Beyond 5 years

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Beyond 5 years

• Francis F. Lopez, MD
• Medical Oncology

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(No Transcript)
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Bakit 5 years????
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Risk of Recurrence
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10 year over-all survival by stage
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Outline

• Cancer treatment-induced bone loss (CTIBL)
• Overweight and obesity
• Contra-lateral breast cancer
• Cardiac Complications from Irradiation
• Neurologic complications

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Cancer treatment-induced bone loss
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• Bone is a dynamic tissue undergoing resorption
  and formation throughout life resulting in a net
  bone balance
• In osteoporosis, resorption usually exceeds
  formation with the net effect of bone loss,
  decreased strength, and an increased risk of
  fracture
• Cause hormone depletion promotes osteoporosis
  and increases the risk of fracture

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• Hormone depletion (hypogonodal) state induced by
  cancer therapies
• Premature menopause resulting from chemotherapy
• Deliberate ovarian ablation
• Hypoestrogenemia secondary to aromatase
  inhibitors (arimidex, femara and aromasin)
• Chemotherapy

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chemotherapy

• Bone loss with chemotherapy extends to
  postmenopausal women, suggesting that
  chemotherapy has a direct effect on bone
• American Journal of medicine 114653-659, 2003

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Aromatase inhibitors (AI)

• Women treated with AI were 2.5 times more likely
  to suffer a fracture compared to women treated
  with tamoxifen

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Fracture Risk
Following end of treatment fracture rates were
similar in both groups (RR0.98 (0.81-1.32), p0.5
J. Cuzick on behalf of ATAC/LATTE Trialists
Group. Poster presented at 12th Milan Breast
Cancer Conference 2010
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Major risk factors for osteoporosis and fracture

• Prior fragility fracture (gt40 years of age)
• Age (gt65 years)
• Low bone mineral density (T-score lt -2.5)
• Family history of osteoporotic fracture
• Vertebral compression fracture
• Osteopenia apparent on x-ray film
• Hypogonadism
• Early menopause (before age 45)

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Minor risk factors for osteoporosis and fracture

• Rheumatoid arthritis
• Low dietary calcium intake
• Smoker
• Excessive alcohol intake
• Excessive caffeine intake (gt4 cups/day)
• Weight (lt120 pounds)
• Weight loss gt 10 of weight at age 25

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Diagnostic tests

• Dual energy x-ray absoptiometry (DXA) scans at
  baseline (bone density)
• Thoracic and lumbar spine x-ray to rule out
  vertebral fracture in patients with kyphosis,
  historical height loss gt 6cm, acute
  incapacitating back pain syndrome, and in
  patients 65 years and older
• Follow-up DXA scans every 1-2 years

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Treatment

• bone hygiene measures lifestyle modification
  that promotes bone health
• Calcium 1000mg per day
• Vitamin D 800IU per day
• Smoking cessation
• modest alcohol intake (lt2 units per day)
• Increase exercise activity

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Overweight and Obesity
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Excuses for Weight Gain

• Masarap kumain
• Tamad
• Busy

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Ideal Body Weight

• 45.5 kg 2.3 x (height in inches 60)
• Example 45.5 2.3 x (62 inches 60)
• 45.5 2.3 x 2
• 45.5 4.6 50kg or 110 pounds
• Overweight gt 121 pounds
• Obese gt 132 pounds

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Body Mass Index (BMI)

• BMI kg/m2
• Example 141 pounds / 2.2 64kg
• 55 65 inches x 2.54 165 cm / 100 1.65 m x
  1.65 m 2.7
• 64/2.7 23.7 kg/m2
• Normal lt 25
• Overweight 25 to 29
• Obese gt 30

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Obesity and breast cancer

• Poor prognostic characteristics on diagnosis
  larger tumor, grade III and more positive lymph
  nodes
• Poor prognosis affects over-all survival and
  disease free survival
• Increased risk of contralateral breast cancer,
  loco-regional recurrence and other primary cancers

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Diet and Exercise

• Healthy Lifestyle
• Five or more servings (dakot o sandok) of 5
  different kinds of fruits and vegetable (VF) per
  day
• Physical activity (PA) Walking 30 minutes per
  day 6 days per week

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Healthy Lifestyle and Mortality

• High VF/high PA 4.8
• Low VF/high PA 10.4
• High VF/low PA 10.7
• Low VF/low PA 11.5

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10 year survival

• High VF/high PA 93
• Other groups 86 to 87
• Therefore, gain 6 to 7 absolute risk reduction
  in mortality at 10 years high VF/high PA
• Observed in both obese and non-obese

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Contra-lateral Breast cancer
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Incidence

• From 1975 through 2006
• 339,790 diagnosed with (first) breast cancer
• 12,886 or 4 developed invasive breast cancer in
  the contra-lateral breast
• 40 occurred within the 1st to 4th year of the
  first breast cancer diagnosis
• 30 between the 5th to 9th year
• 30 10 years or later

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Age when first breast cancer was diagnosed

• 19 before age 45
• 51 between 45 and 64 years old
• 30 between 65 and 84 years old

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Estrogen receptor (ER) status when first breast
cancer was diagnosed

• 60 were ER
• 24 were ER-
• 16 were unknown

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Estrogen Receptor in 2nd breast cancer

• First ER breast cancer
• 67 were still ER
• First ER- breast cancer
• 40 were ER
• 43 were ER-

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Prophylactic mastectomy (PM)

• Majority not high risk and 13 were high risk
  (gene mutation)
• Low risk group Contralateral breast cancer
• No PM (0.5)
• PM 0
• Low risk group Distant metastasis
• No PM 7 (2 to 3 years)
• PM 4

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Cardiac Complications from IrradiationNeurologic
Complications
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• Irradiation to the left breast not associated
  with higher risk of cardiac death up to 20 years
• Cognitive and memory loss (chemo brain) resolves
  a few years after treatment

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Thank you!