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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): • • 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? • • • • 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, • • • • • 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 • • • • • • 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 • • • • 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: • • • 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 • • • a) Short-term: N/V, vaginal, hot flashes b) Long-term: DVT, uterine CA and cataracts Aromatase Inhibitors: • • a) Short-term: same plus arthralgias (lots) b) Long-term: lipids, bones, ?IHD • Herceptin • Herceptin/trastuzumab • • • • • ~ 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