Beyond 5 years Francis F. Lopez, MD Medical Oncology

Bakit 5 years????

Risk of Recurrence

10 year over-all survival by stage

Outline  Cancer treatment-induced bone loss (CTIBL)  Overweight and obesity  Contra-lateral breast cancer  Cardiac Complications from Irradiation  Neurologic complications

Cancer treatment- induced bone loss

 Bone is a dynamic tissue undergoing resorption and formation throughout life resulting in a net bone balance  In osteoporosis, resorption usually exceeds formation with the net effect of bone loss, decreased strength, and an increased risk of fracture  Cause: hormone depletion promotes osteoporosis and increases the risk of fracture

 Hormone depletion (hypogonodal) state induced by cancer therapies  Premature menopause resulting from chemotherapy  Deliberate ovarian ablation  Hypoestrogenemia secondary to aromatase inhibitors (arimidex, femara and aromasin)  Chemotherapy

chemotherapy  Bone loss with chemotherapy extends to postmenopausal women, suggesting that chemotherapy has a direct effect on bone American Journal of medicine 114: , 2003American Journal of medicine 114: , 2003

Aromatase inhibitors (AI)  Women treated with AI were 2.5 times more likely to suffer a fracture compared to women treated with tamoxifen

Fracture Risk Following end of treatment fracture rates were similar in both groups (RR=0.98 ( ), p=0.5 J. Cuzick on behalf of ATAC/LATTE Trialists’ Group. Poster presented at 12 th Milan Breast Cancer Conference 2010

Major risk factors for osteoporosis and fracture  Prior fragility fracture (>40 years of age)  Age (>65 years)  Low bone mineral density (T-score < -2.5)  Family history of osteoporotic fracture  Vertebral compression fracture  Osteopenia apparent on x-ray film  Hypogonadism  Early menopause (before age 45)

Minor risk factors for osteoporosis and fracture  Rheumatoid arthritis  Low dietary calcium intake  Smoker  Excessive alcohol intake  Excessive caffeine intake (>4 cups/day)  Weight (<120 pounds)  Weight loss > 10% of weight at age 25

Diagnostic tests  Dual energy x-ray absoptiometry (DXA) scans at baseline (bone density)  Thoracic and lumbar spine x-ray to rule out vertebral fracture in patients with kyphosis, historical height loss > 6cm, acute incapacitating back pain syndrome, and in patients 65 years and older  Follow-up: DXA scans every 1-2 years

Treatment  “bone hygiene” measures: lifestyle modification that promotes bone health:  Calcium 1000mg per day  Vitamin D 800IU per day  Smoking cessation  modest alcohol intake (<2 units per day)  Increase exercise activity

Overweight and Obesity

Excuses for Weight Gain Masarap kumain TamadBusy

Ideal Body Weight  45.5 kg x (height in inches – 60)  Example: x (62 inches – 60)  x 2  = 50kg or 110 pounds  Overweight > 121 pounds  Obese > 132 pounds

Body Mass Index (BMI)  BMI = kg/m 2  Example: 141 pounds / 2.2 = 64kg  5’5” = 65 inches x 2.54 = 165 cm / 100 = 1.65 m x 1.65 m = 2.7  64/2.7 = 23.7 kg/m 2  Normal < 25  Overweight 25 to 29  Obese > 30

Obesity and breast cancer  Poor prognostic characteristics on diagnosis: larger tumor, grade III and more positive lymph nodes  Poor prognosis: affects over-all survival and disease free survival  Increased risk of contralateral breast cancer, loco-regional recurrence and other primary cancers

Diet and Exercise  Healthy Lifestyle:  Five or more servings (dakot o sandok) of 5 different kinds of fruits and vegetable (VF) per day  Physical activity (PA): Walking 30 minutes per day 6 days per week

Healthy Lifestyle and Mortality  High VF/high PA: 4.8%  Low VF/high PA: 10.4%  High VF/low PA: 10.7%  Low VF/low PA: 11.5%

10 year survival  High VF/high PA = 93%  Other groups: 86% to 87%  Therefore, gain 6% to 7% absolute risk reduction in mortality at 10 years high VF/high PA  Observed in both obese and non-obese

Contra-lateral Breast cancer

Incidence  From 1975 through 2006:  339,790 diagnosed with (first) breast cancer  12,886 or 4% developed invasive breast cancer in the contra-lateral breast 40% occurred within the 1 st to 4 th year of the first breast cancer diagnosis 40% occurred within the 1 st to 4 th year of the first breast cancer diagnosis 30% between the 5 th to 9 th year 30% between the 5 th to 9 th year 30% 10 years or later 30% 10 years or later

Age when first breast cancer was diagnosed  19% before age 45  51% between 45 and 64 years old  30% between 65 and 84 years old

Estrogen receptor (ER) status when first breast cancer was diagnosed  60% were ER+  24% were ER-  16% were unknown

Estrogen Receptor in 2 nd breast cancer  First ER+ breast cancer 67% were still ER+ 67% were still ER+  First ER- breast cancer 40% were ER+ 40% were ER+ 43% were ER- 43% were ER-

Prophylactic mastectomy (PM)  Majority not high risk and 13% were high risk (gene mutation)  Low risk group: Contralateral breast cancer  No PM (0.5%)  PM 0%  Low risk group: Distant metastasis  No PM 7% (2 to 3 years)  PM 4%

Cardiac Complications from Irradiation Neurologic Complications

 Irradiation to the left breast: not associated with higher risk of cardiac death up to 20 years  Cognitive and memory loss (chemo brain) resolves a few years after treatment

Thank you!