Treatment of Breast Cancer after Surgery. What Primary Care Providers Need to Know

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1 Treatment of Breast Cancer after Surgery What Primary Care Providers Need to Know

2 Disclosure of Potential for Conflict of Interest Dr. Chris Ogaranko Treatment of Breast Cancer after Surgery FINANCIAL DISCLOSURE Grants/Research Support: None Speaker bureau/honoraria amounts: None Consulting fees: None Other: None

3 Learning Objectives Understand the usual sequence of postsurgical breast cancer treatments Explain the rationale for these treatment, their basic indications, benefits and toxicities Recognize opportunities for important primary care input during treatment

4 Breast Cancer Treatment Rationale Treatment after complete surgical resection to kill micrometastases; decrease cancer recurrence and improve survival Chemotherapy before surgery if the tumour is large (>5cm) +/- advanced lymphadenopathy to improve resection

5 Breast Cancer Treatment Timeline

6 Who Gets Chemo? Bottom Line (with exceptions): Node + and those > 1 cm get chemo. Node and those < 1 cm (especially cm) may get chemo.

7 Who Gets Chemo?-Tools Adjuvant! Online what is the risk for recurrence and death? Age and health status Lymph node status Size of tumour ER status

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9 Genetic Testing

10 Common Chemotherapies FEC-D regimen: fluorouracil, epirubicin, cyclophosphamide x 3 cycles, and then docetaxel x 3 cycles Fit, higher risk patients TC regimen: Taxotere/docetaxel with cyclophosphamide x 4 cycles Less fit, lower risk patients Both are 21 day cycles

11 Toxicities (short-term) General: fatigue, myalgias, allergic, fluid retension Skin/membranes: rash, stomatitis (Candida), nails, alopecia GI: anorexia, N/V, diarrhea/constipation, colitis GU: vaginitis, cystitis, amenorrhea Marrow: myelosuppression, febrile neutropenia, sepsis Cardiac: CHF Peripheral neuropathy

12 Long-term Complications Of Chemotherapy Premature Menopause especially if older than 40 Cardiac dysfunction Cognitive changes chemo. brain poorly understood Second cancers - AML, MDS Peripheral Neuropathy Fatigue Psychological depression, insomnia

13 Who Gets Radiation? Post-lumpectomy: all Lowers risk of local recurrence (15-20% ARR) Improves overall survival (~ 5% ARR) 5 days per week for 3 5 weeks Usually starts one month after chemotherapy

14 Who Gets Radiation? Post-mastectomy: indications variable, but for sure if: tumor > 5cm at least 4 +ve LN s (and often for 1-3 nodes) +ve deep margin

15 Short-Term Radiation Side Effects Arm edema (especially axillary RT) Pneumonitis (transient; <5%) Fatigue Skin reactions

16 Long-term Complications Of Radiation Lymphedema (arm, breast, chest) Brachial Plexopathy Cardiac Dysfunction Second Cancers (1% - sarcoma, lung esophagus)

17 Endocrine Therapy for ER/PR+ Premenopausal: Tamoxifen for 5 years (will this become 10 years?) Postmenopausal: Aromatase Inhibitors (AI s) preferred e.g. letrozole, exemestane Different strategies for AI use Up front After 2-3 years of tamoxifen Extended adjuvant use after 5 years tamoxifen Started after radiation completed

18 Current Endocrine Strategies Postmenopausal Women Tamoxifen AI 0 Yrs **NEW: 10 years tamoxifen may be better** 5 Yrs 10 Yrs

19 Side Effects Tamoxifen: watch out for interactions a) Short-term: N/V, vaginal, hot flashes b) Long-term: DVT, uterine CA and cataracts Aromatase Inhibitors: a) Short-term: same plus arthralgias (lots) b) Long-term: lipids, bones,?ihd

20 Herceptin Herceptin/trastuzumab ~ 20% breast cancers overexpress HER2 Indication: tumour > 0.5 cm or node + no CHF (EF > 55%) Given i.v. q3 weeks for one year Main toxicity is cardiac (MUGA q3 months)

21 Interactions with Breast CA Treatment Chemo: warfarin, metronidazole, thiazides, phenytoin Herceptin: few Tamoxifen: paroxetine, fluoxetine, ketaconazole, trazodone, estrogen Aromatase Inhibitors: estrogen

22 Primary Care Issues Soy and flax seem to be OK Exercise may lower recurrence Timing matters for influenza and pneumococcal immunizations on chemo. Don t give live virus vaccines on chemo. Calcium (dietary) and vitamin D for bones Screen for, and treat psychological issues

23 Take Home Pearls Breast cancer treatment is a long journey with a variety of therapies to reduce the risk of recurrence and death Primary care providers can support patients, monitor/treat issues like psychological distress, assist with symptom management and recognize potential complications Consider interactions with cancer treatments