Cancer Survivorship: What to Monitor

and When to Intervene

Hyman B. Muss, MD

31th Miami Breast Cancer Conference 2014

Breast Cancer 2013

CA: A Cancer Journal for Clinicians

pages 52-62, 1 OCT 2013 DOI: 10.3322/caac.21203

Incidence Mortality

Survivor

An individual is considered a cancer

survivor from the time of diagnosis,

through the balance of his or her life.

Family members, friends, and

caregivers are also impacted by the

survivorship experience and are

therefore included in this definition.

Adapted from the National Coalition for Cancer

Survivorship

3

18 Million Cancer Survivors Projected in 2022

4

Breast 20-40%

Essential Components of

Survivorship Care

• Surveillance for recurrence

• Screening for new cancers

• Identification and interventions for

consequences of cancer and its treatment

• Health promotion strategies

• ‘Shared Care’ coordination between oncology

specialists and primary care providers

5

Deb Mayer 2014

Bumps on the Road of Life (2010) http://www.lillyoncologyoncanvas.com

Follow-up after Breast Cancer

The Key Question

Does early detection of

metastases to other organs

before the development of any

physical findings or symptoms

improve QOL or survival?

GIVIO Trial JAMA 271:1587-1592, 1994

1320 women

Stage I-III BC

26 Italian hospitals

Physical exam q 3 mo x 8, then q 6 mo

Chest x-ray q 6 mo x 4, then q 12 mo

Bone scan q 12 mo

Liver U/S q 12 mo

Lab tests at same time as physical exam

Physical exam q 3 mo x 8,

then q 6 mo

Clinically indicated tests

INTENSIVE CONTROL

OUTCOMES: SURVIVAL AND HR-QOL

GIVIO Trial Results (Median follow-up 71 months)

• 80% compliance to the two protocols

• 254 distant metastases across 2 arms;

• 31% asymptomatic in intensive, 21% in control (69-

79% presented with symptoms)

Intensive Control

Deaths 132 (20%) 122 (18%)

HR-QOL

NO DIFFERENCE AT

6, 12, 24, or 60 MONTHS

What is the Value of Intensive

Diagnostic Followup

• Roselli Del Turco, JAMA 1994;271:1593

– 1243 women from 12 Italian sites

– Randomized: • Intensive: MD visit, mammogram, CXR, bone scan q 6 mo

• Control: MD visit, mammogram

– Primary endpoint 5 year survival

– Results • More thoracic and bone mets detected in intensive arm

(112 v 70), no impact on survival

#Distant Recurrences (%) Mortality (%)

Intensive 164 (26.4) 18.6

Control 125 (20.1) 19.5

ASCO BC Surveillance

Guidelines: Patient Education

• 30 - 40% recur between routine visits

• Instruct pts on signs/symptoms of mets

– bone; pain and tenderness

– skin; characteristics of lesions

– lung; dyspnea, pleurisy

– CNS; focal findings - loss of function

– gastrointestinal; pain, fatigue

Consensus Recommendations

for Follow-up

• Annual mammography, monthly breast self exam

• Other routine cancer screening

• Regular clinic visits for H and P – Every 3-6 months for 3 years, every 6 months for 2 years, then

yearly

• Health care maintenance – Bone and cardiovascular health

• No routine testing (labs and xrays). Testing as indicated by clinical findings.

• Resources: – NCCN.org

– ASCO guidelines (ASCO.org)

– American Cancer Society

Not Recommended !

• CBC or Chemistry

• Chest X-ray

• Bone Scan

• Ultrasound of Liver

• CT Scans of chest, abdomen or pelvis

• CA 27.29, CA 15-3, CEA

• PET scans

• MRI of breast

What is the Role of Tumor

Associated Antigens? • CEA, CA 15-3, CA 27.29

• Elevated in 30 – 65% of distant recurrences with lead time of about 4-6 months – Measured every 2-3 months:

Chan DW, JCO 1997

Follow-up after Breast Cancer

The Key Question

Does early detection of

metastases to other organs

before the development of any

physical findings or symptoms

improve QOL or survival?

Not in 2014 !

Hard concepts to convey….

• Less is as good if not better

– “My other doctor was so thorough….”

– “I have good insurance…..”

• A normal test does not mean no cancer

– So why is my PET/CT $3000….

• Tumor markers: May take a long time to

be sure a result is a false positive

– Both you and patient may need therapy.

Give all

patients

ASCO

follow-up

guidelines

and

document

it!

Cancer.net

So why do it ? • “Community standard”

– There aren’t really any but can be tricky

• Quality Assurance

– Probably the key issue in future

• Monitor side-effects of Rx (adherence)

• Time to educate and answer questions

– Can be very helpful but hard to measure

• Consider new treatments

– i.e. extended endocrine therapy

– General health assessment

Make a checklist….

• Are you having problems with:

– Signs and symptoms of recurrence

– Lymphedema (breast and arms)

– Weight gain or loss

– Fatigue

– Bone loss (tamoxifen, OA in pre / AIs in post)

– Cognitive function – work, family issues

– Sexual function

– Vasomotor symptoms

– Anxiety or depression

Monitoring and Treatment

Hayes, NEJM 2007;356:2505

Symptom Management options

Hot flashes SSRIs, SSNRIs, gabapentin

Sexual dysfunction (libido, dyspareunia) Vaginal moisturizer, estring(?),

testosterone (?)

Weight gain

Exercise (Daley et al, JCO

2007;25:1713), Diet

Depression, fatigue Counseling, treat underlying cause, time

Cognitive dysfunction Tools for improving function

Osteopenia/porosis Calcium/vit D, weight bearing exercise,

bisphosphonates as indicated

Cardiovascular disease Monitor lipid panel, evaluate symptoms

Thrombosis Family and personal history

Secondary malignancies Screening, evaluate symptoms

Late Complications for which

Interventions/Education Available

• Endometrial

malignancies

• Thromboembolic

events

• Cerebrovascular

events

• Leukemia

• Cardiac dysfunction

• Menopausal symptoms

• Bone loss

• Weight gain

• Sexual difficulties

• Psychological

problems

• Neuropathy

Should Be Addressed

During Follow-up Visit

All Rare and Typically

Present More Acutely

Promoting a Healthy Lifestyle in

Cancer Survivors: ACS Guidelines for Cancer Prevention

• Maintain a healthy weight throughout life.

– Balance caloric intake with physical activity.

– Avoid excessive weight gain throughout the lifecycle.

– Achieve and maintain a healthy weight if currently overweight or obese.

• Adopt a physically active lifestyle.

– At least 30 minutes of moderate-to-vigorous physical activity, on 5 or more

days of the week. 45-60 minutes of intentional physical activity preferable.

• Consume a healthy diet, with an emphasis on plant sources.

– Choose foods/beverages in amounts that maintain a healthy weight.

– Eat five or more servings of a variety of vegetables and fruits each day, choose

whole grains in preference to processed

– Limit consumption of processed and red meats.

• If you drink alcoholic beverages, limit consumption.

– Drink no more than one drink per day for women or two per day for men.

Who should do

follow-up?

Primary Care vs Oncologist Multicenter RCT

n=968

9-15 mo after

diagnosis

f/u in cancer center

n=485

f/u with family physician

n=483

Grunfeld E et al. J Clin Oncol 2006; 24:848-55

• Observed 4.5 yrs after diagnosis

• Primary endpoint: Recurrence-Related Serious Clinical Events (SCEs)

• Secondary endpoint: health-related QOL

Primary Care vs Oncologist

Grunfeld E et al. J Clin Oncol 2006; 24:848-55

Family

Practice

Cancer

Center

Recurrences 54

(11.2%)

64

(13.2%)

Deaths 29

(6.1%)

30

(6.2%)

SCEs 17

(3.5%)

18

(3.7%)

No difference in health-related QOL

Copyright © American Society of Clinical Oncology

Grunfeld, E. et al. J Clin Oncol; 24:848-855 2006

A: Health-related quality of life: Medical

Outcomes Study Short Form 36-

Item (SF-36) Physical and

Mental Component Summary

B: Depression and Anxiety

Conclusions

• For now, use ASCO or NCCN guidelines

– Document discussion and provide guidelines

• Use F/U to explore survivorship issues

– Most pts today will survive breast cancer

– make a checklist and review, keep in record

– Refer for problems

• Doing less is a hard sell but worth it

• Consider sharing care with colleagues

“Before I came here I was

confused about this topic.

Having listened to your

lecture I am still confused,

but on a higher level.”

Enrico Fermi,1938

Nobel Laureate in Physics

In the end it all

comes down to

this…

Mary, do you

think I need a

PET scan?

Thank

You