1. Breast SSG Education Event Anglia Cancer Network 10.2.2012 Sally Donaghey Macmillan AHP Lead sally.donaghey@suffolk.pct.nhs.uk

2. IPx People affected by cancer need information that is timely, relevant, and supported through conversations with health professionals to enable them to make decisions In 2004, National Audit Office found that nearly 40% of cancer patients did not receive written cancer information In 2010, the National Cancer Patient Experience Survey showed information provision has improved but some way to go.

3. IPx In 2007 Cancerbackup defined Information Prescriptions as: “A source of personalised information that lays out clearly and simply the salient points about an individual’s consultation with a healthcare professional about their diagnosis, treatment and/or care plan and points the way to other relevant sources of high-quality information and support. It is designed to improve the dialogue between patients and health professionals and enhance the valuable face-to-face time within consultations”.

4. Ipx – Pathway to Personalisation

5. IPx Rehab section: http://www.nhs.uk/ipg/Pages/IPCreate.aspx?conditionid=880http://www.nhs.uk/ipg/Pages/IPCreate.aspx?conditionid=880

6. IPx Benefits –Better communication –Available to patients and carers –Access information at own pace –Reduced information ‘overload’ –Integration with information centre –Access to local service information –Clinical teams are able to personalise information for patients –Access to a range of quality assured information through a structured approach –Formalising the process of information provision to evidence best practice e.g. Peer Review Measures –Reduced time spent producing in- house patient information leaflets Barriers –Local views –Format –Printers –Succession planning

7. Role of Diet in Breast Cancer Survival Prof Anne-Marie Minihane - UEA Dietary strategies to delay onset of morbidity/ morbidity and compression/life extension Evidence on the relationship of diet and cancer? –We do not know enough to say that diet effects cancer – limited RCT’s –Same advice as general population –Main areas of evidence AlcoholFats Weight gain/BMI Soy isoflavones

8. Role of Diet in Breast Cancer Survival Imperial College London - 2008 report of the updated evidence on food, nutrition and physical activity in relation to the prevention of breast cancer. 2010 update - body mass index, abdominal fatness, adult attained height, alcohol and dietary fibre. Resulting in convincing and probable conclusions. Related article: Dietary fibre and breast cancer risk: a systematic review and meta- analysis of prospective studies. Aune et.al. (2012) Ann.Oncol. Inverse association between dietary fibre intake and breast cancer risk http://www.dietandcancerreport.org/cup/current_progress/breast_cancer.phphttp://www.dietandcancerreport.org/cup/current_progress/breast_cancer.php. World Cancer Research Fund/American Institute for Cancer Research - 2010 Update

9. Role of Diet in Breast Cancer Survival Alcohol Trend towards increased risk of breast cancer with alcohol intake Brennan et.al. (2010) Dietary patterns and breast cancer risk: a systematic review and meta-analysis. Am J Clin Nutr 91 (5) 1294-1302 –Identified a positive association between a drinker dietary pattern and breast cancer (OR = 1.21, P = 0.01). –Cohort and case studies

10. Forest plot of the highest compared with the lowest categories of intake of the drinker dietary pattern and breast cancer risk. Brennan S F et al. Am J Clin Nutr 2010;91:1294-1302 ©2010 by American Society for Nutrition

11. Role of Diet in Breast Cancer Survival Alcohol Lew et.al. (2009) Alcohol and Risk of Breast Cancer by Histologic Type and Hormone Receptor Status in Postmenopausal Women.The NIH-AARP Diet and Health Study. Am J Epidemiol 170 (3) 308-317. –Moderate consumption of alcohol was associated with breast cancer, specifically hormone receptor-positive tumours. Boyle and Boffetta (2009) Alcohol consumption and breast cancer risk. Breast Cancer Research 11, S3. –Evidence consistent with alcohol consumption increasing the risk of breast cancer. –Increase in risk is small - however there is a large portion of women who consume moderate amounts of alcohol. France - 9.4% of breast cancer is attributable to alcohol consumption; Europe - 7.7% of all breast cancers attributable to alcohol consumption. –The risk is potentially stronger (or confined to) women with hormone receptor positive breast cancer

12. Role of Diet in Breast Cancer Survival Fats Chlebowski et.al. (2006) Dietary Fat Reduction and Breast Cancer Outcome: Interim Efficacy Results From the Women's Intervention Nutrition Study, J Nat Cancer Instit 98 (24) 1767-1776 –RCT - dietary intervention to reduce fat intake in early stage breast cancer –Reduced dietary fat intake, with modest influence on body weight, may improve relapse-free survival of breast cancer patients receiving conventional cancer management. Kroenke (2005) Weight, weight gain, and survival after breast cancer diagnosis, J Clin Oncol 23 (7) 1370-8 –Weight before diagnosis and weight gain post diagnosis was positively associated with breast cancer recurrence and death in women who have never smoked. –Stronger association in pre-menopausal women. Beasley et.al. (2011) Post-diagnosis dietary factors and survival after invasive breast cancer. Breast Cancer Res Treat 128 (1) 229-236. –women in the highest compared to lowest quintile of intake of saturated fat and trans fat had a significantly higher risk of dying from any cause. –Associations were similar, though did not achieve statistical significance, for breast cancer survival.

13. Role of Diet in Breast Cancer Survival Soy Isoflavones Dong et.al. (2011) Soy isoflavones consumption and risk of breast cancer incidence or recurrence: a meta- analysis of prospective studies. Breast Cancer Res Treat, 125 (2) 315-23 –Intake associated with a significant reduced risk of breast cancer incidence in Asian populations, but not in Western populations –Intake was also inversely associated with risk of breast cancer recurrence. –Results may be effected by menopausal status

14. Physical Activity Prof John Saxton, UEA Exercise physiology Quality of survivorship from exercise – fatigue, function Long term outcomes Looking to set up multi-centre study considering long term endpoints – currently no prospective RCT to demonstrate these.

15. Physical Activity Daley et.al. (2007) Randomized trial of exercise therapy in women treated for breast cancer. J Clin Oncol 25 (13) 1713-21 –supervised aerobic exercise therapy, exercise-placebo (body conditioning), or usual care –examine the effects of aerobic exercise therapy on quality of life (QoL) and associated outcomes in women treated for breast cancer –FACT-G and FACT B favoured aerobic exercise at 8 wk fup –Psychological outcomes improved for both intervention groups

16. Physical Activity Long Term Outcomes - Survival Holmes et.al (2005) Physical Activity and Breast Cancer Survival, JAMA 293 (20), 2479-86 –Prospective observational study on 2987 nurses dx with stages I-III breast Ca –The greatest benefit from the equivalent of walking 3 to 5 hours per week at an average pace, with little evidence of a correlation between increased benefit and greater energy expenditure –Risk reduction = 6% over 10 years. –Greatest benefit in hormone receptor +ve tumours Holick et.al. (2008) Physical Activity and Survival After Diagnosis of Invasive Breast Cancer. Cancer Epidemiol Biomarkers Prev. 17, 3779. –Greater levels of activity significantly lower risk of dying from breast cancer, and improved overall survival rates, regardless of age, stage of disease, or body mass index Irwin et.al. (2008) Influence of Pre- and Post Diagnosis Physical Activity on Mortality in Breast Cancer Survivors: The Health, Eating, Activity, and Lifestyle Study. J Clin Onc 26 (28) 3958-64 –Compared to inactive pts, pre dx activity not significant in relation to mortality –Compared to inactive pts, increased post dx activity = 45% lower risk of death, and decreased post dx activity = a four-fold greater risk of death

17. Physiotherapy/Lymphoedema Ang CN – Breast Incidence = 2474

18. Physiotherapy Pre-op assessment: ROM, muscle tone, pre-existing issues. Optimise physical and respiratory fitness Post-op exercise advice and education Enable RT Exercise and well-being Mobility Reduce impact of side effects Reduced risk of breast cancer specific mortality and recurrence Reduced hospital stays/GP appointments NICE 2009 CG80 - Arm mobility Breast units should have written local guidelines agreed with the physiotherapy department for postoperative physiotherapy regimens. Identify breast cancer patients with pre-existing shoulder conditions preoperatively as this may inform further decisions on treatment. Give instructions on functional exercises, which should start the day after surgery, to all breast cancer patients undergoing axillary surgery. This should include relevant written information from a member of the breast or physiotherapy team. Refer patients to the physiotherapy department if they report a persistent reduction in arm and shoulder mobility after breast cancer treatment. NCAT 2009, Macmillan Physical Activity Evidence Review 2011, NICE 2009 (Clinical Guideline CG80)

19. Physiotherapy An RCT of a12 week group exercise sessions for women with early stage breast cancer as an addition to standard care. Found significant improvements in physical functioning, active daily living, shoulder range of movement, cardio- vascular fitness, positive mood, and breast cancer- specific quality of life. There were no adverse events reported. Evidence that the intervention group spent fewer nights in hospital and made fewer visits to their GP than the control group. 10% in intervention group and 20% in control group reported at least one night in hospital 72% and 84% respectively reported at least one visit to their GP. Potential for cost savings to the NHS Mutrie, Campbell et al. Benefits of supervised group exercise programmes for women being treated for early stage breast cancer: pragmatic randomised controlled trial. BMJ. 2007.334:517; Macmillan 2011.

20. Workforce Modelling Specialist Lymphoedema Practitioners

21. Modelled against Actual Provision

22. Further Modelling (Moffatt 2003)

23. Lymphoedema - Management International Consensus – Best Practice for the Management of Lymphoedema – Lymphoma Framework (2006)

24. Lymphoedema – NICE 2009 Inform all patients with early breast cancer about the risk of developing lymphoedema and give them relevant written information before treatment with surgery and radiotherapy. Give advice on how to prevent infection or trauma that may cause or exacerbate lymphoedema to patients treated for early breast cancer. Ensure that all patients with early breast cancer who develop lymphoedema have rapid access to a specialist lymphoedema service. NICE 2009 (Clinical Guideline 80)

25. How big is the problem? Moffatt 2003: – 1.33/1000 prevalence total population all lymphoedema –5.4/1000 >65 NICE 2002: –Breast cancer prevalence 25-28% –Anglia – 600 pts at risk year on year Incidence rates vary from 2-65% SLNB – 8% 3yrs; 4.6% 10yrs ALND –14% 3yrs; 34% 10yrs Mixed tx sample: Armer (2010), Shah and Vicini (2011), Ashikaga et al (2010), Wernicke et al (2011)

26. The Answer Awareness Early Intervention Recognise the impact

27. Thank you. Any Questions?