Transcript Summary of BREAST CANCER SURVEILLANCE

Follow-up care for Breast Cancer Survivors:
Surveillance and Survivorship
Dr. Farrah Kassam
STRONACH REGIONAL
CANCER CENTRE
AT SOUTHLAKE
CENTRE RÉGIONAL DE CANCÉROLOGIE
STRONACH À SOUTHLAKE
Which of the following tests should be
ordered as part of the routine surveillance
of asymptomatic breast cancer survivors?
a)
b)
c)
d)
e)
Routine laboratory tests (+/- tumour markers)
Mammography
Bone Scan
Chest x-ray/Abdominal US or CT thorax/abdomen
All of the above
Evidence shows that well follow-up care
provided by Primary Care Physicians is as
effective as care provided by Oncologists?
a) True
b) False
Objectives:
• Surveillance of the Breast Cancer Survivor
– Review current guidelines
– Role of the Primary Care Provider
– SRCC Breast Cancer Surveillance Program
• Survivorship
– Management of common survivorship issues
– SRCC survivorship resources
Breast Cancer Survivors – a growing
population
• Significant advances in breast cancer diagnosis and
treatment have led to a growing number of breast cancer
survivors
• Most women (>80%) diagnosed with breast cancer do
not die of their disease
• In 2008, over 60,000 breast cancer survivors in Ontario
• They require regular high-quality follow up to detect
recurrences and to manage survivorship issues
Ontario Cancer Registry 2009
Breast Cancer Surveillance Guidelines
• Relevant Evidence-based Guidelines
– 2012 American Society of Clinical Oncology
– 2005 Health Canada’s Steering Committee (recently endorsed
by CCO)
– Very similar recommendations
• Despite guidelines, significant variation in follow up
care in Ontario
– Half of patients having more than recommended surveillance
imaging for metastatic disease
– One-quarter having fewer than recommended mammography
J Oncol Practice 6(4):174-181, 2010
CMAJ 172(10):3-4,2012
ASCO Guidelines: Summary of BREAST CANCER SURVEILLANCE
Summary
History/Physical Exam
Every 3 to 6 months for the first 3 years after primary therapy; every 6 to 12 months for years 4 and 5, then
annually.
Patient Education
Counsel patients about the symptoms of recurrence including new lumps, bone pain, chest pain,
abdominal pain, dyspnea or persistent headaches.
Referral for Genetic
Counseling
Criteria to recommend referral include Ashkenazi Jewish heritage; history of ovarian cancer in patient or
any first- or second-degree relative; any first degree relative with a history of breast cancer diagnosed
before age 50; two or more first- or second-degree relatives diagnosed with breast cancer; patient or
relative with diagnosis of bilateral breast cancer; or, history of breast cancer in a male relative.
Breast Self-Exam
All women should be counseled to perform monthly breast self-examination.
Mammography
First post-treatment mammogram 1 year after the initial mammogram that leads to diagnosis, but no earlier
than 6 months after definitive radiation therapy. Subsequent mammograms should be obtained as
indicated for surveillance of abnormalities.
Pelvic Examination
Regular gynecologic follow-up is recommended for all women. Patients who receive tamoxifen should be
advised to report any vaginal bleeding to their physicians.
Coordination of Care
Continuity of care for breast cancer patients is encouraged and should be performed by a physician
experienced in the surveillance of cancer patients and in breast examination, including the examination of
irradiated breasts.
If follow-up is transferred to a PCP, the PCP and the patient should be informed of the long-term options
regarding adjuvant hormonal therapy for the particular patient. This may necessitate re-referral for
oncology assessment at an interval consistent with guidelines for adjuvant hormonal therapy.
BREAST CANCER SURVEILLANCE TESTING - NOT RECOMMENDED
Routine blood tests
CBCs and liver function tests are not recommended
Imaging Studies
Chest x-ray, bone scans, liver ultrasound, CT scans, FDG-PET scans, and breast MRI are not recommended
Tumor markers
CA 15-3, CA 27.29 and CEA are not recommended.
Physician Visits
• Endorse the role of the primary care provider
• Patients on hormonal therapy may require periodic oncology
re-assessment as treatment strategies still evolving over time
Years After Primary Therapy:
History & Physical Exam Occurs:
1, 2, 3
Every 3 to 6 months
4, 5
Every 6 to 12 months
6+
Annually
History
• Screen for signs & symptoms of local or distant
recurrence
– Full ROS including constitutional, MSK, pulmonary, neurologic, GI…..
– Radiographic evaluation for any concerning symptoms
• Assess for residual or late side-effects from primary
treatment
– Eg. lymphedema, premature menopause
• Assess tolerance and compliance of ongoing hormonal
therapy (Tamoxifen, Aromatase Inhibitors)
– Important to ask about vaginal bleeding in women on Tamoxifen
• Assess for pyschological distress (depression/anxiety)
Physical Examination
• Bilateral examination of the breast, chest wall and
axilla to screen for new or recurrent disease
• General exam to screen for signs of distant recurrence
and identify treatment related side-effects (e.g.
Lymphedema, DVT on Tamoxifen)
• Gynecologic Exam – routine gynecologic follow-up
- Patients on tamoxifen at small increased risk of endometrial
cancer and should be advised to report any abnormal vaginal
bleeding to their physicians
Patient Education
• Physicians should council patients about the
symptoms of recurrence including new lumps, bone
pain, chest pain, abdo pain, dyspnea or persistent
headaches
• Patients should be encouraged to report new,
persistent symptoms promptly, rather than waiting for
their next scheduled appointment
• Women should be instructed on how to properly
perform breast self-examination on a monthly basis
(unless provokes high anxiety)
Laboratory Evaluation
• No role for routine blood tests or
tumour markers
• Do not improve outcomes
Imaging Surveillance Guidelines
Mammogram, Mammogram, Mammogram
• Only breast screening tool with evidence to suggest a
mortality reduction in the general population
• In breast cancer survivors:
– Risk of ipsilateral breast recurrence after lumpectomy up
to 4%
– Risk of a second non-inherited breast cancer 0.5-1% per
year
• Should be done annually for screening purposes
• Breast ultrasound not recommended or beneficial for
screening
Breast MRI
• Too sensitive for screening in the general breast
cancer population, leading to unnecessary anxiety and
biopsies, without any documented survival advantage
over mammography alone
• Is recommend for screening of woman at very high risk
for recurrent breast cancer
– BRCA-mutation positive or very strong family history (lifetime
risk >=25%)
– <1% of general population & 5-10% of breast cancers
– Referral to CCO’s OBSP High Risk Screening Program
Referral Criteria for Genetic Counseling
•
Genetic Counseling
Women at high Criteria
risk forforfamilial
breast cancer syndromes
shouldJewish
be referred
to genetic counseling.‡
►Ashkenazi
heritage
►History of ovarian cancer at any age in the patient or any first- or second-degree relatives
►Any first degree relative with a history of breast cancer diagnosed before the age of 50
►Two or more first- or second-degree relatives diagnosed with breast cancer at any age
►Patient or relative with diagnosis of bilateral breast cancer
►History of breast cancer in a male relative
‡ U.S.
Preventive Services Task Force, Genetic Risk Assessment and BRCA Mutation Testing for Breast and Ovarian Cancer Susceptibility, Annals
of Internal Medicine, 2005
Referral Criteria for OBSP High Risk
Screening Program with Annual
Mammography AND MRI
High Risk Criteria
Asymptomatic Woman, Aged 30 - 69
►Known carrier of deleterious gene mutation (i.e. BRCA 1 or BRCA 2)
m
e
n
►First degree relative of a known mutation carrier who declines genetic testing
►≥ 25% lifetime risk of breast cancer based on family history– must have been
assessed using either the IBIS or BOADICEA risk assessment tools, preferably by a
genetics clinic;
a
t
►Received chest radiotherapy before the age of 30
h
i
*<1% general population and only 5-10% of breast cancers g
h
http//www.cancercare.on.ca/obsphighrisk
r
Role of imaging to screen for early metastatic
disease in asymptomatic woman
Symptom-guided approach
• RCTs have compared routine follow-up with history, physical and
annual mammography to regimens with more intensive imaging
(CXR/abdo US/bone scan/CT)
• Even with intensive imaging, asymptomatic recurrences only
account for 15-25%
• Early detection of metastatic disease not associated with
improved survival
• Frequent imaging tests can lead to unnecessary radiation,
anxiety, biopsies and poorer QOL
• Guidelines have adopted strategy of imaging when symptoms
develop
Imaging Studies
The following imaging studies are NOT recommended for routine
breast cancer surveillance:
Chest x-rays
Bone scans
Ultrasound of the liver
Computed tomography
FDG-PET scanning
Breast MRI
Coordination of Care
• Risk of breast cancer recurrence continues through 15 years
after primary treatment and beyond.
• Follow-up by a PCP seems to lead to the same health outcomes
as specialist follow-up, with good patient satisfaction.
• If care transferred to PCP, both PCP and patient should be
informed of the appropriate follow-up and management strategy
• If patient is receiving adjuvant endocrine therapy, she may need
periodic oncology re-assessment/referral as strategies evolving
Current model of Breast Cancer Surveillance
Follow up Year
Mean number of visits*(SD)
Physician Specialty
Year 2
(n=11,219)
Primary Care Physician
Oncology Visits
6.9
4.5 (0.01)
Year 3
(n=10,026)
6.7
Year 4
(n=9,297)
6.6
2.9 (0.01)
2.3 (0.01)
Year 5
(n=8,624)
6.6
1.9 (0.01)
Medical Oncology
1.4
1.1
0.8
0.7
Radiation Oncology
0.8
0.5
0.4
0.3
Surgical Oncology
1.9
1.3
1.1
1.0
4.8
4.5
4.2
4.3
Other MDs
Days between oncology visits,
median [IQR]
*mean per patient per patient year
46 [83]
89 [136]
113 [148]
128 [157]
Source: Grunfeld et al JOP 2010
Why do we need to change to our current
model of care?
1.
Current model is not sustainable


2.
3.
Timely and appropriate acute oncology care at risk
Patient expectations are changing


4.
5.
Incidence and prevalence of cancer increasing
Oncology resource shortage anticipated
Opportunity to better meet their “survivorship” needs
Patient Empowerment key
Accumulating evidence that primary care physicians
deliver equivalent health and patient satisfaction
outcomes to oncology specialists
Opportunity to provide care closer to home
Grunfeld E et al. J Clin Oncol 24(6): 848-855, 2006
From the literature: What we know
There is no hard evidence or consensus on what
model or intervention would work best
Primary care providers
Need:
Patients Need:
•Clinical practice guidelines easy to access & understand
•A patient-specific discharge
•Patient navigation services
•Proactive mental health
monitoring and follow-up
•Advice on survivorship issues
(eg fitness, nutrition, etc)
•Access to community
resources/support (eg social
work)
letter from the specialist
•Expedited re-referral and
access to investigations for
recurrence
•Case management tools
across settings (EMR
templates/reminders, webbased)
Surveillance
versus
Survivorship
Del Giudice, Grunfeld, et al. JCO 27:3338-3345, 2009
Cancer Care Ontario
SRCC
Breast Cancer Surveillance Program
STRONACH REGIONAL
CANCER CENTRE
AT SOUTHLAKE
CENTRE RÉGIONAL DE CANCÉROLOGIE
STRONACH À SOUTHLAKE
SRCC Breast Cancer Surveillance Program
Purpose
Ensure that all SRCC breast cancer patients who have completed active
cancer treatment, have access to exceptional surveillance and
survivorship care.
Objectives
• Provide survivors and their health care providers with a care summary
& follow-up plan
• Empower patients to participate in the management of their care & wellbeing
• Improve knowledge of health care providers regarding survivor needs,
assessment & management strategies
• Improve cancer system efficiency, and enhance transition & coordination of care for cancer survivors
SRCC Breast Cancer Surveillance Program
• Standardized model of shared follow-up care between
Primary Care Providers, Medical oncologists, & Surgeons
• Patients transition into program after active treatment
(surgery, chemotherapy, radiotherapy complete), with early
involvement of PCP
• Foundation based on empowering patients and PCPs to
actively participate in breast cancer surveillance &
survivorship
• Rich array of educational resources developed to support
patients and PCPs through this transition process
SRCC Breast Cancer Surveillance Program Pathway
Active treatment completed
(chemotherapy/herceptin/radiotherapy)
PCP receives: via Referral Out
Patient enters follow-up pathway after 1st
post-treatment mammogram
3. Flyer with Link to online
survivorship course material
4. Info on expedited “fast track”
re-referral process
5. EMR template (via website)
1. Transition Letter
2. Mosaiq Careplan Summary
1. Transition Letter
2. Mosaiq Careplan Summary
Patient receives in a package:
3. Surveillance Passport
Transition Visit with Oncologist
4. Flyer with info on live and
online survivorship course
5. Info on approved OBSP
mammography sites
Orientation Session with NP
6. Other (? community
resources)
7. Appt booked for RTC for NP
Orientation and MO in 8 months
BCSP Supports for Primary Care
• Transition Letter (guidelines)
• Guideline recommendations, including passport schedule
• Info on Tamoxifen/AIs
• Info on expedited referral back to Oncologist
• Copy of patient’s Mosaiq Careplan Summary
• Patient specific diagnosis details and treatment summary
• EMR surveillance templates
• downloadable from our website
• Links to survivorship website materials
• Educational Events – Annual Oncology Day at SRCC
Transition Letter
Mosaiq Care Plan Summary
EMR Templates/Link to Survivorship Material
• Available for Practice Solutions,
Nightingale & Accuro
• Oscar in development
• Instructions on how to
download/build EMR template
on Southlake homepage:
www.southlakeregional.org
Patient Services < Cancer –
Regional Cancer Program <
Breast Cancer Survivorship <
Health Professionals
• Useful Survivorship material
also available online
SRCC BCSP Patient Folder
SRCC Patient Folder (Resources)
• Transition Letter
• Describes surveillance program and follow-up schedule
• Mosaiq Careplan Summary
• Record of tumour and treatment details
• Passport
• Paper and Web/Mobile friendly versions
• Place for patients to record compliance with visits &
mammograms
• Flyer for Live and Online Survivorship Transitions Course
• Info on community support resources
Patient Transition Letter
Mosaiq Care Plan Summary
Passport
Breast Cancer Surveillance Portal
Web & Mobile Passport
Flyer for Survivorship Course & Website
www.southlakeregional.org
< Patient Services
< Cancer – Regional Cancer Program
< Breast Cancer Survivorship
Survivorship Course
• Cancer Transitions Program running at SRCC 3-4x a year
• On-line version http://www.southlakeregional.org/Default.aspx?cid=825&lang=1
SRCC Breast Cancer Surveillance Program
Benefits for Patients
Benefits for SRCC/PCP
•Provides clarity and confidence in
follow-up plan
•Enhanced patient satisfaction
•Empowers patient compliance (passport)
•Avoids unnecessary duplicative visits
•Improved survivorship care delivery
•Improved cancer system efficiency &
transition/co-ordination of care for cancer
survivors
– Reduced SRCC f/u visits, lower wait times
•Involves PCP early
–
–
–
–
Enhances communication with SRCC
Improve PCP knowledge
Improves patient confidence in PCP
Provides care closer to home
•Enhanced Survivorship care
– involvement of PCP
– SRCC surivorship course + website
•Improved coordination/communication
with PCP
•Improved knowledge of health care
providers regarding survivor needs,
assessment & management strategies
•Translatable model to other tumour
types & across LHIN
From Breast Cancer Patient to Breast Cancer
Survivor – more than just surveillance
• Help patients manage long-term and late effects of treatment
• Promote healthy living and psychological well-being
Management of Adverse Effects of Treatment
Local Complications of Breast Cancer Therapy
NEJM 343(15) 1086-1094, 2000
Lymphedema
• Lower rates with sentinal lymph node biopsy
• Responds well to conservative measures
– arm elevation, compression sleeves
• Physical therapy can improve those that do not
respond to conservative measures
• Protect ipsilateral arm from infection, compression,
venipuncture, exposure to intense heat and abrasion
NEJM 343(15) 1086-1094, 2000
Late Complications of Chemotherapy
• Most adverse effects of chemotherapy resolve after
treatment (eg. neuropathy with taxanes)
• Two rare, but life-threatening complications:
– Secondary MDS or leukemias (0.2-1%)
– Cardiac impairment (0.5-1%)
• No routine screening recommended, but patients with
cardiac symptoms or cytopenias should be investigated
Tamoxifen
• Generally well tolerated
• Side-effects: hot flushes, vaginal dryness, irritation, and
discharge.
• 1% risk of thromboembolism & uterine cancer
• Slight risk of earlier cataract formation
• Annual gynecological examination and Pap test
• Postmenopausal woman should see physician promptly if
any vaginal bleeding, abnormal discharge or pelvic pain.
• Follow-up with ophthalmologist every two years
Aromatase Inhibitors
• Generally well tolerated
• Side-effects: hot flushes, arthralgias/myalgias, vaginal
dryness, nausea/emesis, diarrhea, headaches, asthenia
and rash
• Increased risk of osteopenia/osteoporosis and fractures
• BMD q1-2 years
• Bisphosphonate for significant osteopenia/osteroporosis
• Calcium and vitamin D prophylaxis recommended
• Unclear if cholesterol levels altered but should monitor
• 1% risk of thromboembolism
Premature Menopause
• Adjuvant chemotherapy can result in temporary or
permanent amenorrhea from direct toxicity to ovary
• Rapid drop in estrogen levels can cause more severe
symptoms than natural menopause
• Hormonal agents can also cause menstrual dysfunction,
urogenital and vasomotor symptoms
• Can significantly impair QOL and sexual function
• Typically less pronounced over time
Management of Menopausal Symptoms
• HRT generally not recommended
Vasomotor Symptoms (Hot flushes/Night Sweats)
– SSRIs (not with Tamoxifen), Venlafaxine, Clonidine, Gapapentin
Anorgasma/Poor Libido
– Vaginal lubricants, vibrators, couples counselling
Insomnia
– Sleep hygiene, hypnotic medications, treat night sweats & depression
Urogenital Symptoms (Vaginal dryness/Dispareunia)
– Vaginal lubricants, Estrogen rings/creams (need to weigh
risks/benefits)
JCO 30(30), 2012
Sexual Dysfunction – To be covered by Dr.
Anne Katz
• One of the most common and distressing consequences
of cancer treatment
• Premature menopause, post-treatment body image
issues, and psychological distress are contributing
factors
• Screening for sexual dysfunction, and providing support
and suggestions for the management of contributing
factors (eg. vaginal dryness, depression, reconstruction
options) can go a long way to alleviating distress
JCO 30(30), 2012
Pregnancy & Contraception after breast cancer
• Young breast cancer survivors may experience infertility
due to chemotherapy or delays in childbearing to
accommodate five years of hormonal therapy
• Limited data on the effects of pregnancy on breast
cancer survival, however data to date does not suggest
adverse effect
• Many experts suggest waiting at least two years posttreatment
• WHO recommends avoiding hormonal contraception in
women with breast cancer in favour of non-hormonal
options (condoms, diaphragm, copper IUD)
Cognitive Functioning – To be covered by
Dr. Heather Palmer
• “Chemo-brain” - Treatment-related cognitive dysfunction
(eg. impaired memory and decreased concentration) well
described
• Extent of the deficits appear small and appear to improve
with the passage of time
• Limited data on interventions to treat cognitive changes
in cancer survivors, but psychostimulants and cognitive
rehabilitation approaches under investigation
JCO 30(30), 2012
Fatigue
• May affect one-quarter to one-third of breast cancer
survivors
• May persist for years after cessation of treatment.
• Evaluate and manage treatable causes of fatigue
including anemia, thyroid dysfunction, pain, depression,
and lack of sleep
• Psycosocial interventions (eg. self-care/coping
techniques) & exercise can be helpful
JCO 30(30), 2012
Psychosocial issues
• Heightened anxiety after the completion of therapy
common.
– worry about the risk of recurrence and the loss of the security that
many feel while they are actively undergoing therapy
– Dealing with uncertainty and fear of recurrence is often the most
difficult part of recovery, and can persist for years
• Patients should be routinely screened for psychological
distress and mood disorders
• Fortunately psychological distress tends to improve with
time with long-term QOL data quite high
• SRCC: survivorship program (information and peer
support), social workers, and psychosocial clinic (Dr. M.
Katz)
NEJM 343(15) 1086-1094, 2000
JCO 30(30), 2012
Promoting Healthy Lifestyle – Diet & Exercise
• Moderate exercise, avoidance of obesity, and
minimization of alcohol intake associated with decreased
recurrence and death
• Weight gain common post adjuvant chemotherapy
– Multidisciplinary efforts with nutritional advice, counseling, and
exercise can help
• Moderate exercise programs shown to lessen fatigue,
and symptoms of depression and anxiety
– May also help reduce lymphedema
• Limit consumption of alcohol (no more than 1 drink/day)
• Healthy diet and moderation of soy (phytoestrogen)
generally suggested
NEJM 343(15) 1086-1094, 2000
JCO 30(30), 2012
Bone Health
• Cancer treatments can weaken bones
– Chemo-induced early menopause
– Direct chemo toxicity
– Endocrine therapy (AI or tamoxifen if pre-menopausal)
• BMD suggested post chemotherapy
• Encourage smoking cessation, weight-bearing exercise,
and adequate intake of calcium and vitamin D
• Osteopenia and Osteoporosis may require bisphosphonate
Algorithm for management of bone loss in cancer survivors.
Lustberg M B et al. JCO 2012;30:3665-3674
©2012 by American Society of Clinical Oncology
Most Breast Cancer Survivors will not die
of their disease
• Should receive ongoing age-appropriate screening
studies and preventive care, consistent with
recommendations for the general population, for
conditions other than those related to breast cancer and
its treatment.
• Management of CVS risk factors - hypertension, DM and
hypercholesterolemia, as well as smoking cessation
• Cancer screening guidelines for other common cancers
still applicable
Which of the following tests should be
ordered as part of the routine surveillance
of asymptomatic breast cancer survivors?
a)
b)
c)
d)
e)
Routine laboratory tests (+/- tumour markers)
Mammography
Bone Scan
Chest x-ray/Abdominal US or CT thorax/abdomen
All of the above
Evidence shows that well follow-up care
provided by Primary Care Physician is as
effective as care provided by Oncologists?
a) True
b) False
THANK YOU