Transcript Living Beyond Breast Cancer:Post Treatment Concerns

Megan Dunne RN, MA, AOCNP
Nurse Practitioner for Breast Cancer Survivorship
Memorial Sloan Kettering Cancer Center
Experiences of Cancer Survivors
Lance Armstrong Foundation LIVESTRONGTM Survey of 2,307
Post-Treatment Survivors
 99% reported ≥ 1 problem as a result of cancer
 Physical problems (86%)
 Energy, concentration, sexual dysfunction, neuropathy,
pain were most highly endorsed
 Emotional concerns (93%)
 Fear of recurrence, depression, grief/identity issues,
concerns about family members risk
 Practical concerns (58%)
 70% of those in school reported school-related problems
 40% experienced employment issues
 Debt issues (33%); insurance issues (21%)
LIVESTRONG survey 2006
LIVESTRONG Report, 2011.
After Effects of Breast Cancer
Therapies
 Long term effects
 Developed during treatment
 Linger and are chronic after treatment is completed
 Some improve over time


Fatigue
Anemia
 Permanent
Neuropathy- nerve damage
 Numbness, tingling, pain
After Effects of Breast Cancer
Therapies
 Late Effects
 Delayed-can emerge months or even years after
treatment


Lymphedema
Osteoporosis
Late medical effects of
treatment depend
on the type of
therapy . . .
Radiation
Therapy
and the specific
toxicities of each therapy
Surgery
Hormone
Therapy
Chemotherapy
Types of After Effects
 Physical
 Fatigue, Scars, Lymphedema, Osteoporosis
 Emotional
 Anxiety/depression

Fear of Recurrence
 Practical
 Employment
 Health Insurance
Fatigue: Symptoms
 Prevalence in breast cancer survivors 33 to 37%.
 More prevalent and prolonged in patients who’ve
received chemotherapy
 Symptoms reported by patients
 Tired despite sleeping well at night
 Difficulty performing routine activities
 Irritability
 Difficulty concentrating
Goedendorp et al (2007) Cancer Nov 15
Fatigue: Interventions
 Balance activity and rest periods
 Healthy lifestyle choices
 High fiber, low fat diet
 Exercise


Yoga
Aerobic exercise
McMillan et al (2011) Appl Physiol Nutr Metab Dec;36(6) 892-903
Insomnia Related Fatigue
 Prevalence as high as 88% cancer patients
 Lasts for years after therapy is completed
 Becomes chronic when maladaptive responses to the
initial sleep disturbance develop
 Underreported and undertreated
 Contributes to:
 Decreased quality of life (QOL)
 Impaired function
 Impaired cognition
Woodward (2011) CJON 15;4Perlis et al (2008) Cog Behav Tr Insomnia:
session by session guide ONS (2008) PEP: Sleep wake Disturbances
Cognitive Changes:
Symptoms
 Prevalence up to 40% cancer patients
 Difficulty concentrating, attention deficit, easily
distracted
 Short term memory loss
 Inability to perform routine tasks
 Checkbook, multi-tasking, recall names/dates
American Cancer Society (2008)Jansen et al (2005) ONF 32: 6 1151-63. Stewart et al (2008)
PsychoOncology 17:2Ahles et al (2002) JCO 20:485-493
Cognitive Changes:
Interventions
 Exercise- improves brain oxygenation
 Acupuncture
 Antioxidant foods- fruits and vegetables high in vit C
and E can mediate effects of oxidative stress
 Increased fluid intake- prevents dehydration, flushes
toxins
 Inform family and friends- generate support and
understanding
Nelson et al (2007)Palliative and Supp Care 5:3 p 273-80
Barton and Loprinzi (2002) Clin Breast Ca 3 (suppl 3) s121-127
Cognitive Changes:
Interventions
 Sleep habits
 Make lists
 Mental exercises Crosswords, Sudoku puzzles
 Relaxation activities
 Music, hobbies, nature
 Cognitive therapy
 MSKCC Trial- Memory Training
 Pharmacologic Interventions: Effectiveness Not
Established
Wilson et al (2002) J Amer Geriatrics Soc 50:12 p 2041-56
Lymphedema: Symptoms
 Prevalence is estimated at 21% to 49%
 Includes self- reported symptoms
 Swelling of arm or trunk
 Jewelry and clothing feel “tight”
 Fullness or discomfort of arm
 Loss of flexibility of hand, wrist, fingers
 Infections that recur in same area
 Cellulitis
 Skin changes and feels “tight”
Smoot et al (2010) J Cancer Surv; Jun 4:2 p167-78
2010 LIVESTRONG survey, Petrek et al (2001) Cancer 92: 1368-77.
Lymphedema: Interventions
 Multimodality Therapy
 Lymphedema specialist

Occupational Therapy
 Compression garment or “sleeve”
 Manual lymphatic drainage with massage
 Health diet, healthy weight
 Adequate fluid hydration
Shah and Vicini (2011) Int J Rad Onc Biol Phys. 81:4 p907-914
CIPN : Symptoms
 Incidence is greatest in patients treated with taxanes
 Paclitaxel 57%-83%overall; 2%-33% severe
 Docetaxel 11%-64% overall; 3%-14% severe
 Numbness
 Hands or feet most common
 Pain
 Burning, shooting pain
 Sensitivity to temperature
 Loss of reflexes and reduced function of extremities
 Ataxia- gait changes
Quastoff and Hartung. (2002) J Neurol 249 (1): 9-17
CIPN: Interventions
 No proven evidence based interventions
 Control contributing conditions
 Diabetes mellitus
 Thyroid dysfunction
 Physical and Occupational Therapy
 Exercise
 Acupuncture
Visovsky et al. (2007) CJON 11;6 p.901-913
ONS PEP: Evidence Based Interventions for CIPN
CIPN: Education
 Maintain Safety
 Visual input to compensate for sensation loss
 Risk of ischemic and thermal injury
 Protect skin from hot and cold extremes
 Proper foot care and foot wear
 Dangle legs prior to standing
 High fiber diet and adequate fluid intake
Armstrong et al. (2005) ONF. 32:305-311
Marrs and Newton. (2003) CJON, 7:299-303
Osteoporosis
 Primary Osteoporosis
 Major public health issue in general population
 Particularly post-menopausal women

Baseline Bone Mineral Density
 age 50
Wickham (2011) CJON 15:6
Osteoporosis
 Secondary osteoporosis related to cancer therapies
is common in Breast Cancer Survivors
 Premature ovarian failure
 Chemotherapy
 Elective ovarian ablation
 Impaired gonadal function
 Gonadotropin and Androgen blockade
 Estrogen blockade
 Tamoxifen
 Negative effect in pre-menopausal women only
 Aromatase inhibitors
Abdel –Razeq and Awidi: 2011. J of Ca Res and Ther 7:3
Osteoporosis: Symptoms
 Silent disease
 Can exist for years without symptoms
 Loss of height
 Stooped posture
 Spinal curve or “hump”
Osteoporosis: Assessment
 Bone Mineral Density Testing
 T-score
 NTX ( serum and urine)

bone turnover rate
 FRAX ® World Health Organization Fracture Risk
Assessment Tool
 Algorithm
 Estimates 10 year fracture risk
 Stratifies gender, age, co-morbidities
Osteoporosis:
Non-pharmacologic Interventions
 Limit alcohol and stop smoking
 Weight bearing activities
 Maintain a healthy weight
 Strength training
 Safety- falls prevention
 Nutritional considerations
 Calcium and Vit D
Osteoporosis:
Pharmacologic Interventions
 Bisphosphonates
 Alendronate (Actonel®)
 Ibandronate (Boniva®)
 Risedronate IV
 Zoledronic Acid IV
 Other agents
 Denosumab
 Calcitonin
Wickham, R (2011) CJON 15:6 p E90-E104
Drake et al (2008) Mayo Clin Proceedings 83:1032-45
Chronic Pain: Interventions
 Talk to your medical team
 Multidisciplinary approach
 Stretching, exercise
 Complementary therapies
 Acupuncture
 Take medication as directed
 May require frequent monitoring and changes
 Pain specialist consult
Sexual Dysfunction:
Symptoms
 Decreased libido (desire)
 Difficulty reaching climax (orgasm)
 Vaginal dryness
 Painful intercourse
 Painful touching
 Tightness
Sexual Dysfunction:
Interventions
 Consult with GYN who specialized in women’s
issues
 Kegel exercises
 Vaginal dilator
 Psychologic support
 Depression
 Anxiety
 Self- esteem, body images issues
Vaginal Moisturizers
 Apply at bedtime 2 to 5 times weekly
 Vitamin E capsules
 Puncture a vitamin E capsule with a pin. Insert the capsule
into your vagina. You can also empty the capsule onto a
finger. Wipe the vitamin E inside your vagina.
 Replens®
 This vaginal moisturizer comes with an applicator and is
inserted into the vagina.
 K-Y® Brand LIQUIBEADS™
 This is a vaginal bead (OVULE™) suppository placed into
the vagina. It also comes with disposable applicators.
Carter et al (2011) J Sexual Med 8:549-559
Vaginal Lubricants
 Eros® women formula.
 Astroglide®.
 KY® Jelly.
 Pjur® Woman Bodyglide (a silicone-based
lubricant).
 Avoid colors, flavors, spermicides, and warming
liquids
Carter et al (2011) J Sexual Med 8:549-559
Vaginal Hormone
Replacement
 Discuss safety with your medical team
 Opinions vary
 Vagifem® is contained in an applicator. Insert it into
your vagina every night for 14 days. Then insert it
twice a week, at bedtime.
 Estring® comes as a vaginal ring. Insert the ring
into the vagina and push it as far back as possible.
Remove it after 90 days.
Depression and Anxiety
 Common in cancer survivors
 Fear of recurrence
 Body changes
 Support Services
 Community support groups
 Family, friends
 Psychologist, Psychiatrist
Journey Forward: Supporting
Survivors and Providers
ASCO Breast Cancer Adjuvant
Treatment Plan and Summary
Treatment Summary and Care
Plan
 Diagnosis and treatment history
 Co-morbid conditions
 Medications
 Family history
Genetics consult
 Screening recommendations
 Health Promotion Counseling

Routine Screening
 Annual mammogram at age 40
 Annual clinical breast exam
 Self breast awareness
 Notify your NP/MD of changes
 Colonoscopy baseline at age 50
 PAP smear with gynecologist
 Skin cancer screening as indicated
Promote Healthy Life Choices to
Prevent Cancer
 If you smoke- STOP
 Limit alcohol
 Exercise
 Eat a balanced low-fat, high-fiber diet
 Reduce stress
 Health maintenance with Primary Care Provider