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Breast Cancer 101 for Co-Survivors

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Breast cancer basics for co-survivors

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Breast Cancer 101 for Co-Survivors

  1. 1. Breast Cancer 101 for Co-Survivors Deanna J. Attai MD, FACS David Geffen School of Medicine, UCLA @DrAttai
  2. 2. • Patient is overwhelmed • Needs your help, support, stability • You are overwhelmed • New terminology, new doctors, many decisions to make The Co-Survivor’s Challenge
  3. 3. • Remember to breathe!!! • Breast cancer is a “mental emergency” (not medical) • You have time to gather information, make decisions
  4. 4. • The treatment team • Understanding the pathology report • Treatment options and side effects • Unique considerations: fertility, genetics • Metastatic disease • Survivorship • How to help
  5. 5. • Cancer physicians: • Breast surgeon, medical oncologist, radiation oncologist • Primary care physician, gynecologist • Nursing: • Nurse Navigator, oncology nurses • Psycho-Social Support • Social Work, therapist, spiritual care • Other Clinicians • Genetics, nutrition, physical therapy, research staff, other Multidisciplinary Team Approach
  6. 6. “2.5cm grade 3 invasive ductal carcinoma ER/PR negative, Her2/neu not over-expressed” Breast cancer in young women more likely higher stage, higher grade, more aggressive cell type Understanding the Pathology Report
  7. 7. Cell Type: • Ductal • ~80-85% of all breast cancers • Lobular • Less likely to form a well defined mass • Treatment is based on stage, biology features – not cell type Understanding the Pathology Report
  8. 8. 0: Ductal carcinoma in-situ / DCIS / non-invasive I: Tumor < 2cm, no spread to lymph nodes II: Tumor 2-5 cm or spread to underarm nodes OR – Tumor >5cm, no spread to lymph nodes III: Tumor > 5cm and spread to multiple underarm nodes OR – Tumor growing through skin or muscle IV: Spread outside breast: liver, lungs, brain, bone ~2.5cm = 1 inch Cancer Stage: Tumor size, Spread
  9. 9. Measure of cell appearance Higher grade tumors may have more aggressive behavior • Grade 1 – low grade - well differentiated • Grade 2 – intermediate grade – moderately differentiated • Grade 3 – high grade – poorly differentiated Cell Grade
  10. 10. Estrogen / Progesterone Receptors • Estrogen binds to receptor, signals cell growth • ER+(positive): cells have receptor, can be stimulated by estrogen • ER- (negative): cells have lost receptor, don’t respond to estrogen
  11. 11. Her2/neu • Protein on cell surface • Associated with more aggressive growth • Her2/neu positive = “over-expressed”
  12. 12. • May include: • Blood tests • Body imaging to look for metastatic disease (Stage II – III) • Echocardiogram (ultrasound of heart) before chemotherapy or targeted therapy • Genetic testing • Fertility assessment Pre-Treatment Evaluation
  13. 13. • ~10-15% of breast cancers linked to DNA mutation • More likely in younger women even w/o family history • BRCA 1/2 genes and many others • Results may impact treatment • Consider bilateral mastectomy, removal of ovaries • Results may impact other family members Genetic Testing
  14. 14. “I didn’t know I wanted kids until you told me I might not be able to have them” • Consider before chemotherapy: • Reproductive endocrinologist • Egg harvesting +/- embryo • Lupron during therapy Fertility
  15. 15. Pregnancy after Breast Cancer • Retrospective, 1207 patients • History of BC, became pregnant after diagnosis • Matched for ER, nodal status, adjuvant therapy, age at diagnosis < or > 35 J Clin Oncol 2013;31(1): 73-79
  16. 16. Pregnancy after Breast Cancer POSITIVE Study • Pregnancy Outcome and Safety of Interrupting Therapy for Women with Endocrine ResponsIVE Breast Cancer • Evaluate safety, pregnancy outcomes w/interruption of endocrine therapy • Patients complete 18-30 months of endocrine therapy • Stop endocrine therapy for up to 2 years for pregnancy, delivery, breast feeding or failure to conceive, then restart www.clinicaltrials.gov ALLIANCE #A221405
  17. 17. • Local (breast) –breast and lymph node surgery, radiation • Remove the main tumor • Reduce chances of it growing back in the breast • Systemic (whole body) – chemotherapy, hormone blockers • Reduce likelihood of cancer cells surviving an growing outside breast • Liver, lung, bone, brain most common areas of spread Breast Cancer Treatment
  18. 18. • Outpatient surgery, can be combined w/reduction, lift • Potential for change in breast shape, size, numbness of skin • 2nd surgery may be required to get clear margin • Radiation treatment necessary • If cancer comes back in breast, usually need mastectomy • Continued surveillance with mammogram, other imaging Lumpectomy
  19. 19. • Removal of entire breast • 1-5 day hospital stay; drain tubes 7-10 days • Nipple sparing may be an option • If reconstruction: 2-3 procedures may be needed • Radiation if larger tumor, spread to nodes • 1-5% chance of cancer returning at site • Does not keep cancer from spreading • Permanent numbness, post-mastectomy pain syndrome Mastectomy
  20. 20. • Does not keep cancer from spreading • Does not keep cancer from coming back • Double complication rates (20-40%) • ~30% long term body image, sexual function issues • Most appropriate if BRCA gene mutation Contralateral Prophylactic Mastectomy - CPM
  21. 21. • Sentinel node biopsy / dissection: removal of 1-4 underarm nodes • Axillary node dissection may be recommended if cancer has already spread to underarm nodes • Potential complications: numbness of the underarm / back of arm, lymphedema (long term swelling), pain, limitation in movement • Lymphedema: • 5-8% with sentinel node biopsy • 15-30% with axillary node dissection • Radiation therapy also adds to risk of lymphedema Lymph Node Surgery
  22. 22. • Almost always recommended after lumpectomy • After mastectomy if large tumor, spread to nodes • 5 days/week, 3-6 weeks • Potential side effects: • Skin sensitivity, occasionally mild burn • Change in skin color, skin thickening, long term scarring • Fatigue during treatment Radiation Therapy
  23. 23. • Usually need mastectomy if cancer returns after lumpectomy-radiation • Radiation can complicate future reconstruction Radiation Therapy
  24. 24. • Spread to lymph nodes or other areas of the body • More aggressive forms of cancer even with no spread • Triple negative, Her2/neu positive, Elevated Ki67, advanced stage • Additional genomic testing (Oncotype Dx, Mammaprint) may be used to clarify need for chemo • Neoadjuvant (before surgery) or adjuvant Systemic / Whole Body Therapy Chemotherapy
  25. 25. • Given through intravenous line, port may be recommended • Treatment schedule, number of treatments varies • Common side effects: • Fatigue Hair Loss • Neuropathy (nerve damage) Nausea / vomiting • Poor appetite Mouth sores • Decreased blood counts/infection Infertility Systemic / Whole Body Therapy Chemotherapy
  26. 26. • Trastuzumab (Herceptin) and Pertuzumab (Perjeta) • Targeted antibody therapy to Her2/neu protein • Given with standard chemotherapy, often before surgery • Fatigue • Rash • Diarrhea • Heart failure (uncommon, usually reversible) • Trastuzumab continues every three weeks for one year Systemic / Whole Body Therapy Targeted Therapy
  27. 27. • Tamoxifen • Blocks estrogen receptor, pre- or post-menopausal • 5-10 years, may be combined w/lupron • Potential side effects: • Hot flashes, mood swings, depression • Vaginal discharge, ovarian cysts, irregular bleeding • Blood clots (more common if overweight, smoker) • Uncommon – uterine cancer • Some antidepressants might interfere with action Systemic / Whole Body Therapy Hormonal Therapy
  28. 28. • Aromatase Inhibitors • Blocks production of estrogen • Postmenopausal, 5-10 years • Potential side effects: • Hot flashes, mood swings • Vaginal dryness • Joint and bone pains, bone loss / osteoporosis • Decreased libido • “Chemobrain” Systemic / Whole Body Therapy Hormonal Therapy
  29. 29. • ~30% of patients stop treatment due to side effects • May have significant effect on body image, sexual relations • Discuss w/ partner, physician • Role for acupuncture, meditation, pelvic floor physical therapy Systemic / Whole Body Therapy Hormonal Therapy
  30. 30. • Spread outside of the breast – Stage IV • Common sites: lungs, bone, liver, brain • Not curable but often treatable • Treatment can include chemotherapy, targeted therapy, and/or endocrine therapy • Treatment may include radiation therapy, surgery • Clinical trials / research Metastatic Breast Cancer
  31. 31. • Focus shifts from active treatment to surveillance, health maintenance, management of side effects • Congratulations – you made it! • “Go live your life” Survivorship Life After Treatment
  32. 32. • Can be a time of intense stress • Role in family, relationship, work, school has changed • Pressure to get back to “normal” • Body image, concern about recurrence, ongoing pain or other side effects Survivorship Life After Treatment
  33. 33. • ”Survivor” not universally embraced • Some can’t stand the pink • Battle metaphors (warrior, fighter) • Pinkwashing Survivorship Life After Treatment
  34. 34. • Limited only by your time and imagination • Transportation and company for appointments • Help with household chores • Picking up groceries or prescriptions • Cooking meals • Child care How To Help During and After Treatment
  35. 35. Reinforce Healthy Habits
  36. 36. • Everyone wants and needs different things • Be truly present • Let the patient direct you • Don’t forget self-care

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