Current Issues in Breast Cancer Survivorship – The Heart of the Matter
B.I. Bodai, MD, F.A.C.S
Director, Breast Cancer Survivorship Institute
Kaiser Permanente, Sacramento
There are nearly 3 million women in the United States who have been successfully treated for breast cancer with a curative expectation. According to the American Cancer Society, this number will approach 3.9 million by 2020, representing a 25% increase (1,2). Patient awareness and education, coupled with earlier detection and more effective therapies, contribute to these welcome statistics. Breast cancer is no longer an acute disease, but has now become more appropriately referred to as a “chronic condition.” (3)
Future challenges arise from these successes. Current treatment modalities result in achieving an excellent cure rate in the patient with breast cancer, but they also pose significant, long-term morbidities, some of which may result in demise.
|Typical Case Presentation DX:DX: 58 year old, Lt IDCTX: LAD w/RTPATH: 2cm, Grade II, 2/8 + nodes, ER+, PR+, Her2+ADJTX: Cytoxan/Taxotere x 6, Herceptin x 1yr, Aromatase Inhibitor x 5-10 yrs
RT: 5000 cGy Breast/Regional Nodes + 1000 Boost
IDC: invasive ductal carcinoma, LAD: lumpectomy/axillary dissection, ADJTX: adjuvant chemotherapy, monoclonal antibody therapy, hormonal blockade, RT: radiation therapy, COMX: co-morbidities, FBS: fasting blood sugar, BMI: body mass index
- Many chemotherapeutic agents are cardiotoxic with long-term sequalae.
- Radiation therapy (RT) can also result in injury to the coronary arteries, especially when left sided lesions are treated. Currently more than 1 million women have had left-sided RT. Further, the effects of RT may be delayed, peaking 10-20 years after treatment.
- Monoclonal antibody treatment appears to be especially cardiotoxic; fortunately this is reversible with discontinuation of medication administration while the damage from the former two modalities may be permanent.
- Adjuvant hormonal blockade may also affect cardiovascular health by producing elevations in blood pressure and cholesterol, two additional risk factors for potential cardiac events. Furthermore, strong consideration is now being given to recommendations extending a 5 year regimen of hormonal blockade to 10 years and in some cases, even longer (4, 5).
The cardiovascular consequences of the multimodal approach to treatment are, perhaps, best illustrated by a typical case study (SIDEBAR).
Cardiovascular disease (CVD) is the number one cause of death in women in the U.S. Each year 7 times as many women die of cardiovascular disease than breast cancer. Approximately 265,000 women die of a myocardial infarction; an additional 32,000 succumb to congestive heart failure. Females under the age of 50 are twice as likely to die of a myocardial infarction as a cohort male population due to a failure of diagnoses and less aggressive treatment. CVD increases with age. As our patient moves forward she will enter her 60’s, and beyond, and the risk of CVD, as well as the development of other comorbidities (obesity, hypertension, hyperlipidemias, diabetes) will also increase. The long term cardiotoxicities of an effective breast cancer treatment protocol will converge upon her.
The message of this article is simple: those involved in breast cancer survivorship care need to be extensively versed in cardiovascular issues as a serious sequalea of treatment. Survivorship providers must be aware that there are long-term threats to which patients treated effectively have been exposed, especially as they age. Most women diagnosed with breast cancer will not die from this disease. The likelihood of a cardiovascular event ending their lives are significantly higher.
Education. So what to do? First and foremost, we must educate breast cancer survivors of the symptoms of a heart attack in women. These may be quite different from those so well recognized in men. Heart attacks in men typically present with the sudden onset of chest pain radiating to the neck and down the left arm. Women may also experience these initial symptoms, but often the presentation is much more subtle.
Symptoms of a heart attack in females may include the following constellation of symptoms:
- Sudden onset of fatigue/weakness often accompanied by severe sweating
- Anxiety/shortness of breath
- Irregular heart beat and an “ill feeling”
- Pain/pressure (radiating to one or both arms/jaw/back)
- Abdominal pain/indigestion/nausea/vomiting
Lifestyle Modifications. Second, we must strive to eliminate co-morbidities by advising patients on the benefits of lifestyle modifications which are centered on body mass index (BMI) management through exercise and diet. Exercise can impact overall disease free survival by such simple interventions as walking 30 minutes a day, 5 times weekly. Adopting a whole food plant based diet (minimizing or eliminating meat and dairy products) has also been demonstrated, in multiple long-term studies, to significantly decrease recurrence and increase survival (6-9). There is an abundance of evidence to support that such lifestyle interventions can provide an effective tool for women to be pro-active in their ultimate disease free survival (10-14). At the same time, such interventions will decrease the risk of CVD, again the leading cause of mortality in females today.
- DeAngelis R, Tavilla A, Verdecchia, et al: Breast Cancer Survivors in the United States: Geographic variability and time trends, 2005-2015. Cancer 2009; 115: 1954-66.
- American Cancer Society. Cancer Treatment and Survivorship Facts & Figures 2012-2013. Atlanta: American Cancer Society; 2012.
- Bodai BI, Tuso P. Breast Cancer Survivorship: A Comprehensive Review of Long Term Medical Issues and Lifestyle Recommendations. The Permanente Journal 2015; May: (In Press).
- Davies C, Pan H, Godwin J, et al. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomized trial. Lancet 2013; 381: 805-16.
- Gray RG, Ren D, Handley K, et al. aTTom long-term effects of continuing adjuvant tamoxifen for 10 years versus 5 years in 6,934 women with early breast cancer. J Clin Oncol 2013; 31: abstr 5.
- Pierce JP, Stefanick M, Flatt SW, et al. Greater Survival after Breast Cancer in Physically Active Women With High Vegetable-Fruit Intake Regardless of Obesity. J Clin Oncol 2007; 25(17): 2345-51.
- Gonzales JF, Barnard ND, Jenkins DJA, et al. Applying the Precautionary Principle to Nutrition and Cancer. J Amer Coll Nutrition 2014; 33(3): 239-46.
- Kushi LH, Doyle C, McCallough M, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing risk of cancer with healthy food choices and physical activity. CA Cancer J Clin 2012; 62: 30-67.
- Denmark-Wahnefried W, Campbell KL, Hayes SC. Weight management and its role in breast cancer rehabilitation. Cancer 2012, 118: 2277-2287.
- Ford ES, Bergman MM, Kröger J et al. Healthy Living Is The Best Revenge Findings From the European Prospective Investigation Into Cancer and Nutrition-Potsdam Study. Arch Intern Med 2009: 169(15): 1355-62.
- Ford ES, Bergman MM, Boeing H, et al. Healthy lifestyle behaviors and all-cause mortality among adults in the United States. Prev Med 2012; 55: 23-27.
- Bellavia A, Larsson SC, Bottai M, et al. Fruit and vegetable consumption and all-cause mortality: A dose-response analysis. AM J Clin Nutr 2013; 98(2) 454-9.
- Pan A, Sun Q, Bernstein AM, et al. Red Meat Consumption and Mortality Results From 2 Prospective Cohort Studies. Arch Intern Med 2012; 172(7): 555-63.
- Hyman MA, Ornish D. Lifestyle Medicine: Treating the Causes of Diseases. Alternative Therapies 2009; 15(6): 12-14.
Impact of USPSTF Recommendation if Accepted
In April, The U.S. Preventive Services Task Force (USPSTF) released a draft of its updated recommendations for breast cancer screening. If adopted, these guidelines will result in thousands of additional deaths due to breast cancer annually and thousands more women will be subjected to more extensive and expensive treatments resulting from the delayed diagnosis of their disease. The recommendations further threaten to deny millions of American women 40 and older of private insurance coverage (with no co-pays) for routine screening mammograms as is presently guaranteed by the Affordable Care Act (ACA).
The newly released USPSTF guidelines give routine mammographic screening of women ages 40-49 a grade of “C” and a grade of “B’ to biennial screening for women ages 50-74. It is important to note that the Affordable Care Act (ACA) only requires private insurers to cover exams given a grade of “B” or higher. Private insurers may then use these guidelines to refuse coverage for mammographic screening for women age 40-49 and limit screening for women ages 50-74 to every two years. Although the panel claims they want women to have the freedom to decide, the guidelines in effect do the contrary by threatening women’s access to this life saving technology.
Using the same CISNET models used by the USPSTF, it has been estimated that if women who are now in their thirties wait until the age of 50 to begin screening and are then screened every two years, as many as 100,000 women will unnecessarily die of breast cancer, whose lives could have been saved by annual screening starting at the age of 40.
The USPSTF claims to want patients to weigh the benefits vs harms of mammographic screening. A primary harm they cite is the anxiety produced from a false positive screening even though in the vast majority of cases this results in only a few extra mammographic views or an ultrasound. A 2014 study published in JAMA Internal Medicine shows that patients experience only short-term anxiety regarding test results which rapidly declines over time with no measurable effect to women's health from a false-positive exam. Additional research found that nearly all women who experience a false-positive exam support screening and want to know their status. To suggest that the anxiety associated with a false positive mammogram somehow equates with the non-diagnosis of early breast cancer perhaps is explained by the fact that the USPSTF panel again does not include a single individual with any experience caring for breast cancer. The greatest harm possible is to miss the opportunity to diagnose breast cancer early and potentially save a life.
Screening mammography is one of the most studied of all medical technologies. The Randomized Clinical Trials (RCT), considered the gold standard for assessing efficacy, have studied more than ¾ of a million women. Millions more have been studied in Observational Studies. Screening mammography clearly has been shown to achieve statistically significant mortality reduction and this includes women ages 40 to 49. According to National Cancer Institute (NCI) data, there has been a 35% reduction in breast cancer mortality since the introduction of mammographic screening in the U.S. in the 1980s. Despite the weight of the evidence, the USPSTF inexplicably chose to limit its analysis to a small cadre of studies that grossly underestimate the benefit of screening and overestimate perceived harms of over diagnosis. We call on the USPSTF to allow more transparency to their analysis and include input from experts in the field.
The newly stated USPSTF guidelines for breast cancer screening will, if adopted, result in unnecessary deaths and morbidity and may cause millions of women to lose insurance coverage for breast cancer screening. The National Consortium of Breast Centers (NCBC) rejects these guidelines and continues to recommend routine annual mammographic screening for all women beginning at age 40 and continuing until life expectancy is less than 10 years.
|CALL TO ACTION
The Clinical Breast Examination Certification Program is being offered in Knoxville, TN at University Health Systems on August 15-16. This program is part of a calculated effort on behalf of NCBC to promote consistent breast health care throughout the nation.
Certification is available to licensed healthcare professionals (physicians, physician assistants, nurse practitioners, registered nurses and radiologic technologists). It is designed to utilize standardization of clinical breast examination skills as another early detection tool to ultimately reduce breast cancer deaths. CBE's paramount objective is the detection of any dominant breast mass.
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