Living Beyond Breast Cancer: Post Treatment Concerns

1. Living Beyond Breast Cancer:Post Treatment Concerns Megan Dunne RN, MA, AOCNP Nurse Practitioner for Breast Cancer Survivorship Memorial Sloan Kettering Cancer Center

2. Experiences of Cancer Survivors Lance Armstrong Foundation LIVESTRONGTM Survey of 2,307 Post-Treatment Survivors • 99% reported ≥ 1 problem as a result of cancer • Physical problems (86%) • Energy, concentration, sexual dysfunction, neuropathy, pain were most highly endorsed • Emotional concerns (93%) • Fear of recurrence, depression, grief/identity issues, concerns about family members risk • Practical concerns (58%) • 70% of those in school reported school-related problems • 40% experienced employment issues • Debt issues (33%); insurance issues (21%) LIVESTRONG survey 2006 LIVESTRONG Report, 2011.

3. After Effects of Breast Cancer Therapies • Long term effects • Developed during treatment • Linger and are chronic after treatment is completed • Some improve over time • Fatigue • Anemia • Permanent- • Neuropathy- nerve damage • Numbness, tingling, pain

4. After Effects of Breast Cancer Therapies • Late Effects • Delayed-can emerge months or even years after treatment • Lymphedema • Osteoporosis

5. Late medical effects of treatment depend on the type of therapy . . . Surgery Hormone Therapy Radiation Therapy and the specific toxicities of each therapy Chemotherapy

6. Types of After Effects • Physical • Fatigue, Scars, Lymphedema, Osteoporosis • Emotional • Anxiety/depression • Fear of Recurrence • Practical • Employment • Health Insurance

7. Fatigue

8. Fatigue: Symptoms • Prevalence in breast cancer survivors 33 to 37%. • More prevalent and prolonged in patients who’ve received chemotherapy • Symptoms reported by patients • Tired despite sleeping well at night • Difficulty performing routine activities • Irritability • Difficulty concentrating Goedendorp et al (2007) Cancer Nov 15

9. Fatigue: Interventions • Balance activity and rest periods • Healthy lifestyle choices • High fiber, low fat diet • Exercise • Yoga • Aerobic exercise McMillan et al (2011) Appl Physiol Nutr Metab Dec;36(6) 892-903

10. Insomnia Related Fatigue • Prevalence as high as 88% cancer patients • Lasts for years after therapy is completed • Becomes chronic when maladaptive responses to the initial sleep disturbance develop • Underreported and undertreated • Contributes to: • Decreased quality of life (QOL) • Impaired function • Impaired cognition Woodward (2011) CJON 15;4Perlis et al (2008) Cog Behav Tr Insomnia: session by session guide ONS (2008) PEP: Sleep wake Disturbances

11. Cognitive Changes

12. Cognitive Changes: Symptoms • Prevalence up to 40% cancer patients • Difficulty concentrating, attention deficit, easily distracted • Short term memory loss • Inability to perform routine tasks • Checkbook, multi-tasking, recall names/dates American Cancer Society (2008)Jansen et al (2005) ONF 32: 6 1151-63. Stewart et al (2008) PsychoOncology 17:2Ahles et al (2002) JCO 20:485-493

13. Cognitive Changes: Interventions • Exercise- improves brain oxygenation • Acupuncture • Antioxidant foods- fruits and vegetables high in vit C and E can mediate effects of oxidative stress • Increased fluid intake- prevents dehydration, flushes toxins • Inform family and friends- generate support and understanding Nelson et al (2007)Palliative and Supp Care 5:3 p 273-80 Barton and Loprinzi (2002) Clin Breast Ca 3 (suppl 3) s121-127

14. Cognitive Changes: Interventions • Sleep habits • Make lists • Mental exercises- • Crosswords, Sudoku puzzles • Relaxation activities • Music, hobbies, nature • Cognitive therapy • MSKCC Trial- Memory Training • Pharmacologic Interventions: Effectiveness Not Established Wilson et al (2002) J Amer Geriatrics Soc 50:12 p 2041-56

15. Lymphedema

16. Lymphedema: Symptoms • Prevalence is estimated at 21% to 49% • Includes self- reported symptoms • Swelling of arm or trunk • Jewelry and clothing feel “tight” • Fullness or discomfort of arm • Loss of flexibility of hand, wrist, fingers • Infections that recur in same area • Cellulitis • Skin changes and feels “tight” Smoot et al (2010) J Cancer Surv; Jun 4:2 p167-78 2010 LIVESTRONG survey, Petrek et al (2001) Cancer 92: 1368-77.

17. Lymphedema: Interventions • Multimodality Therapy • Lymphedema specialist • Occupational Therapy • Compression garment or “sleeve” • Manual lymphatic drainage with massage • Health diet, healthy weight • Adequate fluid hydration Shah and Vicini (2011) Int J Rad Onc Biol Phys. 81:4 p907-914

18. Chemotherapy Induced Peripheral Neuropathy(CIPN)

19. CIPN : Symptoms • Incidence is greatest in patients treated with taxanes • Paclitaxel 57%-83%overall; 2%-33% severe • Docetaxel 11%-64% overall; 3%-14% severe • Numbness • Hands or feet most common • Pain • Burning, shooting pain • Sensitivity to temperature • Loss of reflexes and reduced function of extremities • Ataxia- gait changes Quastoff and Hartung. (2002) J Neurol 249 (1): 9-17

20. CIPN: Interventions • No proven evidence based interventions • Control contributing conditions • Diabetes mellitus • Thyroid dysfunction • Physical and Occupational Therapy • Exercise • Acupuncture Visovsky et al. (2007) CJON 11;6 p.901-913 ONS PEP: Evidence Based Interventions for CIPN

21. CIPN: Education • Maintain Safety • Visual input to compensate for sensation loss • Risk of ischemic and thermal injury • Protect skin from hot and cold extremes • Proper foot care and foot wear • Dangle legs prior to standing • High fiber diet and adequate fluid intake Armstrong et al. (2005) ONF. 32:305-311 Marrs and Newton. (2003) CJON, 7:299-303

22. Bone Health

23. Osteoporosis • Primary Osteoporosis • Major public health issue in general population • Particularly post-menopausal women • Baseline Bone Mineral Density • age 50 Wickham (2011) CJON 15:6

24. Osteoporosis • Secondary osteoporosis related to cancer therapies is common in Breast Cancer Survivors • Premature ovarian failure • Chemotherapy • Elective ovarian ablation • Impaired gonadal function • Gonadotropin and Androgen blockade • Estrogen blockade • Tamoxifen • Negative effect in pre-menopausal women only • Aromatase inhibitors Abdel –Razeq and Awidi: 2011. J of Ca Res and Ther 7:3

25. Osteoporosis: Symptoms • Silent disease • Can exist for years without symptoms • Loss of height • Stooped posture • Spinal curve or “hump”

26. Osteoporosis: Assessment • Bone Mineral Density Testing • T-score • NTX ( serum and urine) • bone turnover rate • FRAX ® World Health Organization Fracture Risk Assessment Tool • Algorithm • Estimates 10 year fracture risk • Stratifies gender, age, co-morbidities

27. Osteoporosis:Non-pharmacologic Interventions • Limit alcohol and stop smoking • Weight bearing activities • Maintain a healthy weight • Strength training • Safety- falls prevention • Nutritional considerations • Calcium and Vit D

28. Osteoporosis: Pharmacologic Interventions • Bisphosphonates • Alendronate (Actonel®) • Ibandronate (Boniva®) • Risedronate IV • Zoledronic Acid IV • Other agents • Denosumab • Calcitonin Wickham, R (2011) CJON 15:6 p E90-E104 Drake et al (2008) Mayo Clin Proceedings 83:1032-45

29. Chronic Pain

30. Chronic Pain: Interventions • Talk to your medical team • Multidisciplinary approach • Stretching, exercise • Complementary therapies • Acupuncture • Take medication as directed • May require frequent monitoring and changes • Pain specialist consult

31. Sexual Dysfunction

32. Sexual Dysfunction: Symptoms • Decreased libido (desire) • Difficulty reaching climax (orgasm) • Vaginal dryness • Painful intercourse • Painful touching • Tightness

33. Sexual Dysfunction: Interventions • Consult with GYN who specialized in women’s issues • Kegel exercises • Vaginal dilator • Psychologic support • Depression • Anxiety • Self- esteem, body images issues

34. Vaginal Moisturizers • Apply at bedtime 2 to 5 times weekly • Vitamin E capsules • Puncture a vitamin E capsule with a pin. Insert the capsule into your vagina. You can also empty the capsule onto a finger. Wipe the vitamin E inside your vagina. • Replens® • This vaginal moisturizer comes with an applicator and is inserted into the vagina. • K-Y® Brand LIQUIBEADS™ • This is a vaginal bead (OVULE™) suppository placed into the vagina. It also comes with disposable applicators. Carter et al (2011) J Sexual Med 8:549-559

35. Vaginal Lubricants • Eros® women formula. • Astroglide®. • KY® Jelly. • Pjur® Woman Bodyglide (a silicone-based lubricant). • Avoid colors, flavors, spermicides, and warming liquids Carter et al (2011) J Sexual Med 8:549-559

36. Vaginal Hormone Replacement • Discuss safety with your medical team • Opinions vary • Vagifem® is contained in an applicator. Insert it into your vagina every night for 14 days. Then insert it twice a week, at bedtime. • Estring® comes as a vaginal ring. Insert the ring into the vagina and push it as far back as possible. Remove it after 90 days.

37. Emotional After Effects

38. Depression and Anxiety • Common in cancer survivors • Fear of recurrence • Body changes • Support Services • Community support groups • Family, friends • Psychologist, Psychiatrist

39. Journey Forward: Supporting Survivors and Providers

40. ASCO Breast Cancer Adjuvant Treatment Plan and Summary

41. Treatment Summary and Care Plan • Diagnosis and treatment history • Co-morbid conditions • Medications • Family history • Genetics consult • Screening recommendations • Health Promotion Counseling

42. Routine Screening • Annual mammogram at age 40 • Annual clinical breast exam • Self breast awareness • Notify your NP/MD of changes • Colonoscopy baseline at age 50 • PAP smear with gynecologist • Skin cancer screening as indicated

43. Promote Healthy Life Choices to Prevent Cancer • If you smoke- STOP • Limit alcohol • Exercise • Eat a balanced low-fat, high-fiber diet • Reduce stress • Health maintenance with Primary Care Provider