Julie R. Gralow, M.D.

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Long-term Follow-up of Breast Cancer Patients
Julie R. Gralow, M.D. Director, Breast Medical
Oncology, Seattle Cancer Care Alliance Professor,
Medical Oncology, University of Washington School
of Medicine Member, Clinical Division, Fred
Hutchinson Cancer Research Center
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The Cancer Care Continuum

• Detection Treatment Survivorship
• Diagnosis

Optimal care of an individual person differs
along the continuum
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Institute of Medicine 2005 Report From Cancer
Patient to Cancer Survivor Lost in
TransitionHewitt M, Greenfield S, and Stovall E,
eds. http//www.cancer.net/patient/Survivorship/IO
M_Executive_Summary.pdf

• Transition from active treatment to
  post-treatment care critical to long-term health
• Routine follow-up visits are opportunities to
  promote healthy lifestyle, check for cancer
  recurrence, manage lasting effects of the cancer
  experience
• Cancer survivors are a heterogeneous population,
  some having few late effects of cancer and its
  treatment, and others suffering permanent and
  disabling symptoms
• The good news is that there is much that can be
  be done to avoid, ameliorate, or arrest the late
  effects of cancer

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IOM Report All Patients Should Receive a Cancer
Treatment SummarySCCA Breast Cancer Treatment
Summary(modified from asco.org)
Patient Name UW/SCCA medical record number Patient Name UW/SCCA medical record number Patient Name UW/SCCA medical record number Patient Name UW/SCCA medical record number Patient Name UW/SCCA medical record number Date of Birth Date of Birth Date of Birth
Cancer Diagnosis Cancer Diagnosis Cancer Diagnosis Cancer Diagnosis Cancer Diagnosis Date of Diagnosis Age at Diagnosis Date of Diagnosis Age at Diagnosis Date of Diagnosis Age at Diagnosis
Tumor Stage Tumor Size (T) , Nodes (N) , Metastases (M) Tumor Stage Tumor Size (T) , Nodes (N) , Metastases (M) Tumor Stage Tumor Size (T) , Nodes (N) , Metastases (M) Tumor Stage Tumor Size (T) , Nodes (N) , Metastases (M) Tumor Stage Tumor Size (T) , Nodes (N) , Metastases (M) Tumor grade Tumor grade Tumor grade
Hormone receptors Estrogen receptor (ER) , Progesterone receptor (PR) Hormone receptors Estrogen receptor (ER) , Progesterone receptor (PR) Hormone receptors Estrogen receptor (ER) , Progesterone receptor (PR) Hormone receptors Estrogen receptor (ER) , Progesterone receptor (PR) Hormone receptors Estrogen receptor (ER) , Progesterone receptor (PR) HER-2 IHC, FISH HER-2 IHC, FISH HER-2 IHC, FISH
Oncotype DX (if done) Oncotype DX (if done) Oncotype DX (if done) Oncotype DX (if done) Oncotype DX (if done)
Family History of Cancer Family History of Cancer Family History of Cancer Family History of Cancer Family History of Cancer BRCA1/2 testing (if done) BRCA1/2 testing (if done) BRCA1/2 testing (if done)
Significant Past Medical History and Medications Significant Past Medical History and Medications Significant Past Medical History and Medications Significant Past Medical History and Medications Significant Past Medical History and Medications Significant Past Medical History and Medications Significant Past Medical History and Medications Significant Past Medical History and Medications
Cancer Treatment Cancer Treatment Cancer Treatment Cancer Treatment Cancer Treatment Cancer Treatment Cancer Treatment Cancer Treatment
Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery
Breast Surgery Procedure, date Breast Surgery Procedure, date Breast Surgery Procedure, date Breast Surgery Procedure, date Lymph Node Surgery Procedure, date Lymph Node Surgery Procedure, date Lymph Node Surgery Procedure, date Lymph Node Surgery Procedure, date
Reconstruction Procedure, date Reconstruction Procedure, date Reconstruction Procedure, date Reconstruction Procedure, date Reconstruction Procedure, date Reconstruction Procedure, date Reconstruction Procedure, date Reconstruction Procedure, date
Systemic Therapy Systemic Therapy Systemic Therapy Systemic Therapy Systemic Therapy Systemic Therapy Systemic Therapy Systemic Therapy
Chemotherapy Route Route Dose Dose Dose Schedule Number of cycles
Cumulative Anthracycline Dose Administered Doxorubicin____ mg/m2 Epirubicin___ mg/m2 Cumulative Anthracycline Dose Administered Doxorubicin____ mg/m2 Epirubicin___ mg/m2 Cumulative Anthracycline Dose Administered Doxorubicin____ mg/m2 Epirubicin___ mg/m2 Cumulative Anthracycline Dose Administered Doxorubicin____ mg/m2 Epirubicin___ mg/m2 Cumulative Anthracycline Dose Administered Doxorubicin____ mg/m2 Epirubicin___ mg/m2 Cumulative Anthracycline Dose Administered Doxorubicin____ mg/m2 Epirubicin___ mg/m2 Cumulative Anthracycline Dose Administered Doxorubicin____ mg/m2 Epirubicin___ mg/m2 Cumulative Anthracycline Dose Administered Doxorubicin____ mg/m2 Epirubicin___ mg/m2
HER-2 Targeted Therapy Drug, start date, stop date HER-2 Targeted Therapy Drug, start date, stop date HER-2 Targeted Therapy Drug, start date, stop date HER-2 Targeted Therapy Drug, start date, stop date HER-2 Targeted Therapy Drug, start date, stop date HER-2 Targeted Therapy Drug, start date, stop date HER-2 Targeted Therapy Drug, start date, stop date HER-2 Targeted Therapy Drug, start date, stop date
Endocrine (Hormonal Therapy) Drug, start date, stop date Endocrine (Hormonal Therapy) Drug, start date, stop date Endocrine (Hormonal Therapy) Drug, start date, stop date Endocrine (Hormonal Therapy) Drug, start date, stop date Endocrine (Hormonal Therapy) Drug, start date, stop date Endocrine (Hormonal Therapy) Drug, start date, stop date Endocrine (Hormonal 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 Bisphosphonate Therapy for Breast Cancer Indication Drug, start date, stop date Bisphosphonate Therapy for Breast Cancer Indication Drug, start date, stop date Bisphosphonate Therapy for Breast Cancer Indication Drug, start date, stop date Bisphosphonate Therapy for Breast Cancer Indication Drug, start date, stop date Bisphosphonate Therapy for Breast Cancer Indication Drug, start date, stop date Bisphosphonate Therapy for Breast Cancer Indication Drug, start date, stop date Bisphosphonate Therapy for Breast Cancer Indication Drug, start date, stop date
Enrolled in Clinical Trials? Enrolled in Clinical Trials? Enrolled in Clinical Trials? Enrolled in Clinical Trials? Enrolled in Clinical Trials? Enrolled in Clinical Trials? Enrolled in Clinical Trials? Enrolled in Clinical Trials?
Radiation Therapy Radiation Therapy Radiation Therapy Radiation Therapy Radiation Therapy Radiation Therapy Radiation Therapy Radiation Therapy
Date Start Date Start Date Stop Date Stop Date Stop Total Dose (cGy) Total Dose (cGy) Total Dose (cGy)
Fields included Fields included Fields included Fields included Fields included Fields included Fields included Fields included
Complications of therapy Complications of therapy Complications of therapy Complications of therapy Complications of therapy Complications of therapy Complications of therapy Complications of therapy
Providers Providers Providers Providers Providers Providers Providers Providers
Primary Care Provider Primary Care Provider Primary Care Provider Primary Care Provider Primary Care Provider Surgeon Surgeon Surgeon
Radiation Oncologist Radiation Oncologist Radiation Oncologist Radiation Oncologist Radiation Oncologist Medical Oncologist Medical Oncologist Medical Oncologist
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Breast Cancer Follow-Up Includes Three Major
Goals

• Surveillance for cancer recurrence
• Monitoring for toxicities related to therapy
• Maximizing overall health and quality of life

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Breast Cancer Survivorship Care Plan (modified
from asco.org)
Follow-Up Care Test Recommendation
Medical history and physical 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.
Post-treatment breast imaging 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 breast. In some selected patients, a periodic breast MRI or ultrasound may be recommended.
Breast self-examination . Perform a breast self-examination every month. This procedure is not a substitute for a mammogram. Inspection and palpation of irradiated skin and soft tissues every year. Report any unusual symptoms to your medical provider.
Pelvic examination Continue to visit a gynecologist regularly. Women taking tamoxifen should report any irregular vaginal bleeding to their doctor.
Laboratory tests Your oncologist will determine which blood tests are recommended in your case. This may include a periodic complete blood count (CBC), chemistry panel, liver and kidney tests, and tumor markers.
Radiology tests Your oncologist will determine which radiology tests are recommended in your 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 scans or MRIs in asymptomatic patients. Every few years a DEXA scan to evaluate bone density is indicated in postmenopausal breast cancer patients.
Coordination of care 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 have a primary care doctor, to manage non-cancer related health issues.
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Surveillance for Breast Cancer Recurrence

• Local/Regional Recurrence
• Distant Recurrence
• Assessment of risk of cancer recurrence and
  second cancers
• Interventions to further reduce risk of cancer
• Early detection of recurrence and second cancers

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Assessing Risk of Cancer RecurrenceRecurrence
Hazard Rates for Breast Cancer After Primary
Therapy Saphner et al, J Clin Oncol 142738, 1996
0.3
0.2
Recurrence hazard rate
0.1
0
0
1
2
3
4
5
6
7
8
9
10
11
12
Years
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Assessing Risk of Second Cancers How Much Breast
Cancer Is Hereditary?
15-20
5-10
70-80
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Cancer Screening Looking for Cancer Recurrence
and Second Cancers

• Mammography
• Health Professionals Exam
• Self-Exam
• Breast MRI in some very high risk?

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Monitoring for Toxicities Related to Therapy

• Assessing risk of toxicities
• Interventions to reduce risk of toxicity
• Detection and treatment of side effects

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Side Effects of ChemotherapyCardiac Events vs.
Cumulative Chemotherapy Dose
100
80
Doxorubicin
60
Cardiac events ()
40
450 mg/m2
20
0
0
0
100
100
200
200
300
300
400
400
500
500
600
600
700
700
800
800
900
900
1000
1000
Cumulative anthracycline dose (mg/m2)
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Side Effects of ChemotherapyChemotherapy-induced
Menopause in Breast Cancer

• Ovarian damage is a significant long-term
  consequence of adjuvant chemotherapy in
  premenopausal breast cancer patients
• All are affected by resultant menopausal effects
• Infertility seriously affects some
• For women who retain ovarian function after
  breast cancer, pregnancy is possible post-chemo
• Limited data do not show a worse outcome for
  women who become pregnant after breast cancer
• New techniques for preserving ovarian function
  and achieving fertility are under study

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Side Effects of Endocrine TherapyAdjuvant
Hormonal Treatment of Breast Cancer Weighing the
Side Effects

• Arthralgia/myalgia Neurocognition? DVT, CVA
• Hyperlipidemia Sexual function? Uterine CA
• Osteoporosis risk Cardiovascular Dz? Hot
  flashes
• Tamoxifen Aromatase
• Inhibitors

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Assessing Risk of Side EffectsWomen Cancer
Patients Are at Increased Risk for Osteoporosis

• Lack of estrogen
• Estrogen prevents bone breakdown (resorption) and
  preserves bone density
• Estrogen may also help maintain normal levels of
  vitamin D, an important nutrient in bone
  protection
• Premenopausal women
• Chemotherapy-induced menopause
• Ovarian suppression
• Postmenopausal women
• Aromatase inhibitors

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Maximizing Overall Health and Quality of Life
The Effects of Breast Cancer Treatment on
Emotional and Physical Well-Being

• Fatigue/decreased energy
• Nausea/vomiting
• Alopecia (hair loss)
• Menopause
• Infertility
• Sexuality/body image
• Lymphedema
• Depression, anxiety
• Pain
• Fear of recurrence
• Etc.

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Managing Menopause

• Prevalence of Menopausal Symptoms in Women with a
  History of Breast CancerCouzi et al, JCO 1998
• Hot flashes 65
• Night sweats 44
• Vaginal dryness 48
• Pain with intercourse 26
• Insomnia 44
• Depression 44

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Exercise, Physical Activity and Cancer
Team Survivor Northwest Mt. Baker August 2008
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Exercise Decreases Side Effects During
TreatmentFatigue and QOL Outcomes of Exercise
During Cancer TreatmentMock V et al, Cancer
Pract 9 119-127 2001

• Patients 52 breast cancer patients randomized to
  home-based walking program or usual care during
  chemotherapy or radiation therapy
• Results Women who exercised gt 90 minutes per
  week (divided over 3 or more days) reported
  significantly
• Less fatigue
• Less emotional distress
• Higher functional ability
• Better QOL

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Physical Activity Can Impact Breast Cancer
Survival Exercise and Survival After Breast
Cancer Diagnosis (Nurses Health Study)Holmes MD
et al, JAMA 2005

• Patients 2,987 nurses with early stage breast
  cancer
• Physical activity categories
• LOW
• MEDIUM
• HIGH
• Results Compared to women with LOW physical
  activity, risk of dying of breast cancer was
• 20 less for MEDIUM exercise (at least 3 hours
  per week walking at average pace)
• 40-50 less for HIGH exercise

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What About Lymphedema?
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Carefully Monitored Exercise Does Not Increase
LymphedemaWeight Training and Lymphedema in
Breast Cancer SurvivorsAhmed RL et al, J Clin
Oncol 2005

• Patients 45 breast cancer survivors s/p axillary
  lymph node dissection
• Study Randomized to weight training program or
  not
• Weight training sessions 2x per week for 6 months
• For upper body, initially used no weights or only
  wrist weights, weight gradually increased if no
  symptoms of lymphedema developed
• Results
• None of the women in the weight training program
  experienced a noticeable change in arm
  circumference (gt 2 cm)
• Frequency of new lymphedema, or worsening of
  existing lymphedema, was similar in both groups

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Nutrition, Body Weight and Breast Cancer
-Maintain good body weight -Low fat diet -High
fiber -Increase fruits and vegetables -Limit
alcohol
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Nutrition Can Impact Breast Cancer Survival
Womens Intervention Nutrition Study
(WINS)Chlebowski R et al, 2006

• Patients 2,437 postmenopausal women with early
  stage breast cancer
• Intervention Randomized within 1 year of surgery
  to
• dietary intervention (8 biweekly counseling
  sessions by nutritionists and support throughout)
• vs. control
• Results
• At 1 year Intervention group 1/3 less fat intake
  per day
• At 5 years 24 reduction in breast cancer
  recurrence

Conclusion Nutrition interventions can decrease
recurrences in breast cancer patients
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Weight Can Impact Breast Cancer Survival Body
Weight and Breast Cancer

• Weight gain during adulthood has been found to be
  a consistent and strong predictor of breast
  cancer risk
• Overweight women (BMI gt 25) are 1.3 2.1 times
  more likely to die from breast cancer compared to
  women with normal weight (BMI 18.45 24.9)

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Cognitive Function
Urogenital Atrophy
Premenopausal
Postmenopausal
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Sexuality and Body Image
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Strategies for Providing Patient SupportSeattle
Cancer Care AllianceUniversity of
WashingtonWomens Wellness Follow-up Clinic

• Screening for cancers
• Management of menopausal symptoms
• Screening for osteoporosis, cardiac risk factors
• Physical therapy
• Nutrition
• Psychology and social services
• Reconstructive surgery
• Genetic counseling
• Education (newsletter, lectures, retreats)

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OVERALL HEALTH AND WELLNESS RECOMMEDATIONS OVERALL HEALTH AND WELLNESS RECOMMEDATIONS
Health Maintenance Make sure you keep up to date on vaccinations and routine health maintenance screening (cholesterol, blood pressure, skin checks, pelvic exams, colonoscopy, etc).
Exercise and Physical Activity 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 referral to physical therapy for help in setting goals, and/or aid in dealing with physical limitations.
Lymphedema Review lymphedema prevention education. Consider a referral to physical therapy for lymphedema, range of motion, or general exercise recommendations if indicated.
Nutrition 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. 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 youd like help in setting nutrition goals.
Genetic counseling and testing 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.
Fear of Recurrence Develop and strengthen coping skills. Talk to friends and family. Request a referral to a therapist and information on community resources as needed.
Heart Health 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 new onset or worsening of fatigue.
Bone Health Regular weight bearing exercise. Daily Calcium and vitamin D, limit ETOH and no smoking.
Pain Regular exercise both aerobic and resistance training, stretching, yoga, acupuncture and massage can decrease pain.
Fatigue Adequate sleep, regular exercise and good nutrition will facilitate recovery and reduce fatigue after treatment.
Sexual Health/Body Image 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 help with vaginal atrophy and other physical issues.
Memory/ cognitive concerns 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 sleep and nutrition.
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Strategies for Providing Patient SupportTeam
Survivor NorthwestAn Exercise and Fitness
Program for All Women Affected by Cancer Founded
1995

• Weekly workouts
• Twice weekly walks
• Running
• Hiking
• Biking
• Yoga and tai chi
• Dragon boating
• Swimming
• Annual fitness retreat

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Optimizing Health and Wellness After a Diagnosis
of Cancer
Team Survivor Northwest Dragon Boat Team

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

• Clinicians must work with patients on all aspects
  of health and well-being
• regular exercise
• weight control
• healthy diet
• smoking avoidance
• sunscreen
• stress reduction

• controlling co-morbidities hypertension,
  diabetes, hyperlipidemia, osteoporosis