2.  Physicalac<vity3.  Nutri<on4.  Smokingcessa<on

Sisler,2016

HealthPromo@on:WeightManagement

Increasingevidencesuggeststhatobesitystatusiscontributorof:

§  Cancerrecurrence

§  Secondcancer

§  Cancer-relatedmortality

§  Othermetaboliccomplica<ons

Rock,2012Ligibel,2014Cao,2011Pauerson,2010

Benneu,2013Travis,2013Demark-wahnefried,2012


Recommenda@on:

§  Counselpa<entswhoareoverweightorobesetochangedietaryhabitsandincreasephysicalac<vitytopromoteandmaintainweightloss(levelIevidence)

Runowicz,2015



§  Engagepa<entinplan

§  Educa<ononbenefits

§  Customize/adaptweightmanagementplantoeachpa<ent

§  Refertoappropriateresourceswhendeemednecessary

HealthPromo@on:PhysicalAc@vity

§  Numerousobserva<onalstudiessuggestaninverseassocia<onbetweenphysicalac<vityaKeracancerdiagnosisandmortality

§  Alsostrongevidenceofbenefitsofphysicalac<vityinimproving:

-  Fa<gue

-  Depression

-  Pain

-  OverallQOL

Demark-Wahnefried,2015Ballard-Barbash,2012Rock,2012


Recommenda@ons:

§  Counselpa<entstoavoidinac<vityandreturntodailyac<vi<esassoonaspossible

§  Aimforatleast150minofmoderateor75minofvigorousintensityphysicalac<vity/week(levelIevidence)

§  Includestrengthtrainingatleast2days/week(levelIevidence)



§  Helpdefine/clearlyoutlinephysicalac<vitygoals

§  Promotesupervisedexerciseintounsupervisedseyngs

§  Regularpromp<ngtoself-monitorandprac<ce

Bourke,2013Jones,2004Vallance,2008Demark-Wahnefried,2007

*Thesimplerecommenda9onbyaprovidertoincrease/exercisecanmo9vatesurvivorsaswellasprovisionofprintedmaterials


hups://www.nccn.orgUnderClinicalPrac<ceGuidelines,chooseSurvivorship

NCCN,2015

HealthPromo@on:Nutri@on

Studyfindingshaveshown:

§  18to34%ofbreastcancersurvivorsreportea<ng5ormorefruits/vegetablesdaily

§  Ea<ngadiethighinvegetables,fruits,wholegrains,andlegumes,comparedtoWesterndiet,hasbeenassociatedwithreducedriskinall-causemortality

Zhao,2013Irwin,2011Kroenke,2005

Kwan,2009Vrieling,2013


WINS:Women’sInterven<onNutri<onStudy§  2437post-menopausalbreastcancersurvivors§  Low-fatdiet=<15%energyintake

WHELS:Women’sHealthyEa<ngandLivingStudy

§  3088preandpostmenopausalbreastcancersurvivors

§  Low-fatdiet=20%energyintake

DATAfromthese2RTCssuggeststhatdietchangesresul<nginweightlossmaybenecessarytoposi<velyimpactbreastcancerrecurrenceandprognosis

Chlebowski,2006Pierce,2007

2largeRTC


Recommenda@ons:

§  Counselpa<entstohaveadietarypauernhighinvegetables,fruits,wholegrains,andlegumes;lowinsaturatedfats;andlimitedinprocessedandredmeats(levelIevidence)

*UpcomingchangestoCanadianFoodGuide

HealthPromo@on:VitaminsandDietSupplements

Currentevidencefromobserva<onalandclinicaltrialssuggestthatdietarysupplementsareunlikelytoimproveprognosisoroverallsurvival:

§  Meta-analysisVitaminAoran<oxidants

§  10yearstudyassessingmul<vitamins,

§  VitaminE,VitaminC

§  UseofVitaminD:insufficientdata

§  inbothbreastandcolorectalCS

Rock,2012DaviesAA,2006PocobelliG,2009JacobsET,2008

NgK,2008NgK,2009BuyglieroC,2001

§  Scien<ficevidencesupportstheuseofStJohn’sworttohelprelievemildtomoderatedepression.

§  BUT:alsoknowntoreducetheeffec<venessofsometypesofchemotherapyandthehormonetherapytamoxifen

TheCancerCouncilNSW2012


CurrentbodyofevidenceregardingsupplementusebyCSsuggestsomegeneralguidanceshouldbeconsidered:

§  Allauemptsshouldbemadetoobtainneedednutrientsthroughdietarysources

§  Supplementsshouldbeconsideredonlyifanutrientdeficiencyiseitherbiochemicallyorclinicallydemonstrated

Rock,2012


Usefulreferences:

§  MemorialSloan-KeueringCancerCenterwebsite:www.mskcc.org-  Sec<onaboutHerbs,Botanicalsandotherproducts

providesscien<ficevidenceandwarningsforarangeofdietarysupplements.

§  HealthLinkBCwebsite:www.healthlinkbc.ca-  Sec<onaboutDietarySupplements

§  NCCNwebsite:www.nccn.org-  Sec<onSurvivorship–DietarySupplements


HealthPromo@on:SmokingCessa@on

§  Approximately10%to12%ofbreastcancersurvivorssmoke

§  Meta-analysisreporteda33%increasedriskofmortalityfrombreastcancerinsmokersatdiagnosiscomparedwithformersmokers(observa<onalstudy)

Passarelli,2016Schmid,2014Zhao,2013Berube,2014


Recommenda@ons:

§  Counselpa<entstoavoidsmoking

§  Offerorreferforcessa<oncounselingandresources

Sisler,Chaputetal,2016Runowicz,2015

(Level1evidence)



§  Encouragetoquitthroughcessa<onprograms,wriuendocumenta<on,counseling,pharmacotherapy,andregularfollow-up

*Smokingcessa<oninterven<onsshouldbeini<atedat<meofdiagnosis,ifpossible

Nayan,2013



Asageneralrule,anypharmacologicalagentcanbeusedbutcau<onincertaincases:

§  Champixmayworsennauseaassociatedwithchemotherapy

§  NRTcanirritateoralmucosainpa<entsundergoingRT

§  Bupropionmayincreaseefficacyoftamoxifen

Jimenez,2009Wallstrom,1999Desmarais,2009

HealthPromo@on

Component4:CareCoordina@on

CareCoordina@on

§  PCPareincreasinglyleadingthefollow-upcareofbreastcancersurvivors

§  Issuesthatsomebreastcancersurvivors’facearebestaddressedwithmul<disciplinaryapproach

§  Ensurecommunica<onwithoncologist/GPOsforop<malcarecoordina<on

Sisler,Chaput2016

CareCoordina@on

Recommenda@ons:

§  Noclearguidelinesonsurvivorshipshared-careorspecific<metotransi<on

LevelIIIevidence:

§  Obtaintreatmentsummaryandsurvivorshipcareplan

§  Engagebreastcancersurvivorsinmanagementoftheirsurvivorshipcare

§  Encourageinclusionofcaregiversinfollow-upcare

Sisler,Chaput2016Runowicz,2015

Conclusion

§  Breastcancersurvivorsfacepoten<allateandlong-termeffectsfromcanceranditstreatments

§  High-quality,comprehensive,coordinatedsurvivorshipfollow-upcareisessen<al

§  Visitsmustbetailoredtomeetspecificsurvivorshipissues,andtakeinconsidera<onsurvivors’individualriskfactors,otherhealthcondi<ons,andpreferences

Runowicz,2015Sisler,Chaput2016

Thankyouforyourauen<on!Ques<ons?

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