BREAST CANCER Care in Primary Care JOANNE WOODLANDS

BREAST CANCER Care in Primary Care JOANNE WOODLANDS November 2017

Introduction l DIAGNOSIS l Role of Breast Cancer Nurse- Local Cancer Care service –referrals and counselling options l Breast surgery- post op care l Breast cancer treatment : Chemo Radiotherapy Clinical trials/what’s new l SURVIVORSHIP /Endocrine therapy Targeted therapy

Early Diagnosis l STARTS WITH THE WELL WOMENS CHECK ? l Encouraging women to be breast aware and to discuss any changes l Encourage Breast Screening – Its free! l Management of Breast Symptom- Triple test – Patient History – Image – MMG USS Breast MRI – Biopsy – Core FNAB

Awareness of Risk Factors l The main risk factors – being a woman – getting older – having a strong family history of breast cancer inheriting a faulty gene that increases the risk l Other – Being overweight or obese – Alcohol – Smoking – Personal History of Dense breasts DCIS LCIS – Menstrual History – HRT use

DIAGNOSIS Test Results l Biopsy Pathology result – Type- Invasive or Insitu l Surgical Histology – Type – Receptors – Oestrogen – Endocrine receptor – Progesterone – Grade – Her 2 l Imaging – size Nodes? – Grade l Imaging Staging

Genomics l Mammoprint l Oncotype DX

Breast Cancer STAGING

Prognosis

Role of Specialist Breast Cancer Nurse AIMS l Provide Support and Information l Local support services l Encourage high standards of patient care l Optimize Health and wellbeing – Across the various phases – i. e. diagnosis, treatment rehabilitation, advanced cancer care and palliative care.

Nursing Role l Registered Nurse – extra study in Cancer care l Initiate contact as soon as possible after diagnosis or when there is a change in cancer – Referrals from Breast screening and Pre-admission clinics. MDT meetings – Recurrence – Med Oncologist or Rad Onc correspondence. l EBC pathway to exit interview usual end of RT l Ad. Br. Ca Pathway - initial then as treatment changes Advanced Breast Cancer (25 women are presently having Treatment at MNCCI, others will be having endocrine therapy (alone) and managed from private Oncologists rooms Oncologist estimate 30 patients)

Distress Screening

Distress Screening

Counselling l Advanced Communication skills in BCN Role so able to provide initial counselling and assessment – Management of Anxiety related to Cancer diagnosis – Assessment of other concerns – Safety l Social workers in Cancer care l GP for Mental Health Care Plan and referral to Psychologist l Beyond blue New. Access (6 sessions) l Mental Health assessment via PMBH emergency.

Other Supports that may Help l Look Good feel Better l Lymphoedema Nurse l ENCORE Exercise program or the Get Healthy NSW health l Dragon Boating l Cancer Council – Telephone support l BCNA l Local Peer support – Group at Library; Pink Girls l Complementary Therapies – Meditation Yoga Psychologist Physiotherapist Exercise Physiologist

Types of Breast Cancer Surgery l The Breast – Breast conserving Surgery – Mastectomy l The Nodes – Sentinel Node – Axillary Sample – Axillary Clearance

Breast Reconstruction l Implant l FLAPs – TRAM / Latissimus dorsi / – DIEP(Deep inferior epigastric artery perforator flap (like the TRAM but uses only Abdo skin and Fat l Other variations

Radiotherapy l IMRT + Boost l Field Whole Breast; Chest Wall Lymph Nodal areas l Hypo fractionation 4 weeks instead of 7 weeks l Deep Inspiration Breath Hold (DIBH) – Left side to protect heart l Prone – Protect the Lungs (pendulous Breasts)

Breast cancer treatment Radiotherapy

Radiotherapy DIBH (Deep Inspiration Breath Hold)

Radiotherapy l Skin Care – Eviq – Sorboline – BOZ

Medical Oncology l Chemotherapy l Targeted l Immunotherapy l Endocrine Therapy

Breast cancer treatment Chemotherapy l Triple Negative l Her 2 positive l Node positive l High Grade l Neo-adjuvant Vs Adjuvant l Advanced Breast Cancer

Chemotherapy l Hair loss l Nausea l Hematological- Neutropenic Sepsis l Skin/GIT l Neurological

Breast cancer Treatment Targeted Therapy l Her 2 neu receptor positive Breast Cancer – Herceptin (Trastuzumab) – Perjeta (Pertuzumab) with Herceptin – Kadcyla

Clinical trials/what’s new l Keynote - 355 - Study of Pembrolizumab (MK-3475) Plus Chemotherapy vs. Placebo Plus Chemotherapy for Previously Untreated Locally Recurrent Inoperable or Metastatic Triple Negative Breast Cancer (MK-3475 -355) l GSK phase 1 A Phase I/II Dose Escalation and Expansion Study to Investigate the Safety, Pharmacokinetics, Pharmacodynamics and Clinical Activity of GSK 525762 in Combination With Fulvestrant in Subjects With ER+ Breast Cancer

Clinical Trials- Radiotherapy l ANZ 1601/BIG 16 -02 EXPERT EXamining PErsonalised Radiation Therapy – for low-risk early breast cancer (Risk of Recurrence (ROR) score ≤ 60 characterised using Prosigna (PAM 50) Assay) – A randomised phase III trial of adjuvant radiation therapy versus observation following breast conserving surgery and endocrine therapy in patients with molecularly characterized luminal A early breast cancer – Arm A: RT and endocrine therapy; • Arm B: No RT (endocrine therapy only).

SURVIVORSHIP PLAN– life after Cancer l Surveillance / Fear of Recurrence l Long term side effects – Body image – Hair loss – Scar – Mastectomy – Fatigue – Weight / Exercise – Cardiovascular – Peripheral Neuropathy – Menopause

Breast cancer treatment Endocrine therapy l Oestrogen Receptor and Progestrone Receptor positive l Tamoxifen-Selective estrogen-receptor response modulators (SERMs). – Risk of blood clots, especially in the lungs and legs – Stroke – Cataracts – Endometrial and uterine cancers – Bone loss in premenopausal women – Mood swings, depression, and loss of libido – headaches, nausea, vomiting, skin rash, and decreased sexual interest (impotence in Men)

Breast cancer treatment Endocrine therapy l Aromatase Inhibitors – Risk of heart attack, angina, heart failure, and hypercholesterolemia – Bone loss – Joint pain – Mood swings and depression l Afinitor (Everolimus) an m. TOR inhibitor added to Exemestane – Stomatitis (taste changes) – Pneumonitis – Hyperglycemia – Hyperlipidemia – Nausea

Continue Endocrine Therapy l Estrogen-receptor downregulators (ERDs). Fulvestrant injection IM l Pre-Menopausal - Luteinizing hormone-releasing hormone agents (LHRHs). – E. g. Zoladex or – Oophorectomy

THANK YOU QUESTIONS?