Multidisciplinary approach to Young Breast Cancer Nursing. Department of Surgery, Soonchunhyang University, Cheonan Hospital Eunju Lee

Transcription

1 Multidisciplinary approach to Young Breast Cancer Nursing Department of Surgery, Soonchunhyang University, Cheonan Hospital Eunju Lee

2 I have nothing to disclose. No relevant financial relationships with commercial interests.

3 Contents Introduction Treatment Pregnancy Psychotic issues and counseling

4 What is Breast cancer?

5 Definition of Young < 40 years women were concerned with fertility preservation, pregnancy, and lactation Different approach and management from slightly older pre- and peri-menopausal women

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7 Current incidence of breast cancer in Korea # of patients Years

8 Distribution of breast cancer incidence by age in Korea Ratio(%) Young age breast cancer Age

9 Treatment

10 Multidisciplinary Team

11 Prognosis and outcomes amongst young women with breast cancer Is young age a negative prognostic factor?

12 SEER Program data N=243,012 (Year ) < 40 (n=15,548) 40 (n=227,464) P-value T > 2cm 61.4% 48.2% < Node-positive 45.4% 33.6% < ER-negative 28% 14.% < PgR-negative 30.1% 20.4% < Grade % 25.9% < 0.001

13 Inferior prognosis among the youngest women(< 40 years of age) Disease-free survival (%) Disease-free survival (months)

14 Basal Luminal B HER2 Chi-square : p <0.0001

15 Particulary poorer outcome in ER + tumors

16 Major considerations and principles concerning with young age breast cancer Considerations Biological characteristics Diagnostic delay Prognosis Local therapy Adjuvant chemotherapy Adjuvant hormonal therapy Others Unique features Higher proliferation rates, more grade 3 & higher ER negativity More BRCA 1/2 mutations More advanced stage at presentation Worse ER positive breast cancer 5% increased risk of death/1-year reduction in age More IBTR Higher importance of sufficient resection margins Boost radiotherapy should be considered Less chemotherapy-induced amenorrhea Greater benefits from chemotherapy Tamoxifen resistance Premature ovarian failure and infertility More emotional distress and proper quality of life

17 Treatment and Management of young women with breast cancer Should treatment options for young women be more aggressive?

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19 Special considerations in the treatment of young women with breast cancer Fertility Genetics Menopausal symptoms Sexual dysfunction Psychosocial stress

20 Fertility Young women may have fertility concern at diagnosis in follow up: Early referral to reproductive endocrinologist (before treatment start) for patients interested in future pregnancies Young women should be informed that pregnancy after breast cancer is thought to be safe in most cases

21 Genetics Women who develop breast cancer at a young age (<40 years) are at increase risk of harboring a BRCA1 or BRCA 2 mutation Referral to genetic counsellor for all patients under 40 years age at diagnosis If BRCA testing is performed, result may guide local treatments

22 Menopausal symptoms Chemotherapy-related amenorrhea, medical ovarian suppression and/or tamoxifen may substantial cause hot flushes: Dressing in layers, avoiding triggers, cold packs, antidepressants (e.g. venlafaxine) or gabapentin may reduce symptoms

23 Sexual dysfunction Surgical and medical therapies may impair sexual function via change in body image and vaginal dryness: Vaginal lubricant/moisturizers and individual/couples counseling may be recommended depending on the nature of the problem

24 Psychosocial stress Young women may experience distress at diagnosis and in survivorship: Counseling and support group may help young women adapted to the changes that breast cancer brings to their families, work and priorities

25 Genetics

26 Screening Cancer Syndromes and Breast Cancer in Young Women (BCY) HBOC (Hereditary Breast and Ovarian Cancer) (BRCA 1/2) LI-Fraumeni (TP53) Cowden (PTEN) Hereditary Diffuse Gastric Cancer (CDH1) Peutz-Jeghers (STK11)

27 Genetic mutation High Risk * Male breast cancer * Bilateral breast cancer * Age <40 * Coexistence of ovarian cancer * Family History (Breast cancer or ovary cancer)

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29 Family history of Unilateral breast cancer: BRCA:36%, BRCA2:47% Family history of Contra-lateral breast cancer: BRCA:48%, BRCA2:59% Male breast cancer: BRCA1:5%, BRCA2:6% Antoniou A, et al. Am J Hum Genet 2003

30 BRCA1, BRCA2 Genetic mutation penetrance (KOHBRA) BRCA1 BRCA2 Han SA, et al. J Breast Cancer 2009

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32 Examination method (Ovarian cancer) by BRCA carrier - Since Age 35: twice a year * CA 125 * TV-USG

33 Other cancer by BRCA carrier * Stomach cancer, colon cancer, Pancreatic cancer, GB cancer.. * Endoscopic - GFS: Age 40 Every 2year - CFS: Age 50 Every 5-10 year * Prostate cancer - DRE - PSA:4.0ng/ml - TRUS(Transrectal Ultrasonopraphy)

34 Self examination by BRCA carrier BRCA carrier *Since age 18: breast self examination once a month *Since age 25:Clinical breast examination every six months *Since age 25:Baseline mammogram every year & MRI

35 Self examination by BRCA carrier BRCA carrier - male *Since age 35: breast self examination once a month *Since age 35:Clinical breast examination twice a year *Age of 40:Baseline mammogram (Gynecomastia : mammography once a month) *Prostate cancer examination

36 Pregnancy

37 Fertility Number of follicles(fertility) Age

38 Number of follicles(fertility)

39 Pregnancy How long to wait before getting pregnant? * Recurrence rate is higher in the first 2 years after diagnosis. * Endocrine therapy for at least 2 3 years has a substantial impact on survival (Gnantet al., 2011). * Pregnancy After Breast Cancer Does Not Increase Chance of Recurrence For immediate release. ASCO (2017) * A non-hormonal contraception (condoms, diaphragm and IUCD) is recommended until 2 months after the end of tamoxifen treatment even in the lack of regular menstruation.

40 Web site fertilehope (USA) fertiprotekt

41 Psychotic issues & counselling

42 Married & Delivery Work Recurrence Body image Depression

43 Medicare counseling A process that help to understand one s medical and psychological circumstances in relation to their illness and adjust to their relationship with their family.

44 Counseling attitude Respectiveness Genuineness Sympathy

45 Counseling process To Set up objective Break silence Planning Eye contact

46 Interviewing technique 1.Communication Verbal Communication Non-Verbal Communication Matching

47 Interviewing technique 2 Questioning Open-ended Focused Closed-ended Rephasing Reflecting

48 Take Home Messages All patients, both in the early and advanced setting, should be discussed within a multidisciplinary breast unit team (breast nurses crucial as navigators ).

49 Take Home Messages Personalized psychosocial support, counselling on genetic predisposition, sexuality and fertility should be highly recommended as part of the individual treatment planning.

50 Thank you