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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 the primary care physician is
as effective as care provided by the
specialist oncologist
a) True
b) False
Objectives:
• Surveillance of the Breast Cancer Survivor
– Review current guidelines
– Role of the Primary Care Provider
– SRCC patient and PCP resources in development
• 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
– 2006 American Society of Clinical Oncology
– 2005 Health Canada’s Steering Committee (endorsed recently
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
NEJM 343(15) 1086-1094, 2000
Physician Visits
• Endorse the role of the primary care provider
• Patients on adjuvant hormonal therapy may require
periodic oncology re-assessment as treatment
strategies are still evolving over time
• Every 3-6 months for the first 3 years after primary
therapy
• Every 6 months for years 4 and 5
• Yearly after 5 years
2006 ASCO guidelines
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)
• Gynecologic Exam – routine gynecologic follow-up
– Annual pelvic exam particularly important in woman
receiving Tamoxifen due to small increased risk of
endometrial tumours
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)
Breast Self Examination
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 survival advantage over
mammography alone
• Is recommend for screening of woman at very high risk
for recurrent disease
– BRCA-mutation positive or very strong family history (lifetime
risk >20%)
– Referral to CCO’s OBSP High Risk Screening Program
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
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 Supports for Non-Specialist Providers
(PCP)
•
•
•
•
•
Discharge Letter (guidelines)
Copy of patient’s careplan
EMR surveillance templates – in development
Links to survivorship website materials
Instructions on expedited referral back to Oncologist (&
contact info)
• Educational Events – Oncology Day at SRCC Nov 9th
SRCC Patient Supports - Package
• Discharge Letter – describes surveillance program and
follow-up schedule
• Passport & Careplan
• Both paper and mobile/online apps in development
• Record of tumour and treatment details, and suggested
surveillance recommendations
• Place for patients to record compliance with visits &
mammograms
• Flyer for Live and Online Survivorship Transitions Course
• Info on community support resources
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
Survivorship Course
• Cancer Transitions Program running at SRCC 3x/y
• On-line version with useful links in development
Management of Adverse Effects of Treatment
Local Complications of Breast Cancer Therapy
NEJM 343(15) 1086-1094, 2000
Lymphedema
• Lower rates with incorporation of 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%)
• Alkylators/Anthracyclines
– Cardiac impairment (0.5-1%)
• Anthracyclines/Herceptin
• Risk factors: older age, cardiac hx, left-sided radiation,
dose
• No routine screening recommended, but patients with
cardiac symptoms or cytopenias should be investigated
Tamoxifen
• Generally well tolerated
• Potential side-effects include include hot flushes, vaginal
dryness, irritation, and discharge.
• 1% risk of thromboembolism & uterine cancer
• Slight risk of earlier cataract formation
• Annual gynecological examination and a Pap test
• Postmenopausal woman should be advised see a
physician promptly if there is any vaginal spotting,
bleeding, abnormal discharge or pelvic pain.
• Follow-up with an ophthalmologist every two years is also
recommended
Aromatase Inhibitors
• Generally well tolerated
• Potential side-effects include hot flushes,
arthralgias/myalgias, vaginal dryness, nausea/emesis,
diarrhea, headaches, asthenia and rash
• Increased incidence of osteopenia/osteoporosis and
fractures
• BMD q1-2 years, and bisphosphonate initiated for
significant osteopenia or osteroporosis
• Calcium and vitamin D prophylaxis recommended
• It is unclear if cholesterol levels are altered but these
should also be monitored.
• There is a 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
• 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
• “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 with risk factors or Osteoporosis may require
bisphosphonate treament
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.
• Appropriate management of CVS risk factors such as
hypertension, DM and hypercholesterolemia, as well as
smoking cessation warrented
• Cancer screening guidelines for other common cancers
still applicable
FAQ by patients – coming online soon
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 the primary care physician is
as effective as care provided by the
specialist oncologist
a) True
b) False
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
THANK YOU