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Beyond 5 years

Beyond 5 years. Francis F. Lopez, MD Medical Oncology. Bakit 5 years????. Risk of Recurrence. 10 year over-all survival by stage. Outline. Cancer treatment-induced bone loss (CTIBL) Overweight and obesity Contra-lateral breast cancer Cardiac Complications from Irradiation

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Beyond 5 years

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  1. Beyond 5 years Francis F. Lopez, MD Medical Oncology

  2. Bakit 5 years????

  3. Risk of Recurrence

  4. 10 year over-all survival by stage

  5. Outline • Cancer treatment-induced bone loss (CTIBL) • Overweight and obesity • Contra-lateral breast cancer • Cardiac Complications from Irradiation • Neurologic complications

  6. Cancer treatment-induced bone loss

  7. Bone is a dynamic tissue undergoing resorption and formation throughout life resulting in a net bone balance • In osteoporosis, resorption usually exceeds formation with the net effect of bone loss, decreased strength, and an increased risk of fracture • Cause: hormone depletion promotes osteoporosis and increases the risk of fracture

  8. Hormone depletion (hypogonodal) state induced by cancer therapies • Premature menopause resulting from chemotherapy • Deliberate ovarian ablation • Hypoestrogenemia secondary to aromatase inhibitors (arimidex, femara and aromasin) • Chemotherapy

  9. chemotherapy • Bone loss with chemotherapy extends to postmenopausal women, suggesting that chemotherapy has a direct effect on bone • American Journal of medicine 114:653-659, 2003

  10. Aromatase inhibitors (AI) • Women treated with AI were 2.5 times more likely to suffer a fracture compared to women treated with tamoxifen

  11. Fracture Risk Following end of treatment fracture rates were similar in both groups (RR=0.98 (0.81-1.32), p=0.5 J. Cuzick on behalf of ATAC/LATTE Trialists’ Group.Poster presented at 12th Milan Breast Cancer Conference 2010

  12. Major risk factors for osteoporosis and fracture • Prior fragility fracture (>40 years of age) • Age (>65 years) • Low bone mineral density (T-score < -2.5) • Family history of osteoporotic fracture • Vertebral compression fracture • Osteopenia apparent on x-ray film • Hypogonadism • Early menopause (before age 45)

  13. Minor risk factors for osteoporosis and fracture • Rheumatoid arthritis • Low dietary calcium intake • Smoker • Excessive alcohol intake • Excessive caffeine intake (>4 cups/day) • Weight (<120 pounds) • Weight loss > 10% of weight at age 25

  14. Diagnostic tests • Dual energy x-ray absoptiometry (DXA) scans at baseline (bone density) • Thoracic and lumbar spine x-ray to rule out vertebral fracture in patients with kyphosis, historical height loss > 6cm, acute incapacitating back pain syndrome, and in patients 65 years and older • Follow-up: DXA scans every 1-2 years

  15. Treatment • “bone hygiene” measures: lifestyle modification that promotes bone health: • Calcium 1000mg per day • Vitamin D 800IU per day • Smoking cessation • modest alcohol intake (<2 units per day) • Increase exercise activity

  16. Overweight and Obesity

  17. Excuses for Weight Gain Masarap kumain Tamad Busy

  18. Ideal Body Weight • 45.5 kg + 2.3 x (height in inches – 60) • Example: 45.5 + 2.3 x (62 inches – 60) • 45.5 + 2.3 x 2 • 45.5 + 4.6 = 50kg or 110 pounds • Overweight > 121 pounds • Obese > 132 pounds

  19. Obesity and breast cancer • Poor prognostic characteristics on diagnosis: larger tumor, grade III and more positive lymph nodes • Poor prognosis: affects over-all survival and disease free survival • Increased risk of contralateral breast cancer, loco-regional recurrence and other primary cancers

  20. Diet and Exercise • Healthy Lifestyle: • Five or more servings (dakot o sandok) of 5 different kinds of fruits and vegetable (VF) per day • Physical activity (PA): Walking 30 minutes per day 6 days per week

  21. Healthy Lifestyle and Mortality • High VF/high PA: 4.8% • Low VF/high PA: 10.4% • High VF/low PA: 10.7% • Low VF/low PA: 11.5%

  22. 10 year survival • High VF/high PA = 93% • Other groups: 86% to 87% • Therefore, gain 6% to 7% absolute risk reduction in mortality at 10 years high VF/high PA • Observed in both obese and non-obese

  23. Contra-lateral Breast cancer

  24. Incidence • From 1975 through 2006: • 339,790 diagnosed with (first) breast cancer • 12,886 or 4% developed invasive breast cancer in the contra-lateral breast • 40% occurred within the 1st to 4th year of the first breast cancer diagnosis • 30% between the 5th to 9th year • 30% 10 years or later

  25. Estrogen Receptor in 2nd breast cancer • First ER+ breast cancer • 67% were still ER+ • First ER- breast cancer • 40% were ER+ • 43% were ER-

  26. Prophylactic mastectomy (PM) • Majority not high risk and 13% were high risk (gene mutation) • Low risk group: Contralateral breast cancer • No PM (0.5%) • PM 0% • Low risk group: Distant metastasis • No PM 7% (2 to 3 years) • PM 4%

  27. Cardiac Complications from IrradiationNeurologic Complications

  28. Irradiation to the left breast: not associated with higher risk of cardiac death up to 20 years • Cognitive and memory loss (chemo brain) resolves a few years after treatment

  29. Thank you!

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