Transcript Francis-Lopez-Presentation-SL3Beyond-5

Beyond 5 years
Francis F. Lopez, MD
Medical Oncology
Bakit 5 years????
Risk of Recurrence
10 year over-all survival by stage
Outline
 Cancer
treatment-induced bone loss
(CTIBL)
 Overweight and obesity
 Contra-lateral breast cancer
 Cardiac Complications from Irradiation
 Neurologic complications
Cancer treatmentinduced bone loss

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
 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
chemotherapy
 Bone
loss with chemotherapy extends to
postmenopausal women, suggesting that
chemotherapy has a direct effect on bone
• American Journal of medicine 114:653-659, 2003
Aromatase inhibitors (AI)
 Women
treated with AI were 2.5 times
more likely to suffer a fracture compared
to women treated with tamoxifen
Fracture Risk
Following end of treatment fracture rates were similar in both
groups (RR=0.98 (0.81-1.32), p=0.5
J. Cuzick on behalf of ATAC/LATTE Trialists’ Group. Poster presented at 12th Milan Breast Cancer Conference 2010
Major risk factors for osteoporosis
and fracture
 Prior
fragility fracture (>40 years of age)
 Age (>65 years)
 Low bone mineral density (T-score < -2.5)
 Family history of osteoporotic fracture
 Vertebral compression fracture
 Osteopenia apparent on x-ray film
 Hypogonadism
 Early menopause (before age 45)
Minor risk factors for osteoporosis
and fracture
 Rheumatoid
arthritis
 Low dietary calcium intake
 Smoker
 Excessive alcohol intake
 Excessive caffeine intake (>4 cups/day)
 Weight (<120 pounds)
 Weight loss > 10% of weight at age 25
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 > 6cm,
acute incapacitating back pain syndrome,
and in patients 65 years and older
 Follow-up: DXA scans every 1-2 years
Treatment
 “bone
hygiene” measures: lifestyle
modification that promotes bone health:
 Calcium 1000mg per day
 Vitamin D 800IU per day
 Smoking cessation
 modest alcohol intake (<2 units per day)
 Increase exercise activity
Overweight and Obesity
Excuses for Weight Gain
Masarap kumain
Tamad
Busy
Ideal Body Weight
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 > 121 pounds
 Obese > 132 pounds
 45.5
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
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
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%
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
Contra-lateral Breast
cancer
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
Estrogen Receptor in 2nd breast
cancer
 First

67% were still ER+
 First


ER+ breast cancer
ER- breast cancer
40% were ER+
43% were ER-
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%
Cardiac Complications from
Irradiation
Neurologic Complications
 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
Thank you!