P.K. Morrow, M.D.
Assistant professor
Breast Medical Oncology
The University of Texas MD Anderson Cancer Center
Hello, I am Dr. P.K. Morrow and I am the Assistant Medical Director for Breast Cancer Survivorship at the University of Texas MD Anderson Cancer Center. It is a pleasure to talk to you today about our recommendations and guidelines regarding breast cancer survivorship. First, let's talk a little bit about statistics about breast cancer.
As we know, breast cancer is the most common type of cancer diagnosed in women. In 2009, we had approximately 192,000 new cases of breast cancer. Recently, we have noticed a decrease in the overall cancer death rates and as a result, there are more and more women now living with a previous diagnosis of breast cancer and living with the complications and need for evaluation for breast cancer, surveillance and complications of breast cancer treatment.
Today, we are going to touch on the following issues. We know that this is not a comprehensive list of all breast cancers treatment complications, but I hope that you will understand and appreciate this discussion because they will try to touch on the most important areas of breast cancer surveillance and treatment. First of all, we will talk about breast cancer surveillance, then we will talk about monitoring for secondary breast primary--excuse me second primary cancers. We will then discuss bone health, cardiovascular health, sexual health, psychosocial issues, and finally, lymphedema assessment and treatment.
First of all, let's talk about breast cancer surveillance. There are several recommendations that are available currently in the literature and our recommendations at MD Anderson closely dovetail to those recommendations. Two randomized trials as well as a Cochrane review have demonstrated that intense follow-up beyond the measures listed on the slide have not shown to improve survival. As a result here at MD Anderson, these are our recommendations. First of all, we recommend a detailed history, not just discussing what has happened in the past year or month since the last time of breast cancer follow-up, but also to specifically focus on symptoms and signs of recurrence. For example, we need to focus on a detailed review of systems to make sure that patients do not have for example persistent cough which would maybe indicative of need for further imaging to evaluate for lung metastasis or persistent or worsening bone pain which may need or necessitate further imaging for evaluation for bone metastasis. In addition, a detailed physical examination should occur. This should not only include the area of the breast evaluating for local recurrence, but also should involve all areas of the body to ensure that there and make sure that there is no signs of distant recurrence. Physical examination usually occurs every three to six months for the first three years and every six to 12 months for two years and then annually. Of course we always encourage patients to please call us if they have any concerns in between these times because we know that the times of breast cancer detection for recurrence usually occur between the visits and we see these patients, not everyday, but every few months or yearly. Finally, an annual mammogram is recommended if clinically indicated. For example, if the patient has had a lumpectomy, the patient would have a bilateral mammogram. If the patient had had a mastectomy, then the contralateral breast would be mammographied and finally, if the patient had had a bilateral mastectomy, then no mammogram will be clinically indicated.
Furthermore of course, as we are surveilling for breast cancer, we also want to ensure that these patients do not develop any other second primary cancers and for that reason, we need to also survey for other cancer such as the following, first of all, colorectal screening. We do recommend a colonoscopy if possible, if not a CT colonography. Of course colonoscopy is preferred because if one finds a polyp or suspicious lesion at the time, one is able to biopsy immediately. Whereas, a CT colonography, while it only involves a CT scan, it does still recommend--requires, excuse me, the necessary preparation, and also it does not allow for biopsy at that time of findings of polyps or other lesions. We recommend that colonoscopy begin at age 50 in patients with average risk and if patients with higher risk for example a strong family history of colon cancer etcetera, those patients may need earlier colonoscopy as well as more frequent colonoscopy. In addition, we recommend, gynecologic screening to survey for cervical or endometrial cancer. Patients could have the Pap test performed and oftentimes, patients should also be evaluated for the high risk human papillomavirus testing. This looks for certain high risk strains of human papillomavirus which are associated with the increased risk of cervical cancer. Skin cancer screening is also recommended and this is periodic for patients with the high risk of melanoma, basal cell carcinomas, squamous cell carcinomas or other skin malignancies, this may be more frequent than periodic and this is at the discretion of the oncologist. Finally, we need to also keep in mind that many of these patients have had previous radiation therapy and because of their previous radiation therapy they may be at a higher risk for a second non-breast malignancy. What do we mean by this? Well, there was a series of approximately 1,800 patients with clinical stage 1 to stage 2 breast cancers who received excision followed by greater than or equal to 60 Grays of radiation. And by 8-year follow-up they noticed that approximately 8-percent of patients have developed a second non-breast malignancy. What do we mean by non-breast malignancy? This encompasses several malignancies not limited to but including sarcoma, leukemia, lung cancer, as well as esophageal cancer. So, for that reason, we do recommend that patients continue to have close follow up to ensure that they do not develop any of these second non-breast malignancies.
Furthermore, we know that these women who have received chemotherapy or anti-hormone therapy have a greater risk for developing a decline in bone mineral density. In particular, we focus upon those patients who are post menopausal or premenopausal who received tamoxifen. Oftentimes, we are asked why do we look at premenopausal women for those women continue to have some degree of estrogen output from the ovaries and., therefore, should have some degree of maintenance of bone mineral density. And the reason for this is because a study in the Journal of Clinical Oncology which looked at post--excuse me, looked at premenopausal women who had received chemotherapy and then were placed on tamoxifen afterwards did demonstrate a decline in bone loss if they continue to menstruate after chemotherapy. For that reason we recommend that patients who are post-menopausal or who are premenopausal and continue on tamoxifen receive evaluation for baseline vitamin D, as well as a bone mineral density scan. Patients should also have evaluation for risk factors for osteopenia or osteoporosis. Listed on here is the FRAX, F-R-A-X algorithm. This algorithm was developed by the World Health Organization and it may also be called the ten-year fracture risk model. It estimates the likelihood that a person will break a bone due to bone loss over a period of ten years. This algorithm is listed as a reference on the bottom of the slide for your further reference. As we discussed, once you have ascertain the patient's risk factors we do recommend if they need a bone mineral density scan or need to be further evaluated they have a baseline bone mineral density scan at baseline and then every one to two years. If for example the patient is found to have a normal bone mineral density scan at baseline, they do not have to have a repeat bone mineral density scan for another two years. If however, they are found to have a decrease in bone mineral density, as indicated by the terms osteopenia or osteoporosis, the further evaluation and treatment is necessary. A vitamin D level should be checked to determine if it is within normal range. If it is not within normal range, the patient should receive a prescription for vitamin D and to be monitored to determine if this is effectively depleting their vitamin D levels.
In addition, if the patient is found to have osteopenia, we do recommend the universal recommendation. By that we mean calcium--calcium at a dose of 1,200 milligrams per day, vitamin D at a dose of approximately 800 International Units daily and keep in mind that these doses should be divided to increase the gastrointestinal absorption of these vitamins. In addition, we recommend that they avoid tobacco, avoid alcohol and also limit their caffeine intake if possible. Weight bearing exercises also very important part of our universal recommendations for these patients in order to promote healthy bone remodeling. For those patients who are found to have osteoporosis, those patients should be started on bisphosphonate, which is a drug to strengthen the bones in conjunction with calcium and vitamin D. If oncologists or their physicians are not comfortable treating the patient with bisphosphonate, or feel that the patient needs further evaluation for secondary causes of osteopenia or osteoporosis, we recommend referral to a bone health specialist, such as an endocrinologist.
Next, we discuss cardiovascular health. First of all, as we know, cardiovascular disease is a leading cause of death in women that we need to keep this in mind as we have patients who also have had other risk factors that can further increase their likelihood of developing congestive heart failure. First of all, any patient who is seen in breast cancer surveillance should continue [to] be monitored for cardiovascular risk factors for developing coronary artery disease or a cardiac complication such as increased age and hypertension, hyperlipidemia. In addition, many of these patients have received previous chemotherapy and we know about the dose-dependent nature of Anthracycline usage. Specifically we know that as the doses of doxorubicin and epirubicin continue to increase, we show greater and greater likelihood of developing long term congestive heart failure related to these Anthracyclines.
As a result, these patients should be monitored for signs and symptoms of congestive heart failure, such as shortness of breath, increased lower extremity edema or increased (excuse me) decreased exercise tolerance. Furthermore, we know that in this day and age many patients will begin to have history of treatment of trastuzumab for HER2-positive breast cancers and trastuzumab has also been associated with increased likelihood of congestive heart failure. Thus, those patients who have received trastuzumab, in particular those patients who have received trastuzumab in combination with Anthracycline-based therapy, should be extremely closely monitored for long-term complications of congestive heart failure. Finally, we also know that radiation therapy particularly to the left chest wall, and particularly in patients who received higher doses of Anthracycline-based therapy, has been associated with increased likelihood of congestive heart failure, so in those patients who have received chest wall radiation to the left chest wall should be monitored closely for evaluation for congestive heart failure.
Another important aspect that we need to monitor for in patients with history of breast cancer is evaluation for premature ovarian failure as well as estrogen deprivation. What do we mean about premature ovarian failure? What this means is, those patients who, because of the fact that we have given them, for example, many agents such as alkylating agents, have developed menopause at an earlier age than chronologically expected. And therefore, their ovaries are no longer producing estrogen and they have the complications related to this estrogen deprivation. We know that many of our patients will have received an alkylating agent, such as cyclophosphamide, and we also know that this risk of premature ovarian failure is both age and dose dependent. What do we mean by that? Well, we know that regarding age, that younger women are likely to be affected less by the treatment with alkylating agents than older patients. For example one study by Dr. Bines showed that when patients were treated with CMF, it caused amenorrhea and 40-percent of women who were age less than 40, but 76-percent of women who are age older than 40, thus we know that this is age dependent. In addition, the dosing of cyclophosphamide and other alkylating agents also plays a role in the likelihood of developing premature ovarian failure. Furthermore, we need to look at what happens when patients have estrogen deprivation. We talked about premature ovarian failure and then at the other likelihood the patient will receive are those for those patients who have hormone receptor positive cancer as in estrogen receptor positive or progesterone receptor positive cancers, those patients may receive tamoxifen or other agents that inhibit aromatase, such as anastrozole, letrozole and exemestane. Those patients will have symptoms of estrogen deprivation, such as hot flashes, vaginal dryness, decreased libido, or mood changes. How can we treat this and evaluate this? Well, of course it is an important discussion between the clinician and the patient, but things that we have suggested in the past and continue to suggest now, for example for those findings, are drugs such as venlafaxine, which is a drug which has been used for depression, but it is also have been found to be effective in reducing hot flashes and also mood changes. In addition to that we also recommend for patients who have vaginal dryness and other physical symptoms related to estrogen deprivation to be evaluated for other vaginal lubricants. The issue of hormone replacement in these patients is controversial, but in a patient with a personal history of breast cancer, we do not recommend hormone replacement due to the risk of developing a recurrence of an estrogen receptor positive breast cancer or progesterone receptor positive breast cancer. Furthermore, of course given the history of breast cancer, many patients have increasing symptoms of anxiety, depression, and fear of recurrence. Oftentimes, this may not be able to be managed only by an oncologist and we do recommend that these patients be referred also to counseling, to evaluation by support groups, and also possibly evaluation by a psychologist or psychotherapist. This therapy should go, hand in hand, with the treatment by the oncologist and there should be close communication between these individuals to ensure that these issues are appropriately addressed. We know that once the patient has been diagnosed with breast cancer this fear of recurrence will be lifetime, so this obviously is a lifetime issue and needs to be addressed and completely evaluated.
In addition, we know that for patients who have certain risk factors, they will have an increase risk of lymphedema. What are those and what are not those? First of all, in looking at mastectomy, when you compare a mastectomy to segmental mastectomy or, otherwise known as lumpectomy, there is not a significant difference in the likelihood of lymphedema or increased swelling of the arm secondary to mastectomy versus segmental mastectomy. However, the big difference comes in the next two risk factors, axillary lymph node dissection, as well as radiation therapy. Studies have shown, and references are listed at the bottom of the slide, that patients who have developed axillary (excuse me) have undergone axillary lymph node dissection have a much increased likelihood of developing lymphedema versus those who underwent simply a sentinel lymph node biopsy. For example, one study which randomized patients who are clinically node negative, to either axillary lymph node dissection or sentinel lymph node biopsy, showed that at one year the rate of subjective lymphedema was much lower for those who had undergone only sentinel lymph node biopsy, with an odds ratio 0.36. Thus, we know that those patients who have developed (excuse me) have undergone axillary lymph node dissection have a markedly increased likelihood of developing lymphedema. Furthermore, when you add in radiation therapy to this area, it markedly increases the likelihood of lymphedema. A study by Erickson noted that when radiation therapy was added to axillary lymph node dissection, these rates substantially increased and the reference for this is listed at the bottom of the slide.
As a result, what we do recommend are many things. First of all, meticulous skin hygiene, for example, using skin moisturizers to make sure there is not severe dryness, as well as using topical antibiotics after small breaks on the skin, for example after gardening, after shaving, etcetera. We do recommend an electric razor rather than a manual razor when the female patients are shaving the axilla. In addition to that, we recommend avoidance of tight-fitting clothing in that area. We also avoid--recommend avoidance of medical procedures to the affected lymph particularly performance of blood pressure, as well performance of other medical procedures including venipuncture. However, despite preventative mechanisms, many times patients do develop lymphedema, and therefore, these needs to be addressed because it can be a significant source of a poor quality of life. Physical therapy should be involved from the beginning when a patient is suspected to have lymphedema. This can help to educate the patient on various exercises in order to reduce the occurrence of lymphedema. In addition, physical therapists can perform certain decongestive therapies, involving both manual lymph drainage, as well as placement of layer bandaging and compressive devices to increase the mobilization of the fluid from the distal limb to the more central compartment, therefore reducing the risk of lymphedema. We know that elevation can temporarily reduce lymphedema, but it is not a permanent mechanism. We do recommend evaluation for a lymphedema sleeve to produce this greater pressure distally rather than centrally in order to promote mobilization. In conclusion, I know that is a large topic, but I hope that this topic has been greatly or has been elucidated to you today and I appreciate the time that you have taken to watch this presentation and I welcome any questions in the future. Thank you.
Breast Cancer Survivorship video
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