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Survivorship Issues of the Metastatic, Recurrent and Intractable Breast Cancer
Yaelim Lee, PhD, MSN, RNRed Cross College of Nursing, Chung-Ang University
Image: https://kr.pinterest.com/pin/513691901219683111/
Breast cancer, a common cancer in women• In the U.S. • Every 2 minutes a woman is diagnosed with
breast cancer • Every 13 minutes a woman die of breast cancer
• In Korea • The 2nd most common cancer in women• The 6th most common cause of death in women
with cancer
Backgrounds
(National Breast Cancer Foundation (NBCF), 2016; Korean Breast Cancer Society (KBCS), 2016)
Relatively high survival rate (5-year survival) • Prostate cancer 99%• Thyroid cancer 98%• Testis cancer 95%• Melanoma of skin 92%• Breast cancer (female) 89%• …• Cervical cancer 68%• …• Colon & rectum cancer 65%• …• Ovarian cancer 46%• …• Stomach cancer 29%• …• Pancreas cancer 7%
Backgrounds
(American Cancer Society (ACS), 2016)
Backgrounds
(ACS, 2016)
Backgrounds
(KBCS, 2016)
Who are the breast cancer survivors?
Backgrounds
(American Society of Clinical Oncology (ASCO), 2016)
Image: http://dev.natcom.org/CommCurrentsArticle.aspx?id=3636
Cancer survivorship• Living with, through, and beyond cancer• Phases• Acute survivorship
• Begins at cancer diagnosis ~ end of cancer treatment
• Extended survivorship• End of cancer treatment ~ months after
• Permanent survivorship• Later period: Years have passed since cancer
treatment, recurrence less likely
Backgrounds
(American Society of Clinical Oncology (ASCO), 2016)
Survivorship issues• What if…• my cancer goes aggressive
(progressions)• my family gets tired of me
• How should I …• cope with numerous side-effects• keep up with multiple health
appointments
Backgrounds
Image: http://www.trcc.org/survivorship/
(National Cancer Institute (NCI), 2016)
Resources• An integrated literature review using • Multiple databases • Publications of official health parties
• Korean Breast Cancer Society, American Cancer Society, U.S. National Cancer Institute, and etc.
Steps• Three themes on survivorship issues• Five directions for patient encounter & care
based on the discussion of these issues
Methods
Three themes
Survivorship Issues
1.• Suffering from the lingering
symptoms of cancer treatment
2.• Managing conditions acquired from
the treatment
3.• Experiencing complex emotions
Vasomotor symptoms• Hot flashes: warmth, sweating, redness• Often belittled: “Ah.. another flash, open the
window” Sudden & Intense: “Once you have one, there’s no mistaking it” Negatively impact daily livings, sleep, compliance to medication
Survivorship Issues
1.• Suffering from the lingering
symptoms of cancer treatment
Image: http://accesstelehealth.org/understanding-and-dealing-with-hot-flashes/
Survivorship Issues
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Image: https://kr.pinterest.com/janaktyler/hot-flashes-are-real/
Low estrogen levels
Deregulation of
hypothalamus
Symptoms
Survivorship Issues
Chemotherapy, hormonal therapy• Interrupting ovarian function• Decreasing estrogen concentration• Decreasing sensitivity of tissues to estrogen
‘Body’s thermostat’: “Too hot!” Heat-releasing mechanism• Increased heart rate• Dilated vessels (near skin), sweat glands
• Palpitation (nausea, dizziness, anxiety)
• Flash (heat, redness)• Sweating (soaking)
Neuromusculoskeletal pain• Arthralgia, neuropathy
• Impairing activities of daily livings• Chemotherapy, Hormonal therapy (aromatase inhibitor;
AI)• Neurotoxicity• Rapid drop in estrogen release of cytokines which
hasten bone loss and aging of joints • Risk of social isolation• Chronic pain leading to depression
Survivorship Issues
Image: http://www.mollysfund.org/2015/02/peripheral-neuropathy/
Fatigue• Persistent feeling of exhaustion• Cancer treatment in general• Neurotoxicity, hormonal change, chronic stress,
anemia• Comprehensive assessment• Hypothyroidism, cardiomyopathy, depression
Survivorship Issues
Image: http://bottomlineinc.com/health/cancer-treatment/acupuncture-relieves-cancer-fatigue
Anemia
Pain
Emotional Distress
Sleep Problems
Medication
Poor Nutrition
Lack of Exercise
Other Problems
Survivorship Issues
(ACS, 2016)
Cancer-relatedFatigue
Bone marrow suppression
Depression & Anxiety
Pain killer, anti-depressants, antiemetic
Infections, cardiomyopathy,hypothyroidism, depression
Poor appetite, increased energy needs
Pain, “obsessive resting”
Fatigue• Rest, but not too much• 30 minutes or less• “obsessive resting”
• Stay active• Save your energy• Prioritize
• Get help• “Learning to let others help you”
• Eat well• Reduce stress
Survivorship Issues
(ACS, 2016)
Image: http://www.exeromed.com/cancer-related-fatigue-survey/
Impaired sexuality• Surgery, radiation
• Changing body appearance and sensation• Chemotherapy, hormonal therapy (AI>tamoxifen)
• Early menopause, sexual dysfunction• Decreased libido, dyspareunia, anorgasmy
• Less discussed• Uncomfortable (health care providers patients)• Few standard tool screening for sexual dysfunction in
survivors of cancer• Female Sexual Function Index (FSFI)
Survivorship Issues
Cardiac toxicity• Cardiomyopathy
• Breathlessness, swelling of extremities, fatigue• Chemotherapy (anthracycline-based; doxorubicin,
epirubicin)• Special eyes on accumulation dose
• Irreversible Reversible• Early intervention with angiotensin-converting
enzyme inhibitors (ACEI), beta-blockers
Survivorship Issues
2.• Managing conditions acquired from
the treatment
Weight gain• Average weight gain: 2.5-6.2 kg• Sarcopenic obesity• Treatment in general• Lipoprotein lipase (LPL) activity
• LPL: Fat into fat cells and makes it fatter• Estrogen supposed to suppress LPL
• Decreased estrogen
• Decreased physical activity
Survivorship Issues
Image: http://hrprofessionalsmagazine.com/how-to-weigh-in-obesity-in-employment-decisions/
Weight gain• Strong evidence: • Physical exercise – reducing recurrence and
death• American Cancer Society• Moderate-intensity aerobic activity: 150 minutes
per week• Strength training: 2 days per week
Survivorship Issues
Image: http://gymflow100.com/the-importance-of-exercise-while-fighting-cancer/
Cognitive changes• Problems with attention, concentration,
executive function, memory• Chemotherapy > Hormonal therapy • Poorly studied• Slow recovery• Cognitive behavioral training
Survivorship Issues
Image: http://www.leadcincinnati.com/Understanding-Cancer-Therapy-and-Cognitive-Changes/
Increased risk of osteoporosis • Chemotherapy, Hormonal therapy (AIs)• Premature menopause
• Estrogen• Decreases the osteoclasts stimulates osteoblast
• Modifiable risk factors• Weight-bearing physical activity, calcium / vit. D
supplements, smoke cessation Increased risk of other cancers• Leukemia (chemotherapy), lung cancer, uterine
cancer (tamoxifen)
Survivorship Issues
Fears• Disease progression, pain, death, and uncertainty• Obsession in life styles
Anger• “Life is not fair”
Sadness, hopelessness• Thoughts of death
Self-consciousness• Social isolation
Guilty feelings• “I did something wrong” (cancer-causing potential)• To their family members, caregivers
Survivorship Issues
3. • Experiencing complex emotions
Thankfulness• Positive life changes: ‘post-traumatic growth’• Healthier life styles, new perspectives
• Supports and love from family and friend• Stronger spirituality
Motivation• A second chance• Complete one’s will or life plans
Survivorship Issues
Survivorship Issues
Image: https://kr.pinterest.com/explore/breast-cancer-survivor/
Image: https://kr.pinterest.com/pin/459789443177981999/
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Image: https://kr.pinterest.com/jamootz7/my-cancer-journey/
1.• Provide individualized treatment and a follow-up
plan
2.• Provide evidence-based health education and
preventing follow-up loss
3.• Deliver collaborative care with multi-providers
4.• Implement a comprehensive interdisciplinary team
approach
5.• Emphasize the necessity of further efforts
Proposed Directions
1.• Provide individualized treatment and a
follow-up plan
Proposed Directions
Decision sharing, planning together• Valuing each person’s concerns, life priority
Importance of follow-up care• Maintain good health• Manage symptoms (side-effects)• Find signs of progression• Screening for other types of cancers
2.• Provide evidence-based health
education and preventing follow-up loss
Proposed Directions
Too much information• Friends, family, support group, mass media
(internet, television, magazines) Importance of continuity of care• “Learning to let others help you”• “You are not alone”• Support group
3.• Deliver collaborative care with multi-
providers
Proposed Directions
Collaboration with multi-providers• Oncologist, surgeon, gynecologist,
cardiologist, psychiatrist…• ‘Patchwork’
• Multiple outpatient visits, repetitive testing
• Medication• Repetitive drugs, drug-drug
interactions• ‘Prescribing cascade’
Collaboration!! Patient education!!
Image: http://edtansrant.blogspot.kr/2015/11/prescribing-cascade.html
4.• Implement a comprehensive
interdisciplinary team approach
Proposed Directions
Interdisciplinary team approach• Multi-providers + pathologist, radiologist, pharmacist,
nutritionist, physical therapist… Benefits
• Decision making• Balanced care plan through objective second opinions• Up-to-date management plan Optimal management plan among many options
• Supportive care• Integral part of breast cancer management• Compliance
• Managing side-effects from cancer treatment• Empowering
Image: https://n415son11.wordpress.com/interdisciplinary-practice-nurses-as-full-partners-in-care/
5.• Emphasize the necessity of further
efforts
Proposed Directions
Qualitative nursing research• Breast cancer survivors’ experiences• In-depth understanding
Utilizing health informatics• Web-based tools (education, decision making
supports)• Integrated data registry• Genomics: response to drugs, disease prognosis
Image: http://ehealth4everyone.com/did-you-know-health-informatics-trivia/
Breast cancer survivors confront complex changes from cancer and its treatments
Understanding breast cancer survivors’ issues and priority concerns contribute in… • Enhancing communication with the survivors• Providing adequate care• Improving their quality of life
Conclusion
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https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatment-and-survivorship-facts-and-figures/cancer-treatment-and-survivorship-facts-and-figures-2016-2017.pdf
https://www.cancer.gov/about-cancer/coping/survivorship
http://www.cancer.net/survivorship/about-survivorship
https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/fatigue.html
http://www.kbcs.or.kr/journal/file/2016_Breast_Cancer_Facts_and_Figures.pdf
References