Supportive Care During and After Treatment Julie R. Gralow, M.D. Director, Breast Medical Oncology Jill Bennett Endowed Professor of Breast Cancer Professor, Global Health University of Washington School of Medicine Fred Hutchinson Cancer Research Center Seattle Cancer Care Alliance

Breast Health Global Initiative (BHGI) 5th Global Summit (2012) Supportive Care and Quality of Life http://portal.bhgi.org/ 3 resource-stratified guidelines: Long-term Follow-up Care and Survivorship Treatment-related Supportive Care Pain and Palliative Care

Supportive Care During Treatment for Breast Cancer Cardoso F et al: The Breast 22: 593-605, 2013 Providing supportive care during treatment can help: Manage treatment-related toxicities and symptoms Improve adherence to treatment recommendations Address psychological and spiritual needs of patients

Supportive Care During Treatment for Breast Cancer Example: Gastrointestinal Toxicities Cardoso F et al: The Breast 22: 593-605, 2013 Basic: Oral and/or IV hydration Basic anti-emetics (nausea drugs) Basic anti-diarrheals, stool softeners, laxatives Mucositis (mouth inflammation) support: ice chips Limited: Stomach acid blockers (5HT3 blockers, H2 antagonists, antacids) Stimulant laxatives Topical agents for mucositis Enhanced: Enhanced anti-emetics (NK-1 antagonists) Enhanced stomach acid blockers (PPIs) Opioid analgesics for severe mucositis

Supportive Care During Treatment for Breast Cancer Example: Hematologic Toxicity and Infection Cardoso F et al: The Breast 22: 593-605, 2013 Basic: Broad spectrum antibiotics Limited: Antifungals Red blood cell transfusion Enhanced: Granulocyte (white blood cell) growth factors Platelet transfusion Iron therapy

Supportive Care During Treatment for Breast Cancer: Psychosocial Support Psychosocial supportive care should be available soon after diagnosis and during treatment Majority of disease and treatment-related psychosocial issues occur at this time Major impact on roles at home, work and in community

Supportive Care During Treatment for Breast Cancer Cardoso F et al: The Breast 22: 593-605, 2013 Summary: Treatment-related toxicities may be overlooked in LMICs Health systems implementing supportive care programs should devote resources to: Educating professionals, patients and communities about supportive care services Provide resources to support monitoring of treatment-related toxicities Provide psychosocial support

Breast Health Global Initiative (BHGI) 5th Global Summit (2012) Supportive Care and Quality of Life http://portal.bhgi.org/ 3 resource-stratified guidelines: Long-term Follow-up Care and Survivorship Treatment-related Supportive Care Pain and Palliative Care

U.S. National Cancer Institute Office of Cancer Survivorship Established in 1996 http://cancercontrol.cancer.gov/ocs Recognition of increasing number of individuals surviving cancer for long periods of time Dedicated to enhancing length and quality of life of cancer survivors Supports research that addresses long- and short-term effects of cancer and its treatment

Long-term Effects of Breast Cancer on Emotional and Physical Well-Being Fatigue/decreased energy Reproductive hormone effects: estrogen depletion (menopausal symptoms) Infertility Sexuality/body image, sexual function Lymphedema Depression, anxiety, fear of recurrence Cognitive dysfunction Pain/neuropathy Relationships, employment Etc….

IOM 2005 Report on Cancer Survivorship: Essential Components of Survivorship Care Recurrence, second cancers, and assessing medical and psychosocial late effects Recurrence, new cancers, late effects Hewitt 2006, p2, para 7- Box ES-1 Prevention Surveillance Treating the consequences of cancer and its treatments Intervention Coordination Interdisciplinary coordination between specialists and primary care providers Quality cancer survivorship should include 4 essential components within a delivery system that enables access to comprehensive and coordinated care: Prevention of recurrent or secondary cancers, and of other late effects due to the cancer or therapy Surveillance for cancer spread, recurrence, or second cancers; as well as vigilance for medical and psychosocial late effects Intervention and management of symptoms and consequences of cancer and any effects related to cancer treatment. For example, medical problems such as sexual dysfunction or lymphedema that may arise after certain therapies Coordination and teamwork among specialists and primary care providers to ensure that all the cancer survivor’s needs are being met Reference: Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington DC; The National Academies Press; 2005. Hewitt 2006, p2, para 7- Box ES-1 Hewitt M, et al. eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington DC; The National Academies Press; 2005

BHGI: Supportive Care After Curative Treatment for Breast Cancer (Survivorship Care) Ganz PA et al, The Breast 22: 606-615, 2013 Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications In LMICs supportive care services are frequently limited Survivorship care is a distinct aspect of cancer treatment that should be integrated into all breast cancer care programs

Healthy Lifestyle Choices After a Breast Cancer Diagnosis Can… Reduce risk of cancer recurrence and second cancers Help manage early and late side effects of treatment Improve overall health and well-being

Team Survivor Northwest An Exercise and Fitness Program for Women Affected by Cancer Seattle, Washington, USA Established 1995 Weekly workouts Twice weekly walks Running Hiking Biking Yoga and tai chi Dragon boating Swimming Annual fitness retreat

A Model for Providing Survivorship Care Seattle Cancer Care Alliance Women’s Wellness Follow-up Clinic Patient population: breast and gynecologic cancer survivors more than 5 years from diagnosis and without recurrence Providers: Nurse Practitioners Services provided: Screening for cancers Physical therapy Nutrition Psychology and social services Reconstructive surgery Genetic counseling Management of menopausal symptoms Screening for osteoporosis, cardiac risk factors Education (newsletter, lectures, retreats)

BHGI: Supportive Care After Curative Treatment for Breast Cancer (Survivorship Care) Ganz PA et al, The Breast 22: 606-615, 2013 Summary: Survivorship care is intended to maximize health and well-being, while monitoring for recurrence and late-effects of treatments Health professionals must be prepared to educate women about issues they are likely to experience, and to address specific problems in order to enhance recovery, improve functioning, and maximize adherence to medications The most effective way to expand survivorship care in LMICs is through involvement of primary care networks and community-based programs

Supportive Care During and After Cancer Treatment Partnering with Patient Advocates