Breast Cancer:

Its More Then Just Pink Ribbons

OAAPN Marla Sustin RN APRNOctober 20th,2017

Marla Sustin RN APRN-BCBreast Cancer Survivorship

Seidman Cancer Center

Objectives

• Review statistics the breast cancer survivorship from the past and compare survival rates for each stage.

• Discuss the newer chemotherapy, immunotherapy, and endocrine therapy regimens including side effects and how to manage them

• Consider the latest data on complete axillary dissection vssentinel node biopsy. Examine onco-plastic surgery and the benefits of a more natural reconstructed breast after mastectomy

• Understand the management of side effects of breast cancer treatment such as depression, anxiety, body image issues, vaginal atrophy and dryness, sexual dysfunction, bone pain, leg cramps, neuropathy.

2

Statistics

• In 2015 there are over 2.8 million women with a history of breast cancer in the U.S. This includes women currently being treated and women who have finished treatment.

• The 5-year survival rate for women diagnosed with cancer is 80%.

• The good news is that women are living longer with breast cancer. Due to better treatment options, breast cancer mortality rates declined by about 25% since 1990.

New York Times, September 10, 2015

Breastcancer.org accessed September 10, 2015

3

Latest Statistics in Breast Cancer Survival 2016

4

• 246,660 new cases of invasive breast cancer (This includes new

cases in survivors but not recurrence).

• 61,000 new cases of in situ breast cancer

– DCIS (non-invasive BC)

– LCIS (increases risk of BC)

• 40,450 breast cancer deaths

Cancer.gov, New health guide.org, Komen.org

Relative Statistics

5

Based on data from SEER 18 2005-2011. Gray figures represent those who have died from female breast cancer. Green figures represent those who have survived 5 years or more.

7

National Cancer Institute

Cancer Survivorship on the Rise!

10

Summary/SEER

Staging Category

Definition

(for all types of cancer)

5-Year Relative

Breast Cancer

Survival*

Localized

Stage 0 & I

The cancer cells have not spread beyond the

organ where they began to grow.

99%

Regionalized

Stage II-III

The cancer cells have spread beyond the

organ where they began (for example to

nearby lymph nodes), but this spread is

limited.

85%

Distant

Stage IV

The cancer cells have spread to other parts of

the body (metastasis).

26%

Dawood S, Broglio K, Valero V, et al. Circulating tumor cells in metastatic breast cancer: from prognostic

stratification to modification of the staging system? Cancer. 113(9):2422-30, 2008

Adapted from 2006-2012 SEER Data

Why do many more women survive?

12

Breast Imaging

13

Advantages

of Digital Mammography

Radiologist:

– Superior contrast resolution and dynamic range

– Post processing allows for enhancement of specific features (window, level, magnify, inversion)

– Ideal for imaging implants, skin, retroglandular fat

– Fewer callbacks

– Telemammography

Patient:

– Lower average dose of radiation

– Speed – no wait time for film to develop

– Wire localizations – compression time shortened limiting total procedure time and patient discomfort

What is Digital Mammography?

Mammogram acquired electronically

without using x-ray film

Digital detectors divided into individual

picture elements (pixels)

Xray photons pass through the breast and

strike each cell/detector

A shade of gray then assigned to each

cell in proportion to the number of

photons counted at that cell

Ultimately results in a gray scale image

displayed on computer monitors

Dietz, J., PP 2016

Southern Illinois Health Care

B

University Hospitals Case Medical Center 18

Digital Mammogram Tomosynthesis

Dense Breast Tissue vs Fat Replaced Breast Tissue

Southern Illinois Healthcare

Breast Density in the U.S.

10% of women have almost entirely fatty breasts.

40% of women have scattered areas of fibro glandular

density

50% of women have either heterogeneously dense or

extremely dense breast tissue

Breast Density Law in Ohio

• Ohio Resident Anne Gates lost her sister

Chris Nestor to breast cancer January 23,

2013.

• Her sister’s cancer was “invisible” on

mammogram

• Anne Gates lead the cause in Ohio to pass

a breast density law

Image courtesy of ITN January 2017

Breast Density Legislation

In Ohio Bill S.B. No. 54

• ”A physician interpreting a mammogram shall determine based on the breast imaging reporting and data system established by the American college of radiology whether the patient has dense breast tissue. If so, the physician shall include the following in the report or summary sent to the patient pursuant to 21 C.F.R. 15900.12:”

OHIO BREAST DENSITY LAW:

signed by governor Kasich 12-22-2014.

“Your mammogram demonstrates that you have dense breast tissue, which could hide abnormalities. Dense breast tissue, in and of itself, is a relatively common condition. Therefore, this information is not provided to cause undue concern; rather, it is to raise your awareness and promote discussion with your health care provider regarding the presence of dense breast tissue in addition to other risk factors."

Update on Chemotherapy

25

In the old days…..

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NSABP

Protocol B-13 (Schema 1)

To determine whether tamoxifen is more effective

than no treatment

In 1987, added Protocol B-14 (Schema 2) to

evaluate the effectiveness of tamoxifen for 10

years; specifically, to determine whether an

additional 5 years of tamoxifen therapy is

effective in prolonging disease-free survival and

survival in patients with negative nodes and

estrogen-receptor-positive tumors. Patients who

complete the initially assigned 5 years of

tamoxifen therapy were re-randomized to 5

additional years of either tamoxifen or placebo.

NSABP.pitt.edu/B-14.asp

Early Breast Cancer Trialists’ Collaborative Group

(EBCTCG)

Relevance of breast cancer hormone receptors and other factors to the efficacy of

adjuvant tamoxifen: patient-level meta-analysis of randomised trials.

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2011 Aug 27;378(9793):771-84. doi: 10.1016/S0140-6736(11)60993-8. Epub 2011 Jul 28

Paloma1 CT

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Paloma3 CT

• PALOMA-3 is a randomized (2:1), multi-center, double-blind Phase

3 study that evaluates palbociclib in combination with fulvestrant

versus fulvestrant plus placebo in women with HR+, HER2-

metastatic breast cancer whose disease has progressed after prior

endocrine therapy.

• Primary endpoint: investigator-assessed progression-free survival†

• Secondary endpoints: objective response (OR),‡ clinical benefit

response (CBR),§ duration of response (DOR), overall survival

(OS), and safety and tolerability2

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Administration/Side effects Ibrance

For post-menopausal women with metastatic ER/PR+ HER2 - BC

Dosing: 125mg PO on days 1-21 of 28-day cycle.

– CBCw/diff at baseline, Q 2 weeks x6 weeks, then prior to each

cycle.

– Contraindication: Hypersensitivity, ANC < 1000, Caution if

thrombosis risk

Common reactions: Neutropenia, leukopenia, anemia,

alopecia, fatigue, stomatitis, thrombocytopenia, URI, N/V/D,

peripheral neuropathy, asthenia, epistaxis, infection, PE

Severe reactions: anaphylaxis, nephrotoxicity,

myelosuppressoion, ototoxicity, peripheral neuropathy, severe

N/V, vision loss

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Epocrates.com

CALGB 40603 (Alliance)

• One third of patients with triple-negative breast cancer (TNBC)

achieve pathologic complete response (pCR) with standard

neoadjuvant chemotherapy (NACT). CALGB 40603 (Alliance), a 2

× 2 factorial, open-label, randomized phase II trial, evaluated the

impact of adding carboplatin and/or bevacizumab.

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Schema of randomized phase II CALGB (Cancer and Leukemia Group B) 40603 trial. ddAC,

dose-dense doxorubicin plus cyclophosphamide.

William M. Sikov et al. JCO 2015;33:13-21

©2015 by American Society of Clinical Oncology

(A) Pathologic complete response (pCR) breast (ypT0/is); (B) pCR breast/axilla (ypT0/is N0);

95% CIs shown in parentheses.

William M. Sikov et al. JCO 2015;33:13-21

©2015 by American Society of Clinical Oncology

Carboplatin administration/side effects• Dosing:

– Institutions protocol: Seidman - Carbo AUC 6 IVPB w/ filigrastim or peg-filgrastim.Creatanine at baseline, frequent CBC, CMP

HOLD: ANC >or = to 1500, PLTS > or = 100,000, grade III peripheral neuropathy.

• Contraindications:

Thrombocytopenia, anemia, leukopenia, nausea, vominting,

hypomagnesemia, hyponatremia, hypokalemia, hypocalcemia,

elevated alk phos, elevated LFTs, BUN/Cr elevation….

• Common reactions: Hypersensitivity to drug/class, mannitol,

cisplatin, platinum, compounds, myelosuppression, active bleeding,

renal impairtments…

• Serious reactions: anaphylaxis, nephrotoxicity, myelosuppression, ototoxicity, peripheral neuropathy, severe N/V, vision loss, severe hypokalemia, hponatremia, hypocalcemia

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Adverse Events CALGB 40603

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Sikov, W.M. J Clin Oncol 32. © 2014 by American Society of Clinical Oncology

Chemotherapy and Targeted Therapies

Neoadjuvant Chemotherapy

36

Clinical Rationale for neo-adjuvant Chemotherapy

• Regimens should be the same as those established

as safe and active in the adjuvant setting

• No survival advantage

• A variety of clinical, imaging, and pathologic

measurements are available to gauge tumor

response

• clear correlation between tumor response in the breast and lymph

nodes and both disease-free and overall survival. Pathologic

complete

• response and other pathologic measures may be useful as

surrogate end points in evaluating and understanding new

therapies.

• preoperative systemic therapy is effective and can improve breast

conservation rates as a result of tumor response to therapy

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Imaging before and after

Neoadjuvant Chemoptherapy

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PRE POST

Primary systemic

therapy

Conventional

therapy

(Mastectomy)

Local

therapy

(Lumpectomy)

Neoadjuvant Hormonal Therapy

(4 months)

Dietz, Jill MD

Survival after Neoadjuvant Chemotherapy

40

0%

20%

40%

60%

80%

100%

NSABP-18 Royal

Marsden

EORTC

10902

Neoadj OS

Postop OS

Neoadj DFS

Postop DFS

Outcome

neoadjuvant

group =

outcome of

adjuvant

group

Individualized Treatment

• Neoadjuvant Chemotherapy

• Immune Therapies

• Targeted Therapies (Her-2)

• Studies

41

CHRISTUS Stehlin Foundation for Cancer Research

Immunotherapy & Targeted Therapy

• https://www.youtube.com/watch?v=5AXApBbj1ps&sns=em

42

Immunotherapy

• There are several types of immunotherapy, including:

• Monoclonal antibodies

• Non-specific immunotherapies

• Oncolytic virus therapy

• T-cell therapy

• Cancer vaccines

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Check Point Inhibitors

• Ipilimumab (Yervoy)

• Nivolumab (Opdivo)

• Pembrolizumab (Keytruda)

• Atezolizumab (Tecentriq)

• Avelumab (Bavencio)

• Durvalumab (Imfinzi)

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Toxicities• Pneumonitis – 4% (any grade) *more in lung patients then solid

tumor

• Rash or dermatitis (up to 15%)

• Diarrhea or colitis (up to 20%)

• Endocrinopathies, especially hypothyroidism (10% or more)

• Between 1% and 5% of patients each experience grade 3/4

hepatitis and grade 3/4 nephritis.

Rare toxicities:

• neuromuscular toxicity (eg, peripheral neuropathy, Guillain-Barre

syndrome), ocular toxicity (uveitis), pancreatitis, myocardial fibrosis,

polymyositis, or autoimmune hematologic toxicity.

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Toxicity Management

• Steroids!!!

• High doses and then tapering them over a month. Certainly, if the

toxicity is severe, grade 3 or grade 4, the patient needs to be

admitted for intravenous (IV) steroid use. Then the steroids can be

tapered, over at least a month.”

• Generally, for grade 3 or 4 toxicity, we will discontinue the

immunotherapy. There is no dose reduction. You discontinue the

drug and then you treat the toxicity”

• Once the symptoms are under control, patients who had grade 2

toxicity that has improved to grade 1 or entirely resolved and

patients who had grade 3 or 4 endocrine or dermatologic toxicity

can often restart immunotherapy

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Pembrolizumab in Patients With Advanced Triple-Negative Breast

Cancer: Phase Ib KEYNOTE-012 Study

• •Multicenter, nonrandomized phase Ib trial of single-agent

pembrolizumab given intravenously at 10 mg/kg every 2 weeks to

patients with advanced PD-L1-positive (expression in stroma or ≥

1% of tumor cells by immunohistochemistry) TNBC, gastric cancer,

urothelial cancer, and head and neck cancer.

• •This report focuses on the TNBC cohort.

• •Among 111 patients with TNBC whose tumor samples were

screened for PD-L1 expression, 58.6% had PD-L1-positive tumors.

• •Thirty-two women (median age, 50.5 years; range, 29 to 72 years)

were enrolled and assessed for safety and antitumor activity.

Nanda R et al. KEYNOTE-012 Study. JCO 2016 34:2460-7

Joseph Baar MD 2/17

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Baseline Characteristics

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Kaplan-Meier Estimates of (A) Progression-free Survival and (B)

Overall Survival

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Rita Nanda et al. JCO 2016;34:2460-2467©2016 by American Society of Clinical

Oncology

Median

Pembrolizumab (Keytruda)

Toxicities

Common Serious

Fatigue Immune-mediated rxn

Hyperglycemia Pneumonitis

Anemia Septic Shock

Hyponatremia Colitis

Hypoalbuminemia Hepatitis

Increased LFT’s Pancreatitis

Lymphopenia Diabetes Mellitus Type I

Nausea Diabetic Ketoacidosis

Rash Hypophysitis

Decreased appetite Hypothyroidism

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Update 2016

• •As of the data cutoff date of April 26, 2016:

• –Median follow-up duration was 10.7 mo (range, 0.4-32.7)

• –Median OS was 10.2 mo (95% CI, 5.3-17.5)

• –2-mo OS rate was 41.1%

• •Median PFS was 1.9 mo (95% CI, 1.3-4.3) and 12-mo PFS rate was 15.0%.

• •Of the 5 responders (including 1 complete response [CR] and 4 partial responses

[PR]): 3 have had long-lasting benefit from pembrolizumab.

• –CR (1): discontinued study medication 11 mo after achieving CR and has remained

in CR for approximately 15 mo without receiving any additional anticancer

treatment.

• –PR (2) discontinued pembrolizumabafter completing 2 yr of treatment.

• •First pt has maintained response for 22.7 mo

• •Second pt had disease progression after 7.7 mo of response and restarted

pembrolizumab.

• •Median duration of response has not been reached (range, 15-58+ wk

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Conclusion

• Preliminary evidence of clinical activity and a potentially acceptable

safety profile of pembrolizumab given every 2 weeks to patients

with heavily pretreated, advanced TNBC.

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Diagram Freetobreath.org

Chemo-Immunotherapy?

Hypothesis

• 1.The immune system needs tumor antigen to generate a broad

anti-tumor T cell response

• 2.Chemotherapy helps the immune system by

• a)Killing tumor cells to provide a source of such antigen

• b)Suppressing the suppressors

• 3.Further amplifying anti-tumor immunity by interfering with

immunosuppressive pathways (PD-1/PD-L1) is a good thing

53

OT2-01-10: Pilot Study of Carboplatin, Nab-Paclitaxel and

Pembrolizumab for mTNBC (CASE 6115)

DAY 1 8 15 22 29 36 43 50 57

C X X X

N X X X X X X X X X

P X X X

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C, Carboplatin, AUC 6 IV day 1 of 21-day

cycle

N, Nab-paclitaxel, 100mg/m2IV days 1, 8

and 15 of 21-day cycle

P, Pembrolizumab, 200 mg IV every 3 weeks

Aims

• Aim 1. Determine overall response rate (RR) in patients treated

with CNP

• •Aim 2. Determine progression-free survival (PFS) in patients

treated with CNP

• •Aim 3. Identify pathologic and genomic correlates of response to

CNP

55

Other Ongoing Metastatic Trials

OT2

• OT2-01-17. A Phase II randomized trial of pembrolizumabwith

carboplatinand gemcitabinefor treatment of patients with metastatic

triple-negative breast cancer (mTNBC). Obeid E, et al.

• OT2-01-03. Phase II trial of the addition of pembrolizumabto

letrozoleand palbociclibin patients with metastatic estrogen

receptor positive breast cancer who have stable disease on

letrozoleand palbociclib. Yuan Y, et al.

56

Targeted Therapy“is a cancer treatment that uses drugs.

It is different from traditional chemotherapy. The drugs known as targeted therapy help stop cancer from growing and spreading. They work by targeting specific genes or proteins”

Cancer.net

57

58

Herceptin/Perjeta

59

HERCEPTIN (trastuzumab)

• Patients with early breast cancer should be treated for 1 year or until

disease recurrence . 6mg/kg IV Q 3 weeks

• Serious Reactions Common Reactions

– Ventricular dysfunction (severe or fatal) Infusion Rx

– Cardiomyopathy Pain

– CHF Asthenia

– Thromboembolism Fever/Rigors

– Infusion reaction (severe or fatal) Nausea/Vomiting

– Dyspnea Diarrhea

Headache/Fatigue/Cough/Dyspnea

**Echocardiogram required prior to start, monitored routinely during treatment

Dose may differ at initiation of treatment, if tx is for metastatic disease, or if used

in combination with other drugs.**

60

Perjeta (pertuzamab)

• Perjeta (chemical name: pertuzumab) is approved by the U.S. Food

and Drug Administration (FDA) to be used in combination with

Herceptin (chemical name: trastuzumab), another targeted therapy

medicine, and Taxotere (chemical name: docetaxel), a type of

chemotherapy, to treat HER2-positive, metastatic breast cancer

that hasn’t been treated with either Herceptin or chemotherapy yet.

(Perjeta was called Omnitarg in earlier studies.)

• Perjeta also has accelerated FDA approval to be used in

combination with Herceptin and Taxotere before surgery to treat

HER2-positive, early-stage (the cancer must be larger than 2 cm or

cancer must be in the lymph nodes), inflammatory, or locally

advanced-stage breast cancer with a high risk of metastasizing or

becoming fatal. Breast cancer. org

61

Perjeta Side Effects

• Dose: 840MG IVx1 of 21 day cycle then 420mg Q3-6cycles

• Serious Side effects: Common Side Effects:

– Cardiac failure Diarrhea

– Cardiomyopathy Alopecia

– Left ventricular dysfxn Neutropenia

– CHF N&V

– Infusion rxn Fatigue

– Hypersensitivity rxn Rash

– Anaphylaxis Anorexia

– Anemia Mucositis

– Leukopenia/neutropenia Anemia

– Febrile neutropenia Headache, Fever,Stomatitis

62

Cleopatra Trial

63

Cleopatra Study

• The large phase II trial assessed the safety profile during which either

pertuzumab or placebo was added to docetaxel and trastuzumab for

first-line treatment of HER2-positive metastatic breast cancer.

• Toxicity profiles between the pertuzumab and placebo group were

similar for grade 1 and 2 adverse events including diarrhea (46.3 vs.

66.8%), alopecia (60.5 vs. 60.9%), neutropenia (49.6 vs. 52.8%),

nausea (41.6 vs. 42.3%), and fatigue (36.8 vs. 37.6%). For grade 3 or

higher adverse events, neutropenia was the most common (45.8 vs.

48.9%), followed by febrile neutropenia (7.6 vs. 13.8%), leukopenia

(14.6 vs. 12.3%), and diarrhea (5.0 vs. 7.9%).

• Deaths related to adverse effects of the treatment were 2.5% for the

control group and 2.0% for the pertuzumab groups, with infection cited

as the primary cause.29

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Add pertuzamab to trastuzumab

• For HER2 + BC

– Originally FDA in June 2012 for use in combination with trastuzumab

and docetaxel for the treatment of patients with HER2-positive

metastatic breast cancer without prior treatment with anti-HER2 therapy

for metastatic disease.

– 2013, pertuzumab was expeditiously approved by the FDA for

neoadjuvant therapy in HER2-positive patients with locally advanced,

inflammatory, or early stage breast cancer. In this clinical scenario,

pertuzumab is administered with trastuzumab and docetaxel with data

indicating an improved pathologic complete response (pCR) when

compared to trastuzumab and docetaxel alone

65

Maley, J.J. & Macrae, E.R. (2014)Pertuzumab in Combination with Trastuzumab and Chemotherapy in the Treatment of HER2-Positive

Metastatic Breast Cancer: Safety, Efficacy, and Progression Free Survival. Breast Cancer (Auckl). 2014; 8: 81–88.

Cleopatra Study

66

Identification of Multigene panel

67

• Viable option to assess risk for

women at increased risk to

develop BC

2013 Supreme court decision –

NO to Myriad genetics patent

Covers over 100 genese, 21

specifically for breast cancer

Easton, D.F. et al. N Engl J Med 2015; 372:2243-2257. 2015

Hormonal Therapy

• Tamoxifen/Evista (tamoxifen 20mg daily) (Evista 60mg daily)

– Pre or Post-menopausal women

– Evista only in DCIS

– Bone and heart protective

Common Side effects Serous Side effects

Hot flashes Thromboembolism

N/V Stroke

Vaginal discharge Endometrial Cancer

Menstrual irregularities Endometrial Hyperplasia

Vaginal bleeding Endometriosis

Disease flare, transient Uterine Sarcoma

Lightheadedness Uterine Fibroids

Dizziness Ovarian Cysts

Peripheral edema Erythema multiforme

Fatigue Thrombocytopenia

Headache Leukopenia/neutropenia

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Aromatase Inhbitors

• Arimidex (anastrozole) 1mg daily

• Aromasin (exemestane) 25mg daily

• Femara (letrozole) 2.5mg daily

– For post-menopausal women only (natural or artificial)

– Must monitor bone density

– Consider bone health prior to initiating treatment

Common S/E Serious SHot flashes FracturesAsthenia OsteoporosisPain Endometrial CAArthralgias ThromboembolismArthritis MIN/V Stroke

Headaches Angina

Depression HTN

Rash Cataracts

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ER+ disease, 5 yrs v 0, and 10yrs v 5 Breast cancer death rate ratio (rr)

70

ER+ disease, 5 yrs v 0, and 10yrs v 5 Breast cancer death rate ratio (rr)

71

ER+ disease, 5 yrs v 0, and 10yrs v 5 Breast cancer death rate ratio (rr)

72

73

Conclusion: ATLAS TRIAL

• 10 vs. 5 years of tamoxifen improves DFS and OS in ER+ invasive breast cancer

• Increased side effects were modest

• Benefit vs. other switching strategies with aromatase inhibitors for postmenopausal women is unknown

74

75

MA17 Trial :Menopause Status at Primary Diagnosis

76

Silverman, Paula MD, May 2015

MA17: Letrozole was effective in overall study population

77

Silverman, Paula MD May 2015

Among untreated (placebo) women, pre-menoapausal had Greater

Disease Recurrence

78

Silverman,Paula, May 2015

Premenopausal women had a greater benefit from treatment

79

Intergroup Exemestane Study

Tamoxifen2-3 years Exemestane

2-3 years

Tamoxifen2-3 years

Post-menopausal women with ER +/unknown breast cancer

June 2009 dataset = 91 month F/U from randomization

Total 5 years endocrine therapy

Post Treatment Follow up

80

Randomize

Patient Characteristics

• 4724 postmenopausal women recruited between1998

and 2003

• 44% node positive, 33% received adjuvant

chemotherapy

• Mean age at randomization 64

• ER positive 86%,ER unknown 12%

– Excluded 3% ER negative

• N=4599; all analyses relate to the ER positive/unknown

population

81

International Exemestane Study Results

• Overall Survival

– Absolute difference at 8 years 2.5% favoring

exemestane

– HR 0.86 (95%CI: 0.75-0.99, p=0.04)

• Disease free survival

– Absolute difference at 8 years 4.4% favoring

exemestane

– HR 0.82 (95%CI: 0.73-0.92, p=0.0009)

82

IES results SABCS 2009

Hypothesis generating findings

• Distant recurrences not including bone were the same, but there were more recurrences including bone in the tamoxifen group (147 E vs192 T)

• Exemestane had a lower than expected non-breast second primary cancers

– GI, lung, other improved in addition to expected endometrial

– Total 106 E vs 159 T (could not exclude mets)

83

IES conclusions

• In patients treated with tamoxifen for 2-3 years, switching to exemestane as compared to continuing with tamoxifen out to 5 years results in

– Persistent improvement in breast cancer outcome at 9 years

– Modest but persistent improvement in overall survival

84

Silverman,Paula MD May 2015

85

Randomization

86

87

88

Randomization, Treatment, Follow-up

89

Silverman, Paula MD, May 2015

Conclusions: adjuvant endocrine treatment update

1. Late adjuvant letrozole improve DFS, DDFS and OS

2. Premenopausal women who become menopausal while on tamoxifen should be offered letrozole at completion of treatment or after up to 6 years of observation

3. From International Exemestane Study, patients treated with tamoxifen for 2-3 years, switching to exemestane as compared to continuing with tamoxifen out to 5 years results in improved overall survival and breast cancer outcomes

90

Conclusions: adjuvant endocrine treatment update

5. Ovarian suppression plus tamoxifen did not provide a

significant benefit to the overall study population.

However, in women who remained premenopausal

and received adjuvant chemotherapy, there was

improvement in outcomes

6. In premenopausal women where ovarian suppression is

recommend, exemestane combined with ovarian

suppression reduced recurrence

91

Surgery for Breast Cancer

• Whats new?

– New technology

– Margins

– Latest on Axillary Management

– Oncoplastic Surgery

92

MastectomyBreast

Conservation

Surgery for Breast Cancer

GENETICS

94

Oncoplastic Surgery

95

Trying to avoid this

96

Prevent vs Cause deformity

97

Oncoplastic Surgery

An extension of the multidisciplinary approach to the breast cancer patient

Genetics: If gene + consider contralateral prophylactic

Imaging: MRI if remodeling the whole breast. How far from the nipple? Extent of disease?

Med Onc: Would neoadjuvant chemo or hormonal therapy allow for BCT? Timing of therapy…consider delays with more extensive surgery

Rad Onc: PBI or intraop? Post mastectomy radiation needed? Timing of reconstruction needs to be determined.

Path: How to label and assess margins when rearranging the breast.

Plastics: Flaps, reconstruction of the partial mastectomy defect, contralateral symmetry

98

Batwing Procedure Post-op

99

Batwing procedure: One week post-op

100

Nipple Sparing mastectomy in patients with previous

reduction mammoplasty

101

Pre-operative assessment of skin

reduction and symmetry

De-epithelialize skin (before or after mastectomy)

Nipple Sparing Mastectomy

104

Make inferior incision

on superior border of

lower flap

Nipple Sparing Mastectomy Complete

105

Complete skin reduction closure

106

Two months post-op

107

108

Halestead Mastectomy

Nipple Sparing Mastectomy

Sentinel Node Biopsy vs. Complete Axillary Dissection

• Sentinel node biopsy is a surgical procedure used to determine if

cancer has spread beyond a primary tumor into your lymphatic

system. Sentinel node biopsy is used most commonly in

evaluating breast cancer and melanoma. The sentinel nodes are

the first few lymph nodes into which a tumor drains.

• An axillary lymph node dissection (ALND) is surgery to remove

lymph nodes from the armpit (underarm or axilla). The lymph

nodes in the armpit are called axillary lymph nodes. An ALND is

also called axillary dissection, axillary node dissection or

axillary lymphadenectomy.

109

Complete Axillary Dissection

110

Common post-surgery

effects:

Parasthesia – 53%

Lymphedema – 3.5%

Limited arm abductions –

24%

Pain – 27%

Emerson, et al. World Journal of Surgical

Oncology201412:67

Sentinel Node Biopsy

• A sentinel lymph node is the first lymph node to receive lymphatic drainage

from a tumor. It can be detected by injection of a blue dye or radioactive

colloid (Technetium 99m sulfur colloid (Tc99m) around the nipple, which

travels to and identifies the first draining (sentinel) node. Biopsy of a

sentinel lymph node can reveal whether there are lymphatic metastases,

thereby eliminating the need for extensive dissection of the regional lymph-

node basin.

111

Aboutcancer.com

112

The New Normal

113

What is it?

Sadness

Stress

Fear of recurrence

Will life every be the same?

Permanent scars

Emotional scares

Unable to go back to usual

activities

Fear of the unknown

114

Personal Quote

"I'm so exhausted from dealing with all

the emotional ups and downs with my

disease. I'm wondering how much of this

overtiredness is not physical at all. And if

I'll ever feel stronger. I barely sleep since

I've been home from my surgery. I'm tired,

but never tired enough to just sleep

soundly."

— Shawna

115

Exercise - may be the only cure for

fatigue! Do it together, encourage!!

America College of Sports Medicine –

150 minutes of exercise/week . Build

up slowly.

Yoga, tai chi

Walking

Join a class

Swim

Gift of personal trainer

Memory/Concentration

• Chemo brain” – not the entire picture!

Theories:

• Stress has been found to be a cause of memory loss

➢ Too much energy in one area such as coping with cancer

diagnosis can cause lack of energy in other areas

• Not much time from diagnosis to treatments to emotionally

prepare

• Physiological changes – release of stress hormone

cortisol. Excessive stress hormone levels can make it difficult

to think or retrieve long-term memories.

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Stress, Coping and Cognitive Deficits in Women After Surgery for Breast Cancer.

Published online January 10, 2012, in the Journal for Clinical Psychology in Medical

Settings. First author: Stephanie Reid-Arndt, PhD, ABPP, University of Missouri,

Columbia, Mo. Assessed 9/22/15 from Breast Cancer.org

Emotional Change/Fear of Recurrence

• Damocles syndrome.” According to Greek legend, once Damocles realized that a

sword was dangling precariously over his head, he could no longer enjoy the

banquet spread in front of him. In the same way, the specter of cancer hangs over

some cancer survivors. They can become emotionally paralyzed and have a hard

time deciding to get married, change jobs, or make other major decisions.

• Fear of Recurrence – follow up visits, unexplained pain, sights sounds that are

reminders trigger the fear of recurrence leading to anxiety, emotions

• Post-traumatic stress - recognize triggers; office visits, other survivors

• Survivorship guilt – “Why me” “Why not me”

Recognize and understand these emotions!

• McDonald, Ann:The mental and emotional challenges of surviving breast

cancer . POSTED March 28, 2011. 5:03 PM Updated March 29,2011

9:27AM

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Emotions: Pain, Anger, Loneliness

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PainSkin sensitivity where you received

radiation

Painful scars from cancer surgery.

Pain in a missing limb or breast.

Pain in breast from surgery

Pain or numbness in the hands and

feet due to injured nerves

Vaginal pain/discomfort

How we can help:

Recognize the pain as real!!

Advocate for your partner

Pain medications Hypnosis, meditation, yoga

Anti-depressants Relaxation skills

Physical Therapy Acupuncture

Emotions: Pain, Anger, Loneliness

“Anger is nothing more than a cover for hurt, frustration or fear or all three”

- Phil McGraw

• “I was healthy; I did everything right. I exercised, ate right, went for my

mammograms every year and I still got cancer.” - my anonymous patient

• I am angry that I am alive and my friend is not

• I am angry that I have to live with pain

• I feel angry at the friends and family that abandoned me during treatment

• I am angry that I had to quite my job

• I get angry when people complain about minor things because I had to face my

mortality

• I feel grateful to be alive but I am still angry

!After Breast Cancer Treatment, Breast Cancer and Mental Health, depression and breast cancer. Denise4health.December

9, 2013

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• “There is no greater agony than bearing an untold

story inside you.” - Maya Angelou

• Loneliness

– Loneliness in recognizing mortality

– Loneliness in symptom burden

– Changed sense of identity and connection with others

– Altered threshold for distress (coping)

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Mary Rosedale, PhD, APRN-BC, NEA-BC: Survivor Loneliness of Women

Following Breast Cancer. Oncology Nursing Forum • Vol. 36 No2 March 2009 183

Lymphdedema

• Build up of lymph fluid under fatty tissues under skin

• Interruption of the lymph nodes and lymph vessels that carry fluid

from distant parts of the body back to the heart.

• Lymph system is part of the immune system, fights of harmful

substances; infection, cancer.

• Surgery can disrupt the lymphatic system causing swelling (breast

surgery, lymph node removal)

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American Cancer Society:Signs and symptoms of lymphedema. Accessed

9/22/15

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Natural remedies.org

Sexual Issues/Intimacy

• Chronic or acute illness can affect can disrupt intimate relationships

• Body image issues after surgery/treatment

• Loss of desire

• Chemotherapy, oophorectomy or hormonal therapy can cause

immediate menopause which can lead to physical difficulties with

intimacy

– Vaginal dryness

– Dyspareunia (painful intercourse)

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Sexual issues and intimacy

• Educate patient and partner:

– Encourage partner to share feelings

– Decrease alcohol, caffeine, chocolate

– Foreplay

– Encourage to discuss treatments with provider:

• Natural lubricants Anti-depressants:

– Olive oil Effexor

– Coconut oil Paxil (Brisdelle)

• Vaginal moisturizers Celexa, Prozac

– Replens Neurontin

• Vaginal lubricants

– KY Jelly– Astroglide– goodcleanlove.com– yesyesyes.co

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Work and Family Issues

• Family issues:

– Role changes

– Hard for family to come to terms with the cancer diagnosis

– Children or grandchildren may fear cancer means “will die”

– Increased responsibilities while managing emotions and trying to

be sensitive to the needs of the family member with cancer

– Communication from all family members is key

– Talk with someone who has had a relative diagnosed with cancer

– Seek out community resources

• The Gathering Place (Cleveland)

• Stewarts Caring Place (Akron

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Weight and Eating Habits

• Weight gain is common during/after cancer treatment. If received

chemotherapy were 65% more likely to gain weight then women who

did not have chemotherapy.

• Average weight gain is 5-15 pounds

• Weight gain is enhanced if patient goes through menopause

• Reasons – change in metabolism, decreased activity

• Only way to increase metabolism is through exercise

Saquib N, Flatt SW, Natarajan L, et al. Weight gain and recovery of pre-cancer weight after breast cancer treatments: evidence from the women's healthy eating and living (WHEL) study. Breast Cancer Res Treat. 105(2):177-86, 2007. - See more at: http://ww5.komen.org/BreastCancer/Treatment_References.html#sthash.vrd5hNfv.dpuf

Stan D, Hershman D, Loprinzi CL. Chapter 51: Management of menopausal symptoms in breast cancer survivors, in Harris JR, Lippman ME, Morrow M, Osborne CK. Diseases of the Breast, 5th edition. Lippincott Williams and Wilkins, 2014.

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Weight and Eating Habits

• How we can help - educate:

– One area where partners can have most impact!

– Do the shopping, prepare the meals

• Encourage:

– 3 meals a day

– Avoid snacks

– Use healthy fat (olive oil, coconut oil, nuts, natural nut

butters, avocados

– Limit refined carbs (white stuff – pasta, white rice,

cookies, cake, ice cream)

– Half the plate should be vegetables

– Avoid other activities while eating – turn off tv!Komen.org. assessed September 21, 2015

127

Bone Pain

• Joint pain (arthralgia) and muscle pain (myalgia) are common side effects

of aromatase inhibitors. The pain may be in the hands and wrists, feet and

ankles, knees, back or other parts of the body.

• Up to 36 percent of women in clinical trials of aromatase inhibitors have

reported joint pain and up to 15 percent have reported muscle pain. Other

studies have found even higher rates of these side effects.

• Joint and muscle pain can mimic carpal tunnel syndrome. And, in rare

cases, aromatase inhibitors can cause carpal tunnel syndrome.

• Although aromatase inhibitors can cause joint and muscle pain, they don’t

cause permanent joint or muscle damage.

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Bone pain treatment/Leg Cramps

• NSAIDS Magnesium 500mg

• Acupuncture Banana

• Exercise hydrate

• Tumeric (1,500mg/day – though dose varies by type used)

• Cortisone injection

• Livestrong.com updated 10.3.2017

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Neuropathy

Chemotherapy. Specific types of chemotherapy can injure peripheral

nerves, particularly high-dose chemotherapy. These include:

• Bortezomib (Velcade)

• Platinums, including cisplatin (Platinol), oxaliplatin (Eloxatin), and

carboplatin (Paraplatin)

• Taxanes, including docetaxel (Docefrez, Taxotere) and paclitaxel

(Taxol)

• Thalidomide (Synovir, Thalomid)

• Vinca alkaloids, including vincristine (Vincasar), vinorelbine

(Navelbine), and vinblastine (Velban)

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Cancer.net

Neuropathy Treatment

• Pain relievers (OTC, though may need opioids; tramadol, oxycontin,

used only if other treatments have failed.

• Anti-seizure medications Lyrica (pregabelin), Neurontin (gabapentin)

• Topical treatments - Capsaicin cream (may have burning sensation at

first. Theory is the heat deadens the nerves

• Lidocaine patch

• Antidepressants – amitriptyline,nortryptiline, cymbalta, effexor

• Transcutaneous electrical nerve stimulation (TENS)

• Physical therapy

• GLA (gamma linolenic acid) ALA (Alpha Lipoic Acid), Vitamin B1 & B6

• Amino Acids - acetyl-L-carnitine

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Mayoclinc.org

Favorite Quote

"The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their "The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss,

ant"The most beautiful people we have known are those who have

known defeat, known suffering, known struggle, known loss, and

have found their way out of the depths. These persons have an

appreciation, a sensitivity, and an understanding of life that fills

them with compassion, gentleness, and a deep loving concern.

Beautiful people do not just happen."

- Elizabeth Kubler Ross

hem with compassion, gentleness, and a deep loving concern. Beautiful people dThe most beautiful people we have known are those

who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, a sensitivity, and an understanding of life that fills them with compassion, gentleness, and a deep loving concern.

Beautiful people do not just happen."

132

Thank- you!!!!

Pink ribbon

The pink ribbon is an international symbol

of breast cancer awareness. Pink ribbons,

and the color pink in general, identify the

wearer or promoter with the breast cancer

brand and express moral support for

women with breast cancero not just happen."

- appreciation, a sensitivity, and an understanding of life that fills them with compassion, gentleness, and a

deep loving concern. Beautiful people do not just happen."

- Ross

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