Download Treatment of Breast Cancer after Surgery

Treatment of Breast
Cancer after Surgery
What Primary Care Providers Need to
Know
Disclosure of Potential for
Conflict of Interest
Dr. Chris Ogaranko
Treatment of Breast Cancer after Surgery
FINANCIAL DISCLOSURE
Grants/Research Support: None
Speaker bureau/Honoraria amounts: None
Consulting fees: None
Other: None
Learning Objectives
• Understand the usual sequence of post-
surgical breast cancer treatments
• Explain the rationale for these treatment, their
basic indications, benefits and toxicities
• Recognize opportunities for important primary
care input during treatment
Breast Cancer Treatment Rationale
•
Treatment after complete surgical resection
to kill micrometastases; decrease cancer
recurrence and improve survival
•
Chemotherapy before surgery if the tumour
is large (>5cm) +/- advanced
lymphadenopathy to improve resection
Breast Cancer Treatment Timeline
Who Gets Chemo?
• Bottom Line (with exceptions):
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•
Node + and those > 1 cm get chemo.
Node – and those < 1 cm (especially 0.6 – 1 cm)
may get chemo.
Who Gets Chemo?-Tools
• Adjuvant! Online – what is the risk for
recurrence and death?
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Age and health status
Lymph node status
Size of tumour
ER status
Genetic Testing
Common Chemotherapies
• FEC-D regimen: fluorouracil, epirubicin,
cyclophosphamide x 3 cycles, and then
docetaxel x 3 cycles
•
Fit, higher risk patients
• TC regimen: Taxotere/docetaxel with
cyclophosphamide x 4 cycles
•
Less fit, lower risk patients
• Both are 21 day cycles
Toxicities (short-term)
• General: fatigue, myalgias, allergic, fluid retension
• Skin/membranes: rash, stomatitis (Candida), nails,
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alopecia
GI: anorexia, N/V, diarrhea/constipation, colitis
GU: vaginitis, cystitis, amenorrhea
Marrow: myelosuppression, febrile neutropenia,
sepsis
Cardiac: CHF
Peripheral neuropathy
Long-term Complications Of
Chemotherapy
• Premature Menopause – especially if older than
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40
Cardiac dysfunction
Cognitive changes – “chemo. brain” poorly
understood
Second cancers - AML, MDS
Peripheral Neuropathy
Fatigue
Psychological – depression, insomnia
Who Gets Radiation?
• Post-lumpectomy: all
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Lowers risk of local recurrence (15-20%
ARR)
Improves overall survival (~ 5% ARR)
5 days per week for 3 – 5 weeks
Usually starts one month after
chemotherapy
Who Gets Radiation?
• Post-mastectomy: indications variable, but for
sure if:
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tumor > 5cm
at least 4 +ve LN’s (and often for 1-3 nodes)
+ve deep margin
Short-Term Radiation Side Effects
• Arm edema (especially axillary RT)
• Pneumonitis (transient; <5%)
• Fatigue
• Skin reactions
Long-term Complications Of
Radiation
• Lymphedema (arm, breast, chest)
• Brachial Plexopathy
• Cardiac Dysfunction
• Second Cancers (1% - sarcoma, lung esophagus)
Endocrine Therapy for ER/PR+
• Premenopausal: Tamoxifen for 5 years (will
this become 10 years?)
• Postmenopausal: Aromatase Inhibitors (AI’s)
preferred – e.g. letrozole, exemestane
• Different strategies for AI use
• Up front
• After 2-3 years of tamoxifen
• Extended adjuvant use after 5 years
tamoxifen
• Started after radiation completed
Current Endocrine Strategies
Tamoxifen
AI
Postmenopausal Women
0 Yrs
5 Yrs
**NEW: 10 years tamoxifen may be better**
10 Yrs
Side Effects
• Tamoxifen: watch out for interactions
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a) Short-term: N/V, vaginal, hot flashes
b) Long-term: DVT, uterine CA and cataracts
Aromatase Inhibitors:
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a) Short-term: same plus arthralgias (lots)
b) Long-term: lipids, bones, ?IHD
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Herceptin
• Herceptin/trastuzumab
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~ 20% breast cancers overexpress HER2
Indication: tumour > 0.5 cm or node +
no CHF (EF > 55%)
Given i.v. q3 weeks for one year
Main toxicity is cardiac (MUGA q3 months)
Interactions with Breast CA Treatment
• Chemo: warfarin, metronidazole, thiazides,
phenytoin
• Herceptin: few
• Tamoxifen: paroxetine, fluoxetine,
ketaconazole, trazodone, estrogen
• Aromatase Inhibitors: estrogen
Primary Care Issues
• Soy and flax seem to be OK
• Exercise may lower recurrence
• Timing matters for influenza and
pneumococcal immunizations on chemo.
• Don’t give live virus vaccines on chemo.
• Calcium (dietary) and vitamin D for bones
• Screen for, and treat psychological issues
Take Home Pearls
• Breast cancer treatment is a long journey with
a variety of therapies to reduce the risk of
recurrence and death
• Primary care providers can support patients,
monitor/treat issues like psychological
distress, assist with symptom management
and recognize potential complications
• Consider interactions with cancer treatments