Breast Cancer Surveillance Guidelines & Wellness Recommendations

Lynne P Clark MD F.A.C.S.Tacoma, Washington

March 13, 2012Fourth Annual Pierce County Cancer Survivorship Conference

Objectives Review recommendations for

surveillance type of surgery/ stage of your

cancer Review opportunities for wellness to

help prevent recurrence of breast cancer

Survivorship goals Prevention tips

Surveillance How it was found Type of surgery performed What stage your cancer is Type of adjuvant therapy

Chemotherapy Hormonal therapy

Breast conservationHow was your cancer found? Screening mammogram

Continue diagnostic mammograms every six months for the first two years and then diagnostic mammograms annual for five years

Self found breast mass/not found on mammogram More difficult situation, continue with diagnostic

mammograms but may additional studies Tomosynthesis, MRI, BSSI

Self breast exams monthly report changes

After mastectomy NO reconstruction

Typically no need for mammograms

Monthly self chest exams critical

After reconstruction Implants -- saline Implants -- silicone

need MRI to look at integrity of silicone implants every three years

Flap ? need periodic MRI to look behind

the flaps -- not standard of care to offer this

Breast imaging MRI of the breast Breast specific sestabimi – BSSI Tomosynthesis Whole breast ultrasound Thermography ???

Stage of cancer Stage 1 - limited to breast Stage 2 – larger tumors or

involved nodes may require additional studies

annually PET, CXR, BONE SCANS, MRI, CT

scans, LABS Stage 3 additional metastatic

studies annually Stage 4 additional metastatic

studies annually

What treatment you had Breast conservation with radiation

Follow up q 6 months with surgeon and radiation oncologist

Mastectomy/reconstruction Breast surgeon for surveillance q 6 months to

annually Chemotherapy

Oncologist follow q 3 months first few years and then q 6 months labs to follow your blood levels

Type of adjuvant therapy Chemotherapy

Check labs serially DEXA scans

Hormonal therapy Tamoxifen

Gynecological exams yearly Monitor for abnormal bleeding DVT prevention

Aromatase Inhibitor DEXA scan baseline and yearly

Need for physical therapy After surgery ? Range of motion of upper body After radiation ? Range of motion of upper

body Breast Edema Arm edema Prevention of lymphedema

Physical therapist Lymphedema therapist

GOAL is to get back to original level of functioning

Vitamin D supplementation Minimal replacement of 2000 IU

daily Check vitamin D 25OH level in

blood but many insurances companies won’t pay for it

Vitamin D makes breast cells more resistent to toxins, decrease ability for breast cancer cells to grow and boosts immune system

Opportunities for wellness Dietary recommendations ( Tricia Sinek

talks) Exercise Body weight (Body Mass Index) Social habits – tobacco and alcohol ingestion Sleep habits Stress Family issues Intimacy issues

Dietary recommendations Vegetables variety at each meal

Phytochemicals/phytoestrogens Each color is a potent natural medicine Eat the rainbow daily Fills you up, adds elimination , remove toxins 5-8 servings a day Cruciferous vegetables most powerful(40% reduction)

Fruits 3-4 servings a day Berries, grapes, apples antioxidants

Red meats no more than 18 oz a week rich in saturated fats, hormones

Fish 2-3 times a week Omega 3 fatty acids

Healthiest type of fat Lowers risk of metastases

Legumes - one serving daily inhibits reproduction of cancer cells anti angiogenesis properties

Whole grains- 3 or more servings a day fiber , antioxidants, phenols 25 gm/day (54% reduction)

Nuts and seeds – one serving daily Omega 3 fatty acids, , phytoestrogen

Exercise 30 minutes five days a week aerobic activity

reduces risk of recurrence of breast cancer by 30-50 %

Strength training a few days a week Start slow, listen to your body, make it part of

your day 15 minutes a day then add 5 minutes every couple of weeks, add weights

Join gym Get friends to commit with you Even during chemotherapy can be helpful!!

Body Weight Maintain or strive for BMI of under 25 Body fat produces estrogens and proteins that

cause inflammation and increase blood insulin levels which encourages cancer cell growth

Find a program that will help YOU Hospital based programs with dieticians Weight watchers Spark people online programs.

Overweight women higher risk of recurrence and of dying from breast cancer

Body habits Tobacco

now associated with breast cancer Avoid second hand smoke

Alcohol moderation 1-2 times a week 1 drink increases risk 11% 2 drinks increase risk by 22 %

Sleep Habits Natural rhythm of nature

Go to bed before 10 pm Get up before 6 am

Hormonal fluctuations will be optimal

Melatonin levels will be highest Avoid light in your bedroom

Stress reduction Family, job, changes in your body

form, hormonal changes in your body

Find out what you can do to alleviate your stress Counseling/communicate with family

members Remove stressors!!!

Change job Separation / abusive relationships

Meditation/exercise/music/dancing…..

Family situation How is the rest of your family dealing with your disease Is it a topic discussed or avoided? Women can be the dominant figure in the family and

fear of loss of the woman can bring a lot of negative interactions with other family members out of FEAR

Make sure you communicate with each other Have people take responsibility for chores in the house Make family time

This has to be agreed upon and maintained by all Individual or family counseling

Intimacy issues Change in your body form/deformity

Is it your problem or your partner’s problem??? Weight gain – work with lifestyle coach Vaginal dryness – estrace cream can be

prescribed Loss of libido – short course of testosterone ???estrogen replacement QUALITY OF LIFE!!!!!!

Survivorship goals Write down your own goals Prioritize them Change one thing a month Revisit it semiannually Visit with professionals that can

help you

YOUR SUVIVORSHIP PLAN DIAGNOSIS: WORKUP: SURGERY: CHEMOTHERAPY: RADIATION: PHYSICAL THERAPY: ANTI ESTROGEN TREATMENT: VITAMIN D THERAPY RECOMMENDED: DEXA SCAN EVALUATION:

Survivorship plan -2 MAMMOGRAM FOLLOWUP

SCHEDULE MRI NEEDED IF HAD BIOPSY? LYMPHEDEMA PREVENTION IF

NODES REMOVED CURRENT BMI GOAL < 25 EXERCISE: CURRENT? GOAL 30

MINUTES 5 DAYS A WEEK

Survivorship plan 3 HEALTHY EATING: ALCOHOL INTAKE ONLY ONE OR TWO DRINKS A WEEK ABSENCE FROM TOBACCO OR SECOND HAND SMOKE WEIGHT REDUCTION PREVENTION OF OSTEOPOROSIS STRESS REDUCTION FAMILY SITUATION FEMININITY OR INTIMACY ISSUES/VAGINAL DRYNESS COUNSELING SPIRITUAL PERSONAL NEEDS /SATISFACTION

Dr. Clark’s TIPS for Prevention P - plants foods daily R - reduce alcohol intake E - exercise 30 minutes five days a week V - vitamin D 2000 IU or more daily E - examine your breasts monthly N - No tobacco or secondary smoke T - take care of yourself first /be an example to others I - ideal body weight less than 25 O- olive oil in your diet (mediterranean diet) decreases mammographic density suppress HER2 N - eat the RAINBOW

Our community is very rich in organizations dedicated or involved in breast cancer and prevention

Seek out these programs Wellness programs Support groups Hospital based programs

Be a warrior goddess!!!!

SPARKPEOPLE.COMAMERICAN CANCER SOCIETYSUSAN G KOMEN ORGANIZATIONBREAST CANCER RESOURCE CENTERPERSONAL TRAININGFHS ONCOLOGY DIETICIANMULTICARE DIETCIAN,NATIONAL COALITION FOR CANCER SURVIVORSHIPWaking the Warrior Goddess by Christine Horner MD

Final thoughts We cannot do everything at once

but we can do something at once!

A vision must be followed by a venture. It is not enough to stare up the steps we Must step up the stairs.