Breast Cancer - SURVIVORSHIP Flashcards
Breast Cancer Survivorship
ASCO/ACS Joint Guidelines
Women should have a detailed cancer-related history and physical examination every 3 to 6 months for the first 3 years after primary therapy, then every 6 to 12 months for the next 2 years, then
annually.
- Should be performed by the treating oncology team
Patients should be educated regarding the symptoms associated with breast cancer recurrence (new lumps, bone pain, chest pain, dyspnea, abdominal pain, or persistent headache).
Women at high risk of familial breast cancer should be referred for genetic counseling.
Women should be referred for annual mammography
- Intact breast for women who received a unilateral mastectomy
- Both breasts for women who received breast conserving surgery
Primary care clinicians should counsel patients to adhere to adjuvant endocrine therapy
Primary care clinicians should consult with the cancer treatment team and obtain a treatment summary and survivorship care plan.
Regular gynecologic exams are recommended.
- Postmenopausal women who receive tamoxifen are at increased risk for endometrial cancer and should report any abnormal vaginal bleeding to their provider immediately.
Breast Cancer Survivorship
Bone Health
Causes of Bone resorption
Increased bone resorption can result from:
- Chemotherapy-induced ovarian failure
- Tamoxifen in premenopausal women
- LHRH agonists or oophorectomy in premenopausal women
- Aromatase inhibitors in postmenopausal women
Breast Cancer Survivorship
Bone Health
Screening and Monitoring
Screen for osteoporotic risk factors
Consider use of FRAX algorithm
Baseline and periodic bone mineral density (every 1 to 2 years) in patients on an AI, premenopausal women taking tamoxifen and/or a LHRH agonist, and women who experience ovarian failure due to treatment
Breast Cancer Survivorship
Bone Health
Treatment
Physical activity (all women)
Adequate calcium + vitamin D intake (all women)
- 1,000 mg of calcium and 600 IU of vitamin D/day in healthy adults
- No more than 600 mg calcium at one time
Women > 50 y/o
- 1,200 mg of calcium/day
Women > 70 y/o
- 800 IU of vitamin D per day in adults > 70 y/o
25-OH vitamin D levels of 20 ng/mL (50 nmol/L) as adequate, corresponding to 600 IU/day of vitamin D.
NCCN® Task Force recommends 1,200 mg of calcium and 800-1,000 IU of vitamin D for all patients at risk for cancer treatment-associated bone loss.
Breast Cancer Survivorship
Bone Health
T-Score
T-Score > -1
- Repeat DXA Scan every 2 years
T-score between -1 and -1.5
- Consider checking a 25(OH) vitamin D level
- Repeat DXA scan every 2 years
T-score between -1.5 and -2.0
- Consider checking a 25(OH) vitamin D level
- Consider pharmacologic therapy
- Repeat DXA scan every 2 years
T-score < -2.0 OR FRAX 10 year risk >20% for major fracture or > 3% for hip fracture
- Consider checking a 25(OH) vitamin D level
- Strongly consider pharmacologic therapy
- Repeat DXA scan every 2 years
Breast Cancer Survivorship
Bone Health
Treatment Options
Bisphosphonates
Optimal Duration has not been established
Dental Exam recommended prior to initiation of bisphosphonate
Both Oral and IV bisphosphonates are valid options
Oral - alendronate, ibandronate, risedronate
IV - zoledronic 4mg q 3-6months
- zoledronic 5mg yearly
Breast Cancer Survivorship
Bone Health
Treatment Options
Denosumab
Denosumab 60mg SQ q 6 months
- FDA approved to tx bone loss in women at high risk of fracture receiving adjuvant AI therapy for breast CA
- Can be considered for prevention of AI-induced bone loss based on the recent results of ABSCG-18
Breast Cancer Survivorship
Bone Health
Treatment Options
Estrogen, Progesterone or SERMs
NOT RECOMMENDED
Breast Cancer Survivorship
Lymphedema
Presentation
Common complication after treatment for breast cancer, occurring on the same side of the body as the cancer treatment, because of dysfunction of the lymphatic system
Most often diagnosed w/i 18 mo of treatment
Breast Cancer Survivorship
Lymphedema
Treatment
Early detection optimal (stages 0 and 1 are reversible)
Medical procedures such as venipuncture and blood pressure measurement is recommended to be done on the non-at-risk arm/limb if possible, If necessary, procedures may be done using the at-risk arm/limb.
Breast Cancer Survivorship
Cardiotoxicity
Monitoring
Primary care clinicians should monitor lipid levels and provide cardiovascular monitoring as indicated, educate survivors on health lifestyle modifications, and when to report relevant symptoms (shortness of breath or fatigue)
Breast Cancer Survivorship
Fatigue
Monitoring
Estimated prevalence 28-91%
Screen for:
- Anemia
- Thyroid Dysfunction
- Cardiac Dysfunction
Mood disorders, sleep disturbance and pain should be addressed
Breast Cancer Survivorship
Fatigue
Treatment
Treatment strategies may include regular exercise regimen and cognitive behavioral therapy. Minimal data to support use of pharmacologic agents in this population.
If treating concomitant depression or anxiety, consider less-sedating antidepressants such as bupropion.
ASCO guidelines
Breast Cancer Survivorship
Cognitive Impairment
Factors
Can be a result of cancer and cancer treatments
limited evidence to guide management
Assess contributing factors
- medications
- emotional distress (depression/anxiety)
- symptom burden (pain, fatigue, sleep disturbance, nutritional issues)
- comorbidities (i.e., endocrine dysfunction, cardiac dysfunction, infection, anemia, etc.)
- alcohol or other agents that alter cognition
Breast Cancer Survivorship
Cognitive Impairment
Interventions
Interventions (see NCCN Survivorship Guidelines® for specific behavioral recommendations):
First line
- Neuropsychologic evaluation and recommendations (including group cognitive training)
- Cognitive rehabilitation (occupational therapy, speech therapy, and neuropsychology)
- Psychotherapy
- Routine physical activity
Second line
- Consider use of psychostimulants (methylphenidate, modafinil, or donepezil)
Breast Cancer Survivorship
Hot Flashes
Presentation
Hot flashes affect 65 – 85% of breast cancer survivors as a result of therapy.
Chemotherapy and tamoxifen can cause more frequent and severe hot flashes than natural menopause, which often results in decreased quality of life and may affect adherence.
Breast Cancer Survivorship
Hot Flashes
Treatment
Hormonal Therapies are RELATIVE CONTRAINDICATION
Antidepressants:
- Venlafaxine - Considered preferred options by NCCN Guidelines
- Commonly used daily dose 75mg
- desvenlafaxine, escitalopram, paroxetine, fluoxetine, sertraline, citalopram
Breast Cancer Survivorship
Hot Flashes
Treatment
Antidepressants
Antidepressants:
- Venlafaxine - Considered preferred options by NCCN Guidelines
- Commonly used daily dose 75mg
- desvenlafaxine, escitalopram, paroxetine, fluoxetine, sertraline, citalopram
NOTE OF CAUTION:
- Some SSRIs and SNRIs have been shown to alter the PK of tamoxifen and its active metabolites (decrease concentrations of active metabolite endoxifen through inhibition of CYP 2D6).
- Strong to moderate inhibitors should be avoided during tamoxifen therapy if possible (sertraline, paroxetine, fluoxetine, bupropion, duloxetine)
- NCCN Guidelines® recommend that weak CYP2D6 inhibitors (listed as citalopram, escitalopram, and venlafaxine) appear to have minimal effect on tamoxifen metabolism
Breast Cancer Survivorship
Hot Flashes
Treatment
Gabapentin
Considered preferred option by NCCN Guidelines
- recommend to start at lowest possible dose (100-300) and increase as tolerated.
- Consider starting at night time
- Recommended daily dose 900mg (typically 300mg TID)
Breast Cancer Survivorship
Hot Flashes
Treatment
Oxybutynin
Start with 5 mg and titrate to recommended daily dose = 5 – 10 mg; may cause urinary retention along with other anticholinergic side effects
Breast Cancer Survivorship
Hot Flashes
Treatment
Clonidine
Caution with hypotension; recommended daily dose = 0.1 mg (oral or transdermal).
Transdermal preparations may have fewer side effects.
Breast Cancer Survivorship
Hot Flashes
Treatment
Non-Pharmacologic Treatments
- Weight loss if overweight or obese
- acupuncture
- exercise/physical activity
- lifestyle modifications
- integrative therapies including yoga and hypnosis.
Breast Cancer Survivorship
Vaginal Dryness
Treatment
- Use lubricants for sexual activity
- Local estrogen treatment (ie, rings, suppositories, creams) – limited data in breast cancer survivors suggest minimal systemic absorption with rings and suppositories; therefore, they are preferred over creams for survivors of hormonally sensitive tumors
Breast Cancer Survivorship
Fertility Preservation for females with breast cancer
Treatment Options
Refer patients of childbearing age who experience infertility to reproductive specialist
- Embryo cryopreservation
- Cryopreservation of unfertilized oocytes – option particularly for patients who do not have a male partner, do not wish to use donor sperm, or have religious or ethical objections to embryo freezing
- Ovarian transposition – can be offered when pelvic irradiation is performed as cancer treatment. Should be performed as close to time of radiation as possible
- Ovarian suppression with LHRH agonists – conflicting evidence as a means of fertility preservation. It can be recommended when proven fertility preservation methods (above) are not feasible and in the setting of young women with breast cancer.
- Ovarian tissue cryopreservation and transplantation (considered experimental)– does not require ovarian stimulation or sexual maturity and hence may be only method available in children.
Breast Cancer Survivorship
Fertility Preservation for females with breast cancer
Treatment Options
LHRH agonists
NCCN Guidelines® state that GnRH agonist therapy (aka LHRH agonists) administered during adjuvant chemotherapy in
premenopausal women with breast tumors (regardless of HR status)
may preserve ovarian function and diminish the likelihood of chemotherapy-induced amenorrhea
