Megan Dunne RN, MA, AOCNP

Nurse Practitioner for Breast Cancer Survivorship

Memorial Sloan Kettering Cancer Center

Experiences of Cancer SurvivorsLance 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 Report, 2011. LIVESTRONG survey 2006

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

After Effects of Breast Cancer

Therapies

Late Effects

Delayed-can emerge months or even years after

treatment

Lymphedema

Osteoporosis

Late medical effects oftreatment dependon the type oftherapy . . .

and the specifictoxicities of each therapy

RadiationTherapy

Surgery

Chemotherapy

Hormone Therapy

Types of After Effects

Physical

Fatigue, Scars, Lymphedema, Osteoporosis

Emotional

Anxiety/depression

Fear of Recurrence

Practical

Employment

Health Insurance

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

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

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

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

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 273-80Barton and Loprinzi (2002) Clin Breast Ca 3 (suppl 3) s121-127

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

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 p167-782010 LIVESTRONG survey, Petrek et al (2001) Cancer 92: 1368-77.

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

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

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.901-913ONS PEP: Evidence Based Interventions for CIPN

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. 32:305-311Marrs and Newton. (2003) CJON, 7:299-303

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

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

Osteoporosis: Symptoms Silent disease

Can exist for years without symptoms

Loss of height

Stooped posture

Spinal curve or “hump”

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

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

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-E104Drake et al (2008) Mayo Clin Proceedings 83:1032-45

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

Sexual Dysfunction:

Symptoms

Decreased libido (desire)

Difficulty reaching climax (orgasm)

Vaginal dryness

Painful intercourse

Painful touching

Tightness

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

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

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

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.

Depression and Anxiety Common in cancer survivors

Fear of recurrence

Body changes

Support Services

Community support groups

Family, friends

Psychologist, Psychiatrist

Journey Forward: Supporting

Survivors and Providers

ASCO Breast Cancer Adjuvant Treatment Plan and Summary

Treatment Summary and Care

Plan

Diagnosis and treatment history

Co-morbid conditions

Medications

Family history

Genetics consult

Screening recommendations

Health Promotion Counseling

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

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