Smilow Cares Survivorship Education Series: "Caring for Yourself After A Diagnosis of Breast Cancer"

Transcript

• 00:01Welcome for welcome for joining
• 00:03us. Welcome,
• 00:04tonight. And we're so grateful
• 00:06to,
• 00:07Valerie Cassella,
• 00:09who is, one of our
• 00:10nurse leaders,
• 00:12and really the heart of
• 00:13the Norma Freme Breast Center
• 00:15here in
• 00:17Trumbull for organizing this cancer
• 00:20survivorship
• 00:20series.
• 00:21She is, very connected to
• 00:24our patients and has,
• 00:26been for quite some time.
• 00:28And she asked me tonight
• 00:29to talk about,
• 00:31caring for yourself after a
• 00:33diagnosis of breast cancer.
• 00:44So when we think about
• 00:45breast cancer incidence and survivorship,
• 00:48we really think about the
• 00:49phases of care, the experience
• 00:51of women as, they are
• 00:53screened for, diagnosed, or treated
• 00:54for breast cancer.
• 00:57This is,
• 00:59the cancer survivorship
• 01:00continuum as
• 01:02defined in the,
• 01:04National Academy
• 01:05of Medicine report, delivering high
• 01:07quality cancer care that was
• 01:08published initially in twenty thirteen.
• 01:11But this cancer continuum really
• 01:14has come to define,
• 01:16both how we do research
• 01:17into,
• 01:19cancer,
• 01:20types and also how would
• 01:21we think about, treatment.
• 01:23And so tonight, we're gonna
• 01:24focus on this,
• 01:26divide our talk up based
• 01:27upon this,
• 01:29cancer survivorship
• 01:30continuum.
• 01:36Breast cancer is the most
• 01:37common cancer of women in
• 01:38the United States, accounting for
• 01:40about thirty percent of all
• 01:41cancers in women.
• 01:47In twenty twenty five, we
• 01:48estimate there will be three
• 01:49hundred and sixteen
• 01:51thousand cases of invasive breast
• 01:53cancer in the United States,
• 01:56and with a relative five
• 01:58year survival of over ninety
• 02:00percent.
• 02:01So breast cancer
• 02:03is a very curable
• 02:05cancer.
• 02:07This graph,
• 02:09demonstrates
• 02:09the rates of breast cancer,
• 02:12over time,
• 02:14where they have held relatively
• 02:16stable
• 02:17and breast cancer mortality,
• 02:19which continues
• 02:20to decrease.
• 02:22And the difference between our
• 02:24rates of incidence and mortality
• 02:26is the success of our
• 02:28our screening treatment and,
• 02:31cure.
• 02:36Again, breast cancer survival,
• 02:38when you take all comers,
• 02:39is greater than ninety percent.
• 02:42It's great to see it
• 02:43graphically,
• 02:44to know that most women
• 02:46with breast cancer,
• 02:48will,
• 02:50achieve a cure.
• 02:55We know that the likelihood
• 02:57of cure is really related
• 02:58to breath, stage at diagnosis.
• 03:01And women who are diagnosed
• 03:03with early stage
• 03:05localized disease
• 03:07have very high rates of
• 03:09long term survival.
• 03:11Regional disease, which would include
• 03:13lymph positive lymph nodes, also
• 03:15have a high rate of
• 03:16cure.
• 03:17And then women with metastatic
• 03:19disease or distant disease,
• 03:22have lower rates of,
• 03:24long term survival.
• 03:30And, again, just another way
• 03:31of looking at,
• 03:33this relative success that we
• 03:35have with breast cancer screening,
• 03:37we know that sixty four
• 03:39percent of women are diagnosed
• 03:41with localized or early stage
• 03:43disease.
• 03:44Another twenty eight percent was
• 03:45spread to regional lymph nodes.
• 03:48And this group, the majority
• 03:50of that pie graph are
• 03:51the women who have,
• 03:53the highest rates of survival,
• 03:55averaging at ninety percent.
• 04:03This is one of a
• 04:04number of studies that have
• 04:05looked at the experience of
• 04:07breast cancer,
• 04:08screening
• 04:09on breast cancer survival.
• 04:12And in this graph, you
• 04:13can see in the top
• 04:14line here that women who
• 04:16undergo regular breast cancer screening
• 04:19have a ninety percent survival.
• 04:22These women who are diagnosed
• 04:23at the earliest possible stage.
• 04:26The next line with the
• 04:27green triangles
• 04:29are women who develop
• 04:31cancer
• 04:32in between their screening intervals.
• 04:34So these are typical
• 04:36typically more aggressive or faster
• 04:38moving tumors that will where
• 04:40women will develop symptoms in
• 04:42the year after a normal
• 04:44screening mammogram.
• 04:47The orange line at the
• 04:49bottom here are women who
• 04:50have never undergone screening.
• 04:53So, again, this is more
• 04:54evidence
• 04:55that the of the value
• 04:57of screening mammography,
• 04:59for to,
• 05:01diagnose women at the earliest
• 05:02possible stage and to ensure
• 05:05the best outcomes.
• 05:09So when we think about
• 05:10how to care for yourself
• 05:11with breast cancer, it's about
• 05:13caring for yourself before we're
• 05:15even diagnosed.
• 05:16And that is making sure,
• 05:19that we're all getting annual
• 05:21screening mammograms
• 05:22and also having regular breast
• 05:25self exams
• 05:26and an annual clinical breast
• 05:28exam with our physician.
• 05:35Once we have screening, imaging,
• 05:36and have an abnormality,
• 05:39most women will then undergo,
• 05:42diagnostic
• 05:43image guided biopsy.
• 05:47The standard of care, of
• 05:48course, is to have a
• 05:49biopsy before
• 05:51any surgery is completed.
• 05:53An image guided biopsy can
• 05:55be completed under ultrasound guidance,
• 05:57mammogram guidance, or MRI guidance
• 06:00if MRI was used as
• 06:02part of the screening plan.
• 06:09And then after a biopsy,
• 06:10there will be a pathology
• 06:11report.
• 06:13In the pathology report, the
• 06:15type of tumor will be
• 06:16described
• 06:17along with the tumor grade.
• 06:21Grade one is the best
• 06:22differentiated,
• 06:24the most normal looking cells.
• 06:26Grade two, they start to
• 06:28appear a little more abnormal.
• 06:29And grade three
• 06:31are the most abnormal appearing
• 06:33cells.
• 06:34Grade three tumors are faster
• 06:36growing
• 06:37and tend to be,
• 06:40of a more,
• 06:41aggressive,
• 06:43type requiring more therapy.
• 06:46Also in the pathology report
• 06:48will be the breast cancer,
• 06:51receptors or biomarkers.
• 06:53These receptors on the cell
• 06:55surface determine what's,
• 06:58what will control the cell's
• 07:00growth.
• 07:01There are three receptors that
• 07:02we evaluate.
• 07:04The estrogen receptor and progesterone
• 07:06receptor are the female hormones.
• 07:09The other receptor is called
• 07:11HER2,
• 07:12which is a marker of
• 07:13a very specific cancer that
• 07:15we treat with targeted molecular
• 07:18therapy.
• 07:22And so the breast cancer
• 07:24stage
• 07:25is determined by a combination
• 07:27of factors.
• 07:29It includes
• 07:30the estimate of the tumor
• 07:31size,
• 07:32based on the imaging findings
• 07:34and the physical exam.
• 07:36The lymph node status,
• 07:39also determined based upon physical
• 07:41exam and the imaging findings.
• 07:45We will look for metastatic
• 07:46disease if anyone has if
• 07:48a patient has a symptom.
• 07:50Otherwise, there's usually not a
• 07:52reason to do,
• 07:54scans for metastases
• 07:56elsewhere in the body,
• 07:58at the time of diagnosis.
• 08:01Then we look at the
• 08:02tumor biomarkers, the receptors of
• 08:04the estrogen,
• 08:05progesterone,
• 08:06and HER2 receptor,
• 08:08and the tumor grade.
• 08:10These are all then put
• 08:12together
• 08:13to determine the tumor stage.
• 08:20So once you've been through
• 08:21screening
• 08:22and imaging and have a
• 08:24diagnosis
• 08:25of breast cancer,
• 08:27it's time to gather your
• 08:28team
• 08:29to then identify your sources
• 08:31of social support,
• 08:33to help walk you through
• 08:35the process,
• 08:36of breast cancer treatment and
• 08:38into survivorship.
• 08:42Your team might include family
• 08:44members,
• 08:45friends,
• 08:46spiritual advisors.
• 08:48It could be coworkers,
• 08:50supervisors, or mentors.
• 08:52Can include your health care
• 08:54providers,
• 08:56patient advocates,
• 08:58other cancer survivors,
• 09:00support group members.
• 09:02I included this picture from
• 09:04when I was treated for
• 09:05breast cancer
• 09:06in twenty sixteen.
• 09:08This is as I'm getting
• 09:09ready to roll back to
• 09:10the operating room, and my
• 09:12daughters
• 09:13my daughters, my son, my
• 09:15sister were all there with
• 09:16me on that day.
• 09:18This is my daughter, Eleanor.
• 09:25The benefits of social support
• 09:26and breast cancer treatment and
• 09:28outcomes are are very well
• 09:29documented.
• 09:31Several studies have looked at
• 09:32different types of social support
• 09:34and the benefits that they
• 09:35offer.
• 09:38Social support is clearly
• 09:40linked to reduce anxiety and
• 09:43stress,
• 09:45reduced fatigue,
• 09:46and reduced experience of pain.
• 09:50Social support is also linked
• 09:51to improved ability
• 09:53to, cope for feelings of
• 09:55control,
• 09:57improved mood, self image, and
• 09:59sexual function.
• 10:01And social support has a
• 10:03long term association with improved
• 10:05physical well-being
• 10:06and ability to perform daily
• 10:08tasks.
• 10:14So consider all the help
• 10:15that is available,
• 10:17to provide support as you
• 10:18go through treatment planning and
• 10:21treatment and survivorship for breast
• 10:22cancer.
• 10:24The kinds of help that
• 10:25are available can come from
• 10:26family and friends,
• 10:28can come from a patient
• 10:29navigator.
• 10:30We have on-site patient navigators
• 10:33in all of our treatment
• 10:34sites, but there are also
• 10:35patient navigators that are available
• 10:37from national organizations including,
• 10:41organizations like the Susan Komen
• 10:43Foundation where they have navigators
• 10:45available,
• 10:47for consultation at their website.
• 10:51It's always important to consider
• 10:52the cost of cancer treatment
• 10:54and and,
• 10:56other opportunities for support include
• 10:58a financial counselor.
• 11:00It could be a physical
• 11:01therapist,
• 11:02fertility specialist,
• 11:04a physical trainer,
• 11:05a massage therapist,
• 11:07support with house cleaning and
• 11:09childcare,
• 11:10acupuncture, music therapy, and other
• 11:12integrative mental therapies.
• 11:15Most important thing is to
• 11:16be willing to ask for
• 11:18help.
• 11:25And so after you've,
• 11:28gathered your team and identified
• 11:30social support,
• 11:32then you move into the
• 11:33phase of shared decision making
• 11:35or making a treatment plan.
• 11:41I'm gonna stop my share
• 11:42for just a minute
• 11:44and see if there are
• 11:45any questions.
• 11:47I'm looking at the chat.
• 11:50I don't see any chats
• 11:52yet. Any questions in the
• 11:53chat yet?
• 11:57So if there are any
• 11:58questions, don't hesitate to put
• 11:59them in the chat. I'm
• 12:00gonna go back to
• 12:02to sharing my screen.
• 12:10Okay.
• 12:22So we know that multidisciplinary
• 12:25care is associated with improved
• 12:28outcomes in breast cancer treatment.
• 12:31Multidisciplinary
• 12:32care
• 12:33includes a coordinated
• 12:35team
• 12:36of professionals,
• 12:38dedicated to the treatment of
• 12:39women with breast cancer.
• 12:42The multidisciplinary
• 12:43team can include a breast
• 12:45surgeon, a a medical oncologist,
• 12:47a radiation oncologist,
• 12:49a pathologist,
• 12:52a breast radiologist,
• 12:53a patient navigator,
• 12:55our out outpatient clinical nurses,
• 12:58and all the supportive services
• 13:00that we just discussed.
• 13:03The improved outcomes associated with
• 13:05a multidisciplinary
• 13:06team include improved time to
• 13:09treatment,
• 13:11the receipt of guideline,
• 13:13concordant treatment,
• 13:15improved patient satisfaction,
• 13:18and improved overall survival.
• 13:27And at the heart of
• 13:28the multidisciplinary
• 13:29team and that model
• 13:31is shared decision making.
• 13:34For every treatment
• 13:36that is provided,
• 13:38it is a decision that
• 13:40is made in in,
• 13:44a shared format
• 13:46amongst providers,
• 13:48patients,
• 13:49and their support, whether it's
• 13:50their family or their friends.
• 13:53So the patient and family's
• 13:55goals and preferences,
• 13:57that provider's clinical experience and
• 14:00expertise,
• 14:02what science has to offer,
• 14:06in terms of making a
• 14:07treatment,
• 14:08choice,
• 14:10And then the biological,
• 14:11psychological,
• 14:12and social context.
• 14:14Things like
• 14:15where you live, what resources
• 14:17are available,
• 14:18how old the patient is.
• 14:23Those will all come into
• 14:24play as we make a
• 14:25decision,
• 14:27in a shared way as
• 14:29a team.
• 14:33In this context, you'll make
• 14:35a treatment plan. And the
• 14:37treatment plan for breast cancer
• 14:38includes both local regional treatment,
• 14:41managing the cancer in the
• 14:42body where it is.
• 14:44Systemic treatment,
• 14:46preventing the development of cancer
• 14:48elsewhere in the body.
• 14:50It will include a consideration
• 14:52of genetic counseling and testing
• 14:55and fertility preservation.
• 15:02Local regional treatment can include
• 15:05breast conservation,
• 15:06which could be a lumpectomy
• 15:08or a partial mastectomy removing
• 15:10the area where the cancer
• 15:11is with a clear margin
• 15:13or a total mastectomy removing
• 15:15all of the breast tissue.
• 15:19The lymph node surgery might
• 15:20include simple lymph node sampling
• 15:23or an axillary dissection where
• 15:25all the lymph nodes from
• 15:26underneath the arm are removed.
• 15:29Increasingly,
• 15:30our lymph node surgery may
• 15:32be no lymph node surgery
• 15:33needed at all.
• 15:38Part of breast conservation is
• 15:40the use of radiation therapy
• 15:42after lumpectomy
• 15:44to help reduce the risk
• 15:46for local recurrence.
• 15:52Systemic therapies,
• 15:55could include hormone therapy, which
• 15:56are estrogen blockers.
• 15:59These are drugs like tamoxifen
• 16:00or anastrozole.
• 16:02Targeted therapies that include monoclonal
• 16:04antibodies like trastuzumab
• 16:06for HER2 positive cancer,
• 16:10a new class of drugs
• 16:11called tyrosine kinase inhibitors,
• 16:14cyclin dependent kinase inhibitors,
• 16:17immunotherapy,
• 16:19or or standard chemotherapy
• 16:21agents like cyclophosphamide
• 16:23or taxider.
• 16:29So once you've brought together
• 16:31the multi your you've identified
• 16:33your social support, you've brought
• 16:35together your multidisciplinary
• 16:36team,
• 16:37and through shared decision making,
• 16:39you've put in place a
• 16:40treatment plan
• 16:42to begin treatment for breast
• 16:43cancer.
• 16:44That may be surgery as
• 16:46the first course of treatment
• 16:47or it may be systemic
• 16:48therapies as the first course
• 16:50of treatment.
• 16:51As you go through treatment,
• 16:54a big part of self
• 16:55care is managing the symptoms
• 16:58related to treatment.
• 17:03I'm gonna stop for a
• 17:04minute. I see there's a
• 17:05question in the chat.
• 17:09Can you talk more about
• 17:10systemic therapies and when they
• 17:12might be useful or appropriate?
• 17:14Happy to.
• 17:16Systemic therapies will be recommended
• 17:19for every
• 17:21breast cancer treatment plan. There
• 17:23will not be a time
• 17:25when we don't recommend some
• 17:26systemic therapy for an invasive
• 17:28breast cancer.
• 17:30The only time we would
• 17:31not necessarily
• 17:32recommend
• 17:34systemic therapy might be for
• 17:35ductal carcinoma in situ, which
• 17:37is noninvasive
• 17:38disease.
• 17:40The systemic therapies will be,
• 17:43tailored to the stage of
• 17:45the disease
• 17:46and the biology of the
• 17:48tumor.
• 17:49And so for early stage
• 17:51estrogen receptor positive,
• 17:53cancer,
• 17:54we might recommend
• 17:55estrogen blocking therapy, a drug
• 17:57like Tamoxifen.
• 18:00For a HER2 positive
• 18:02cancer,
• 18:02we would recommend
• 18:04if the tumor is bigger
• 18:05than five millimeters, we would
• 18:07recommend
• 18:07chemotherapy
• 18:09that would include
• 18:10HER2 targeted antibodies.
• 18:13And so, the the systemic
• 18:16therapy would be recommended for
• 18:18every invasive breast cancer,
• 18:20and then the type of
• 18:21therapy is really tailored to
• 18:23the stage of the disease
• 18:24and the biology of the
• 18:25tumor.
• 18:27Happy to talk more about
• 18:28that or answer more questions.
• 18:34I'm gonna move on to
• 18:35symptom management.
• 18:37And so self care during
• 18:38treatment is really about managing
• 18:41the symptoms related to the
• 18:43treatment.
• 18:44These symptoms really focus on,
• 18:48pain,
• 18:49anxiety,
• 18:50nausea,
• 18:52insomnia,
• 18:54constipation,
• 18:55and fatigue.
• 19:01Based upon the system a
• 19:02systematic review of the literature,
• 19:04the Society for Integrative Oncology
• 19:06recommends integrative therapies that can
• 19:09help you manage those symptoms.
• 19:11As you are go through
• 19:13treatment, your provider,
• 19:14whether it's your medical oncologist
• 19:16or your surgeon or your
• 19:17radiation oncologist,
• 19:19will,
• 19:20have recommendations
• 19:21and provide support
• 19:23for symptoms related to treatment.
• 19:25These are additional integrative,
• 19:28therapies that can be considered
• 19:29for symptom management.
• 19:31For pain, you might consider
• 19:33acupuncture,
• 19:35reiki, or hypnosis.
• 19:36This is in addition
• 19:38to pain,
• 19:39therapies that might be prescribed
• 19:41by your providers.
• 19:43For anxiety,
• 19:45there is evidence that supports
• 19:46the use of music therapy,
• 19:48meditation,
• 19:49stress management techniques, and yoga.
• 19:53Nausea
• 19:54can be also managed with
• 19:55acupuncture
• 19:56and yoga.
• 19:59Insomnia,
• 20:00which I hear
• 20:01a lot about from patients,
• 20:03can be managed with sleep
• 20:04hygiene techniques and yoga.
• 20:07Yoga is good for just
• 20:08about all of it.
• 20:10Constipation
• 20:11can be managed with brachy
• 20:12and acupuncture as well.
• 20:15Fatigue
• 20:17is best managed with exercise.
• 20:19I know that seems counterintuitive
• 20:21that when you're most fatigued
• 20:23that exercise can help, but,
• 20:25the data on that's very
• 20:26clear.
• 20:28For depression or depressed mood,
• 20:30meditation, relaxation,
• 20:32yoga, massage, and music therapy
• 20:34are effective.
• 20:36And for neuropathy,
• 20:38acupuncture can be helpful.
• 20:46So now that we've talked
• 20:48a little bit about,
• 20:49symptom management
• 20:52during treatment,
• 20:53I wanna talk up now
• 20:55about breast cancer survivorship.
• 21:00The National Cancer Institute
• 21:02has defined breast cancer survivorship
• 21:04or breast cancer survivors
• 21:06as individuals,
• 21:08from the time of diagnosis
• 21:11through the balance of their
• 21:12lives.
• 21:14So two years after I
• 21:15was treated for breast cancer,
• 21:17my daughter and I did
• 21:18a backpacking trip,
• 21:20in in the Alps in
• 21:22Europe.
• 21:23This was to celebrate my
• 21:25survivorship and her thirtieth birthday,
• 21:27and this is a photo
• 21:29from,
• 21:31a part of that backpacking
• 21:32trip.
• 21:38And so what are the
• 21:39components of breast cancer survivorship
• 21:41care?
• 21:42There are four key components
• 21:44of every survivorship
• 21:46visit.
• 21:47Survivorship
• 21:48really starts at the end
• 21:49of active treatment
• 21:51and extends for
• 21:52five years.
• 21:55The components of survivorship
• 21:57care include
• 21:59monitoring for breast cancer recurrence,
• 22:02monitoring for the late effects
• 22:03of treatment,
• 22:06supporting adherence to ongoing treatments,
• 22:09and health promotion.
• 22:14And just take a quick
• 22:15look at the chat and
• 22:16see if there are any
• 22:17other questions. Okay.
• 22:23So I'm
• 22:27I'm showing you the National
• 22:29Cancer Center Network guidelines for
• 22:31survivorship care.
• 22:33These are the guidelines for
• 22:34best practice
• 22:36that,
• 22:38define,
• 22:41what we do and how
• 22:42we provide survivorship care.
• 22:45This these guidelines are developed
• 22:47by an expert panel
• 22:49based upon review of the
• 22:51available scientific literature.
• 22:54And so, again, just to
• 22:55reiterate,
• 22:57the
• 22:58cancer survivorship
• 22:59focuses on
• 23:00surveillance for cancer spread or
• 23:02recurrence
• 23:04and screening, for subsequent primary
• 23:06cancers.
• 23:08Monitoring
• 23:09for the long term effects
• 23:10of cancer
• 23:12including psychosocial,
• 23:13physical, and immunologic
• 23:15effects
• 23:16of the cancer itself,
• 23:19the prevention and detection of
• 23:20the late effects of cancer
• 23:22and cancer therapy.
• 23:24I see there's a question
• 23:25in the chat of what
• 23:26do you consider the late
• 23:27effects of treatment.
• 23:28We're gonna jump into that
• 23:29now. But with regards to
• 23:31breast cancer, this can,
• 23:33include neuropathy related to chemotherapy,
• 23:37lymphedema
• 23:38related to surgery and radiation,
• 23:41depression
• 23:42related to the trauma of
• 23:44cancer treatment.
• 23:46These would all be considered
• 23:47late effects.
• 23:51Evaluation management of cancer related
• 23:53syndromes,
• 23:55coordination of care with a
• 23:57primary care provider,
• 23:59to ensure all,
• 24:02breast cancer survivors,
• 24:03health needs are met,
• 24:05and planning for ongoing survivorship
• 24:08care.
• 24:14So in monitoring for breast
• 24:16cancer recurrence,
• 24:18we can talk about,
• 24:20screening for local recurrence.
• 24:22Many women ask, don't I
• 24:24need a mammogram more often?
• 24:26And,
• 24:27the answer is no.
• 24:29Screening afterwards
• 24:31is at,
• 24:33annual mammogram is is adequate.
• 24:37A clinical exam though is
• 24:39equally, if not more important
• 24:41than screening imaging.
• 24:43The clinical exam, it would
• 24:45include a clinical breast exam
• 24:47if there's been breast conservation,
• 24:49an exam of the mastectomy
• 24:51site and the reconstruction.
• 24:53And those should occur at
• 24:54six month intervals for five
• 24:56years.
• 24:57Screening imaging can include a
• 24:59mammogram and an ultrasound or
• 25:01mammogram alone depending on if
• 25:03you, have had breast conservation
• 25:05or not.
• 25:07For young women or women
• 25:08with dense breasts who have
• 25:09breast conservation, we might recommend
• 25:11screening with a breast MRI.
• 25:13That screening plan will be
• 25:15tailored to every patient.
• 25:17We also look to monitor
• 25:19for symptoms and signs of
• 25:20a dis of distant recurrence
• 25:23that's done with clinical history
• 25:25and exam
• 25:26and screening imaging only when
• 25:28appropriate.
• 25:35Our evaluation for the late
• 25:37effects of treatment are really
• 25:38specific to the cancer stage,
• 25:40the tumor biology, and the
• 25:41treatments that have been received.
• 25:43And these can might include
• 25:46clinical exam,
• 25:47labs,
• 25:48testing,
• 25:51or imaging.
• 25:56So this, monitoring for,
• 25:59the
• 26:00late effects of treatment and
• 26:02for recurrence is complex,
• 26:04and this is an example
• 26:06of a rubric that we
• 26:07would use.
• 26:09This one is the one
• 26:10that is recommended by the
• 26:12National Cancer Center Network
• 26:14for monitoring cancer survivors and
• 26:16for evaluating for symptoms,
• 26:20related to treatment,
• 26:21cancer effects and treatment effects.
• 26:25They include monitoring
• 26:26for cardiac health,
• 26:28anxiety, depression, and trauma,
• 26:32cognitive function,
• 26:34fatigue,
• 26:36lymphedema,
• 26:38pain,
• 26:40hormone related symptoms,
• 26:43sexual health,
• 26:45fertility,
• 26:46sleep disorders,
• 26:49monitoring for a healthy lifestyle,
• 26:52immunizations
• 26:53and infections,
• 26:55and employment, and return to
• 26:57work.
• 27:04Here's an example of a
• 27:06fatigue assessment.
• 27:07And so
• 27:09the kinds of things that
• 27:10we can do when patients
• 27:11report fatigue,
• 27:13it would include a history
• 27:15and physical exam, an evaluation
• 27:17of disease status,
• 27:19looking at contributing factors to
• 27:21fatigue,
• 27:23screening for emotional distress and
• 27:25sleep disturbance,
• 27:27a laboratory evaluation, and other
• 27:29diagnostic testing
• 27:31to help sort out of
• 27:32the issues that related to
• 27:35long term fatigue.
• 27:39Here's another example
• 27:41of the evaluation for lymphedema.
• 27:43We're gonna talk a little
• 27:44bit more about this.
• 27:47Women who have axillary surgery
• 27:49have,
• 27:50a ten percent,
• 27:52risk of lymphedema
• 27:54if, they have sentinel lymph
• 27:55node biopsy only. It can
• 27:57be up to a thirty
• 27:58percent risk for lymphedema
• 28:00for women who have, axillary
• 28:02dissection.
• 28:04And so screening and,
• 28:07for lymphedema
• 28:08is an important part of
• 28:09what we do at survivorship
• 28:11follow-up visits.
• 28:12Once we identify a concern,
• 28:15we have ways of working
• 28:16it up and then
• 28:19referring,
• 28:20for treatment
• 28:21that includes both
• 28:23specialized physical therapy,
• 28:25wearing a compression sleeve,
• 28:27or possibly even reconstructive
• 28:29surgery.
• 28:33Lymphedema can be associated with
• 28:35any axillary surgery.
• 28:39The risk of lymphedema
• 28:41increases,
• 28:42with the extent of surgery
• 28:45with, related to obesity,
• 28:47diabetes,
• 28:48someone who's smoking,
• 28:50someone who has a history
• 28:51of preexisting lymphedema,
• 28:53and for patients who receive
• 28:55radiation therapy.
• 28:57The important thing to know
• 28:58is that the most common
• 28:59time to develop lymphedema is
• 29:01eighteen months after the initial
• 29:02operation. Lymphedema
• 29:04often does not happen right
• 29:06away.
• 29:07Lymphedema can occur in stages
• 29:11where the arm only appears
• 29:12mildly swollen, maybe rings don't
• 29:14fit on fingers or watch
• 29:16leaves an impression.
• 29:18Stage two, lymphedema
• 29:21is,
• 29:22managed
• 29:23easily with elevation.
• 29:27And then stage three is
• 29:28when permanent swelling develops.
• 29:32Stage four lymphedema
• 29:33can be associated with significant
• 29:35skin changes.
• 29:42So screening for lymphedema
• 29:44can include
• 29:45physical exam,
• 29:47monitoring of symptoms,
• 29:49limb measurements,
• 29:51or the use of bioimpedance,
• 29:52which is what we use
• 29:53in our practice here.
• 29:55Bioimpedance
• 29:56is,
• 29:58using a small electric current
• 30:00and looking at resistance to
• 30:02flow of that electric current.
• 30:04If we see that change
• 30:05over time, we know that
• 30:06patients are developing lymphedema
• 30:08and we may be able
• 30:09to identify lymphedema
• 30:11before patients ever have symptoms.
• 30:15Treatment for lymphedema as we,
• 30:17you know, mentioned includes physical
• 30:19therapy with a specially trained
• 30:21lymphedema therapist and wearing a
• 30:23compression sleeve.
• 30:25More severe lymphedema can be
• 30:26treated with a a lymphedema
• 30:28pump or with wraps.
• 30:36So now that we've talked
• 30:37a little bit about survivorship,
• 30:39which is a huge complex
• 30:40topic, we can talk,
• 30:42move on to the five
• 30:43things that we can all
• 30:45do every day
• 30:47to help reduce our risk
• 30:49of cancer recurrence.
• 30:55So our survivorship healthy habits
• 30:57are five things that we
• 30:58can do.
• 31:00Number one is a plant
• 31:01based diet.
• 31:02Number two, limit alcohol.
• 31:05Number three, maintain a lean
• 31:07body mass.
• 31:08Number four is regular exercise.
• 31:11And number five is smoking
• 31:13cessation.
• 31:17So the plant based diet,
• 31:20this is really a Mediterranean
• 31:22diet
• 31:23focusing on fresh fruits and
• 31:24vegetables,
• 31:25at least five servings a
• 31:28day,
• 31:30healthy grains,
• 31:32and healthy proteins.
• 31:35So we know that,
• 31:37one of the sources of
• 31:38estrogen in our diet comes
• 31:40through
• 31:40meat and dairy.
• 31:42And so making sure that
• 31:43we limit that.
• 31:45And when we have meat
• 31:46or dairy that it's,
• 31:48not treated with hormones.
• 31:52The American Institute for Cancer
• 31:54Research
• 31:55is the most authoritative
• 31:57website
• 31:59on cancer risk and nutrition.
• 32:01It has a
• 32:03wonderful,
• 32:06resource for
• 32:08how to set up your
• 32:09kitchen,
• 32:11for recipes,
• 32:12for cooking classes.
• 32:15They currently have the Healthy
• 32:16Ten Challenge, which is this
• 32:18ten week interactive program,
• 32:20to kind of help build
• 32:21healthier habits around nutrition
• 32:24and everyday diet that is
• 32:27simple,
• 32:28and easy to achieve.
• 32:31This is really the the
• 32:32best and most authoritative
• 32:34resource,
• 32:35for nutrition and cancer.
• 32:41Limiting alcohol is also essential
• 32:44for, cancer risk reduction.
• 32:46The nurses health study found
• 32:48a seventy percent increase in
• 32:49breast cancer
• 32:51among women who reported more
• 32:53than three alcoholic drinks per
• 32:55week.
• 32:56The,
• 32:57most recent Surgeon General's report
• 33:00has a really identified that
• 33:01there's no level of alcohol
• 33:03consumption that was not associated
• 33:05with an increased cancer risk.
• 33:08We know that alcohol consumption
• 33:10is associated with an increase
• 33:11in circulating estrogen levels which
• 33:14is a risk factor for
• 33:15estrogen receptor positive breast cancer.
• 33:19And so,
• 33:20there is really
• 33:23no
• 33:24safe level of alcohol.
• 33:26We know that,
• 33:28keeping alcohol consumption to less
• 33:30than three drinks per week,
• 33:32should help reduce your risk
• 33:34of both
• 33:36developing breast cancer and breast
• 33:37cancer recurrence.
• 33:44Regular exercise. This could be
• 33:46a talk
• 33:47in and of itself.
• 33:48I'm
• 33:50actually I'm seeing a a
• 33:52question in the chat. How
• 33:53about fish and seafood?
• 33:56So fish and seafood is
• 33:57an excellent source of protein
• 33:59with not a significant cancer
• 34:01risk associated with it.
• 34:07There's always this question about
• 34:09sugar and cancer. Does sugar
• 34:12feed cancer?
• 34:13We can't say that it's
• 34:15sugar by itself,
• 34:17but we know it's excess
• 34:18calories,
• 34:19that can be associated with
• 34:21cancer risk.
• 34:22And so making sure that
• 34:24food is, has nutrients and
• 34:26as few calories as possible
• 34:28as in fruits and vegetables
• 34:30that can be,
• 34:32most associated with cancer risk
• 34:34reduction.
• 34:37And I promise at the
• 34:38end, I'll go back to
• 34:39the,
• 34:40AICR,
• 34:42information in that link, the
• 34:43American Institute for Cancer Research.
• 34:49With regards to exercise in
• 34:50cancer, there are I could
• 34:52talk about that for quite
• 34:53a while. So I just
• 34:54wanted to,
• 34:56summarize in one slide
• 34:58that there are several
• 34:59large
• 35:00multicenter trials
• 35:02that have demonstrate the benefit
• 35:03of regular exercise
• 35:05and reduction of risk for
• 35:06developing breast cancer
• 35:08and for the prevention of
• 35:10breast cancer
• 35:11recurrence.
• 35:12Current recommendations
• 35:14is for at least thirty
• 35:15minutes of exercise
• 35:17five times a week.
• 35:20The most recent large trial
• 35:22in colon cancer that was
• 35:23in the New England Journal
• 35:24of Medicine just this month
• 35:26found that a combination
• 35:28of both aerobic and
• 35:30exercise and weight training
• 35:33was the most effective in
• 35:35preventing preventing cancer recurrence in
• 35:37patients with colon cancer.
• 35:41So we just can't emphasize
• 35:42enough the importance of regular
• 35:44exercise
• 35:46in cancer survivorship.
• 35:48I'm not great at this
• 35:50myself, so I have
• 35:51to improve my habits there.
• 35:56The next is maintain a
• 35:57lean body mass.
• 35:59So increased body mass index
• 36:01is associated with the increased
• 36:03risk of cancer
• 36:04recurrence and mortality in several
• 36:06large epidemiologic
• 36:08studies.
• 36:09The increase in mortality ranges
• 36:11from thirty to seventy percent
• 36:13in most studies.
• 36:15Increased BMI is also associated
• 36:17with the increased risk of
• 36:19developing breast cancer,
• 36:21but really for postmenopausal
• 36:22women only.
• 36:24In studies that have been
• 36:25done in cancer risk in
• 36:26premenopausal
• 36:27women, BMI or
• 36:29body mass index does not
• 36:31seem to play as important
• 36:32a factor as in postmenopausal
• 36:34women.
• 36:36The current recommendation is to
• 36:37maintain a healthy weight with
• 36:39a BMI less than thirty.
• 36:45And at last, smoking cessation,
• 36:47which I'm not gonna say
• 36:47a lot about. We do
• 36:49have smoking cessation programs that
• 36:51we refer patients to and
• 36:52and other resources that are
• 36:54available through the American Cancer
• 36:55Institute for smoking cessation.
• 37:02And so here are a
• 37:03list of survivorship resources that
• 37:05are available,
• 37:08for cancer survivors and for
• 37:10health care professionals.
• 37:11This is all available,
• 37:13through patient,
• 37:16resources
• 37:16from the National Cancer Center
• 37:18Network.
• 37:20The website for the AICR
• 37:23is here, the American Institute
• 37:25for Cancer Research,
• 37:28which,
• 37:29again, I think is is
• 37:31a very well designed and
• 37:32very authoritative
• 37:33site for information on nutrition,
• 37:36and weight management in cancer.
• 37:39The American Cancer Society,
• 37:42has wonderful resources available,
• 37:45as well as all of
• 37:46these other
• 37:47organizations
• 37:48including Livestrong.
• 37:56So caring for yourself after
• 37:57a breast cancer diagnosis.
• 37:59It starts before you're diagnosed
• 38:02with an annual screening mammogram
• 38:05and, self exam and clinical
• 38:07exam to make sure cancer
• 38:08is diagnosed at its earliest
• 38:10possible stage.
• 38:11Once you have a cancer
• 38:12diagnosis,
• 38:13gathering your team and developing
• 38:15your resources for social support.
• 38:19Then
• 38:20identifying your clinical team
• 38:22and developing a treatment plan
• 38:25with shared
• 38:26decision making,
• 38:28managing the symptoms
• 38:30of cancer,
• 38:31treatments as you're going through
• 38:33active treatment,
• 38:35And then survivorship care, which
• 38:37we we discussed
• 38:38including monitoring for recurrence and
• 38:41the late effects of treatment.
• 38:43And then the five things
• 38:44that you can do every
• 38:45day to help reduce your
• 38:47risk of cancer recurrence.
• 38:49I've been talking for a
• 38:50while.
• 38:51I'm gonna stop and see
• 38:52if there any other comments
• 38:53or questions. I'm seeing everybody
• 38:55in the chat. I'm gonna
• 38:56stop my share.
• 39:20I have to say, my
• 39:21family have been some of
• 39:22my best advocates as I
• 39:24have
• 39:25gone through my treatment for
• 39:27breast cancer in in my
• 39:28survivorship.
• 39:32And I feel very fortunate
• 39:34that I, I have such
• 39:35engaged, loving family members.
• 39:59Wow.
• 40:02If there are no other
• 40:03questions,
• 40:05I think we will
• 40:07we'll end end this,
• 40:09and I really appreciate the
• 40:10opportunity to have this
• 40:12conversation tonight. And,
• 40:16hopefully, next year, we can
• 40:17can do something in in
• 40:19person.
• 40:21Again, thank you to Sally
• 40:22Cassella.
• 40:27Oh, yes.
• 40:29Danielle, thank you for mentioning,
• 40:32Thrive,
• 40:33which is a,
• 40:35organization
• 40:36that has been spearheaded by
• 40:38doctor Neil Fishback, one of
• 40:39our medical
• 40:40oncologists
• 40:41here,
• 40:42to provide
• 40:43a resource
• 40:44for cancer survivors in our
• 40:45community here in Trumbull.
• 40:49It,
• 40:50provides exercise classes,
• 40:52and a workout room
• 40:53and other support services, and
• 40:56it is it's a really
• 40:57dynamic
• 40:59engaging place. So thank you
• 41:01for mentioning that.