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Follow up and survivorship issues after treatment for breast cancer Michael Jefford MBBS, MPH, MHlthServMt, PhD, MRACMA, FRACP Clinical Consultant, Cancer Council Victoria Consultant Medical Oncologist, Peter MacCallum Cancer Centre Associate Professor of Medicine, University of Melbourne

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follow up and survivorship issues after treatment for breast cancer

Follow up and survivorship issues after treatment for breast cancer

Michael Jefford

MBBS, MPH, MHlthServMt, PhD, MRACMA, FRACP

Clinical Consultant, Cancer Council Victoria

Consultant Medical Oncologist, Peter MacCallum Cancer Centre

Associate Professor of Medicine, University of Melbourne

Michael.Jefford@petermac.org

key points
Key points
  • There are a large number of breast cancer survivors – high incidence x high survival rates
  • Current focus of follow up / surveillance is (largely) on detection of cancer recurrence
  • Women with a prior experience of breast cancer have much broader survivorship issues
key points3
Key points
  • Women should be informed of ways to maintain their health and wellness
    • Survivorship care plan
    • Advice and coaching regarding healthy lifestyle
  • Alternative models of care (rather than led by medical specialists) should be explored
cancer council resources
Cancer Council resources
  • Cancer Council Helpline 13 11 20, and database
  • DVD and booklet
  • Regional seminars
  • Survivors Cancer Connect
  • Support groups – face to face, telephone, internet
breast cancer incidence and mortality trends victoria
Breast cancer – incidence and mortality trends (Victoria)

Canstat: Cancer in Victoria 2006. The Cancer Council Victoria Epidemiology Centre 2009

potential issues after completing treatments for breast cancer
Varied reactions to finishing treatment

Fear of recurrence

Ongoing treatment side effects

Relationship issues

Work / financial issues

Impact on family

Late and long-term effects of treatment

menopausal symptoms, loss of fertility, osteoporosis, cognitive disturbance, weight changes, altered body image, sexual problems, fatigue, heart problems, risk of second cancers

Distress, anxiety, depression

Potential issues after completing treatments for (breast) cancer
the us institute of medicine iom report
From Cancer Patient to Cancer Survivor: Lost in Transition

Landmark report

Argued that the post treatment phase is a distinct phase that requires increased attention by clinicians

17 minute video on YouTube at www.youtube.com/watch?v=7y0msS6KNAA

The US Institute of Medicine (IOM) report
the us institute of medicine report
The US Institute of Medicine report

Recommends four components of quality survivorship care

prevention of recurrent and new cancers

surveillance for cancer recurrence as well as for medical and psychosocial late effects

strategies to deal with the broad consequences of cancer and its treatment

coordination between specialists and primary care providers

strategies to improve outcomes for cancer survivors
Strategies to improve outcomes for cancer survivors
  • Information
    • Survivorship care plans
  • Strategies to remain well
  • Regular surveillance
    • Hospital, GP, nurses?
  • Supports
survivorship care plans
Survivorship care plans

A key component of optimal survivorship care is the use of a survivorship care plan (SCP)

The SCP is a summary of:

Cancer diagnosis and treatments

Plans for follow up

Current medical, psychosocial, practical issues, and a plan for management

Potential future issues and a plan for management

Ideally discussed with someone toward the end of potentially-curative treatment(s)

why do we need them
Why do we need them?

Because patients are ‘lost in transition’ (from cancer patient to cancer survivor)

Fragmented, poorly coordinated healthcare system

Patients need a coordinated plan for follow up and a plan to protect their health

Patients (and GPs) want to be informed and help ensure good survivorship outcomes

the scp in more detail
The SCP in more detail

Essential elements include details about:

(i) the cancer (diagnosis and stage), all treatments (with dates, doses, complications), and potential short and long-term consequences

(ii) the content and timing of recommended follow up (monitoring for treatment toxicity, cancer recurrence, and psychosocial / supportive care issues)

the scp in more detail22
The SCP in more detail

Essential elements include details about:

(iii) who will take responsibility for survivorship care (oncologist, primary care doctor (GP), survivor, carers)

(iv) health promotional strategies (e.g. weight, exercise, diet, smoking cessation)

(v) practical information and advice (e.g. regarding employment, insurance), and

(vi) the availability of psychosocial/supportive care services

the scp
The SCP

For whom?

Person affected by cancer, GP, other treating doctors

In what format?

Paper and electronic

Tailored to the person’s (a) diagnosis, treatment, (b) own identified needs, and (c) to their preference for information (brief  detailed)

the scp27
The SCP

Completing the SCP

? Nurse or oncologist

Many components are ‘generic’

Resources available: (a) ‘implementing SCP’ workshop reports are available free (next slide); (b) ASCO guidelines for follow up; (c) community-based supports

Limited implementation to date

health behaviours of cancer survivors
Health behaviours of cancer survivors
  • An Australian study (2007) compared health behaviours of cancer survivors to a cohort of people without cancer
  • 968 survivors, 5808 controls
  • Asked about smoking, physical activity, servings of fruit and vegetables, alcohol use, skin checks

Eakin EG et al. Cancer Causes Control 2007; 18(8): 881-894.

health behaviours of cancer survivors31
Health behaviours of cancer survivors
  • More likely to have comorbidities (and more of them)
  • More likely to be current smokers
  • More likely to have regular skin checks
  • (not stat sig) More likely to be overweight / obese
  • (not stat sig) Had higher alcohol consumption
  • No differences regarding physical activity, fruit and vegetable consumption

Eakin EG et al. Cancer Causes Control 2007; 18(8): 881-894.

information about staying well
Information about staying well
  • Maintain a healthy weight
  • More fruit and vegetables
  • Less fat
  • Exercise
  • Limit or avoid alcohol
  • Stop smoking
weight
Weight
  • In women who had never smoked, those who gained between 0.5-2.0 kg/m2 had a relative risk of 1.35 of death from breast cancer, compared to those who maintained their weight
  • In women who had never smoked, those who gained > 2.0 kg/m2 had a relative risk of 1.64

Kroenke CH et al. J Clin Oncol 2005; 23(7): 1370-8. Epub Jan 31

dietary change
Dietary change
  • WHEL study
    • Women’s Healthy Eating and Living randomised controlled trial
    • Diet very high in vegetables, fruit, fibre and low in fat
    • People were able to adopt / maintain the diet
    • Did not reduce breast cancer recurrence / deaths

Pierce JP et al. JAMA 2007; 298(3): 289-98

dietary change35
Dietary change
  • WINS study
    • Women’s Intervention Nutrition Study randomised controlled trial
    • % of calories from fat to 15% (realistic aim of 20% of calories from fat)
    • 2437 women enrolled, median follow up 60 months
    • Significant reduction in cancer recurrence – 9.8% vs 12.4% (HR 0.76, 24% reduction in risk of cancer recurrence)

Chlebowski RT et al. J Natl Cancer Inst 2006; 98: 1767-76

information about staying well36
Information about staying well
  • Stop smoking
  • Maintain a healthy weight
  • More fruit and vegetables
  • Less fat
  • Exercise
  • Limit or avoid alcohol
views of survivors and health professionals regarding follow up and the scp peter mac
Views of survivors and health professionals regarding follow up and the SCP (Peter Mac)

General support for the notion of a SCP

Support for core content areas

Support for information for, and involvement of GPs

Uncertainties regarding: (a) who coordinates follow up; (b) who might complete / discuss the SCP; (c) content of the SCP

survivorship care
Survivorship care

The SCP needs to be integrated into a more complete approach / strategy

Alternate models of follow up may include nurse-led follow up (face to face, telephone), GP follow up, survivorship clinics

gp follow up of women with early stage breast cancer
GP follow up of women with early stage breast cancer
  • Work of Dr Eva Grunfeld (series of RCTs of GP vs specialist follow up) shows that GP follow up is associated with
    • Similar disease outcomes (recurrence)
    • Similar quality of life
    • Greater satisfaction
    • Lower costs (patient, health service)
an example from our current work
An example from our current work

We are developing a ‘comprehensive survivorship package’ including

DVD, booklet and a question prompt list

SCP – for patient and for GP

Nurse-led ‘end of treatment’ session

Telephone-based follow up

Review needs

Discuss QPL

Discuss SCP

Given DVD, booklet, QPL

End of treatment session

Treatments

Telephone-based follow up

conclusions
Conclusions
  • There are a large number of breast cancer survivors
  • The current focus of follow up is (likely) inadequate and probably inefficient
  • There are different models of providing survivorship care – these need to be piloted and evaluated
  • The most appropriate model will depend on local factors
conclusions47
Conclusions

Tailored, survivorship care plans are part of good survivorship care

We need to determine the ideal way to develop and discuss the SCP and how this is best integrated into survivorship care (models of care)

Ideally ongoing survivorship care should screen for, and respond to unmet needs