Breast cancer survivors face a variety of potential long-term side effects from their treatment. These include cardiac dysfunction from chemotherapy drugs like anthracyclines and trastuzumab, neuropathy from taxanes, bone loss from aromatase inhibitors and premature menopause, neurocognitive effects from chemotherapy, sexual dysfunction and infertility from hormonal treatments, and risk of secondary malignancies from chemotherapy drugs like anthracyclines. Careful screening and monitoring of survivors can help identify and manage these late effects to improve quality of life. Lifestyle factors like exercise and diet also impact long-term health after breast cancer.

1. Breast cancer survivorship
Earlyand late toxiceffectof adjuvant
treatmentof breastcancer

2. What do you think of when you
your breast cancer patient says

3. Are there problems you should
consider and put a plan to care so
as you and your patient can
celebrate

4. The Definition of a Cancer Survivor
(National Coalition for Cancer Survivorship)
“A ‘Cancer Survivor’ is defined by the National
Coalition for Cancer Survivorship as anyone
with a history of cancer, from the time of
diagnosis and for the remainder of life, whether
that is days or decades”

5. Acute Extended Permanent
Three Seasons of Survivorship

6. With advances in treatment of breast
cancer , there is increasing in numbers of
breast cancer survivors
There are an estimated 2.5 million breast cancer survivors in
the United States
90
81
74
0
20
40
60
80
100
5 10 15
Patients
Alive
(%)
Years After Diagnosis
Is It Benefit Or Problem
???!!!!!!!!

7. Hot flashes/night sweats
Sexual dysfunction
Cognitive
dysfunction
Depression
Other 2nd-malignancy
(ie, endometrial cancer)
Chronic fatigue
Cardiovascular effects
Osteoporosis/
bone fractures
Early breast cancer
treatments including:
Radiation therapy
Chemotherapy
Monoclonal antibody
Hormonal therapy
Weight gain
Genitourinary symptoms
Spectrum of Potential Side
Effects
Arthralgia/joint symptoms

8. 1-CARDIAC DYSFUNCTION:
Causes
Trastuzumab Anthracyclines
Late-onset, occurring at
least 1 year after
completion of therapy.
Late-onset cardiotoxicity
tends to be irreversible,is
related to cumulative
anthracycline dose, and
may reflect a variety of
intracellular mechanisms
including free radical
formation.
Typically occurring during
time of medication
administration, and
generally reversible with a
hold in therapy and use of
cardiac medication.
Trastuzumab leading to
temporary cellular
changes.

9. Management and Prevention:
1-Prechemotherapy identifıcation of individuals at risk of
Cardiac toxicity would improve selection of chemotherapy regimens.
Clinical risk factors predictive of cardiotoxicity:
age, pre-existing hypertension, low baseline left ventricular ejection
fraction, and elevated body mass index.
2-Novel imaging, including echocardiographic techniques with greater
sensitivity to discern subclinical cardiac dysfunction.
3-Cardiac biomarkers, may have even more promise as predictive tools.
There is no clear role for routine screening for left ventricular dysfunction
in breast cancer survivors in the absence of clinical symptoms, however,
for survivors with suspected cardiac toxicity, imaging with
echocardiography and referral to cardiology are strongly recommended

10. 2-NEUROPATHY (Peripheral sensory or motor neuropathy):
*Cause :microtubule inhibitors such as taxanes
*Symptoms: both paresthesias and pain, which can
signifıcantly affect a patient’s quality of life.
*Risk Factors :agent selection, dose, schedule, and
comorbidities.
*Management:
1-Dose modifıcation and treatment delay.
2-Glutathione, acetyl-L-carnitine,and alpha-lipoic acid.
3-Gabapentin or venlafaxine
Ultimately, best management of peripheral neuropathy
would be avoidance of the toxicity through identifıcation
of individuals at greatest risk.
Pharmacogenomic analysis has identifıed single
nucleotide polymorphisms (SNPs) associated with
the development of moderate to severe peripheral
neuropathy after paclitaxel exposure

11. 3-BONE LOSS:
Bone loss
Causes Symptoms Management
1-Premature
menopause.
2-Breast cancer
therapies,
specifıcally
aromatase
inhibitors
1-Bone pain
2-Increased
fracture risk
1-Screen at-risk
individuals by dual-
energy x-ray
absorptiometry every 1
to 2 years
2-Consider initiation of
bisphosphonate therapy
3-Pursuing weight-
bearing exercise and
adequate calcium and
vitamin D.

12. 4-NEUROCOGNITIVE DYSFUNCTION:
“chemo-brain”
- 75% of women who receive chemotherapy will report a change in cognitive
function in the 2 years after treatment.
-Patients typically describe problems with attention, memory ,and
concentration.
-The etiology of cognitive dysfunction is likely multifactorial; although
exposure to chemotherapy may contribute, other factors, including other
modalities of treatment (surgery, radiotherapy, endocrine therapy), supportive
care medications, menopausal symptoms, anxiety, depression, fatigue, or
other comorbid conditions.
-Patients may be especially sensitive to neurocognitive effects of
chemotherapy, including those of advanced age or lower cognitive reserve
,genetic polymorphisms in susceptibility genes, including apolipoprotein E
(APOE) and catechol-O-methyltransferase (COMT) may identify individuals
with vulnerability to cognitive dysfunction after chemotherapy.
There is interest in whether prophylactic or therapeutic interventions,
including the psychostimulant modafınil,fluoxetine,or structurel
cognitive behavioral therapy, may improve symptoms.

13. 5-OVARIAN FAILURE: PREMATURE MENOPAUSE,
INFERTILITY, SEXUAL DYSFUNCTION:
I-Sexual Dysfunction Symptoms:
*40% to 100% of cancer survivors report some form of sexual dysfunction
(ie, vaginal dryness, painful intercourse)
*Multiple dimensions:
Psychological/body image
Hormonal treatment effects
*Specifıc interventions may include vaginal lubricants, avoidance of
concomitant medications which decrease libido, and counseling with a
sexual health specialist
Vaginal Dryness
Non-estrogenic vaginal lubricants
Vaginal estrogens (Cream or ESTRING)
Pilocarpine
Vaginal Testosterone Cream

14. II-Infertility and premature menopause:
Although the majority of women may experience temporary
amenorrhea, in many, ovarian function will return in the months
following completion of treatment.
However, a subset will experience permanent chemotherapy
induced ovarian failure, with the risk of permanent
menopause increasing with age and modulated by chemotherapy
type and duration.
Pretherapy referral to a fertility specialist for a
discussion of fertility preservation may help alleviate
concerns.
Assisted reproductive technologies may be considered
for patients facing infertility after treatment, although
there are theoretical concerns about ovarian
stimulation in the setting of hormone receptor–positive
cancer.

15. Symptoms of premature menopause:
-Chemotherapy can induce ovarian failure
-Hormone therapy can exacerbate vasomotor symptoms
-Hot flashes and sleep disturbances are common
-May lead to additional physical and psychosocial symptoms
including mood lability
Gabapentin 300 mg
Gabapentin 900 mg

16. 6-SECONDARY MALIGNANCY:
Heamatologic malignancies
Mylodysplasia(MDS) AML
Topoisomerase II–targeted agents
(anthracyclines), present within 5 years
of exposure, may not be preceded by
MDS, and may have abnormal
cytogenetics of 11q23.
Alkylator (cyclophosphamide)
related malignancies present after a
longer duration of time, may be
preceded by MDS, and may have
cytogenetic abnormalities of
chromosomes 5 and 7.
Adjuvant regimens which replace anthracycline with a taxane have
demonstrated slightly decreased rates of secondary myeloid
malignancies, and could be considered in a situation where risk of
myeloid malignancy is a signifıcant concern.

18. Take Home Message