Pruthi, Sandhya

43 Background: Strategies to detect and treat breast cancer continue to improve, and as such, the number of survivors has grown dramatically. To date, there has not been a well-established model to provide cohesive care for breast cancer survivors. Care often feels fragmented and important issues are overlooked due to lack of continuity. The adoption of Survivorship Care Plans has aimed to fill this gap in care, but the literature still demonstrates that our patients’ needs are not being met. Methods: We present a comprehensive model for breast cancer care, within a multidisciplinary breast center, which incorporates consistent management from time of diagnosis through survivorship. This model utilizes the appointment of a dedicated breast internist that meets with each patient at the time of diagnosis and again assumes care at time of survivorship. The breast internists or “onco-generalists” have specialized training in breast cancer/survivorship and work alongside the entire multidisciplinary team. This unique approach incorporates individualized surveillance, integrative management of late treatment effects, and appropriate risk reducing lifestyle education. Results: The inclusion of a dedicated breast internist into survivorship care has been the standard within our center for over 10 years. With this model, we have found that survivorship care is more holistic with a focus on the patients’ overall needs. There is dedicated time to individualized risk assessment, appropriate surveillance, and modifiable risk factor education. The model also allows for incorporation of integrative medicine including mindfulness, acupuncture, and massage therapy to improve quality of life for patients. With this model, patients do not feel the abandonment that is so often experienced by survivors, but rather they feel empowered to enter their new life as a survivor. Conclusions: Continuity of care during and after breast cancer treatment remains a significant issue. By designating an internist with specialized breast training who initially meets with patients upfront, we have been able to create a more integrative approach to survivorship care, which encompasses the patients’ needs both surrounding and outside of their cancer diagnosis.

PURPOSE: Hot flashes can be a prominent problem in women with a history of breast cancer. Given concerns regarding the use of hormonal therapies in such patients, other nonhormonal means for treating hot flashes are required. Based on anecdotal information regarding the efficacy of fluoxetine and other newer antidepressants for treating hot flashes, the present trial was developed. PATIENTS AND METHODS: This trial used a double-blinded, randomized, two-period (4 weeks per period), cross-over methodology to study the efficacy of fluoxetine (20 mg/d) for treating hot flashes in women with a history of breast cancer or a concern regarding the use of estrogen (because of breast cancer risk). Eligible patients had to have reported that they averaged at least 14 hot flashes per week; they could have received tamoxifen or raloxifene as long as they were on a stable dose. The major outcome measure was a bivariate construct representing hot flash frequency and hot flash score, analyzed by a classic sums and differences cross-over analysis. RESULTS: Eighty-one randomized women began protocol therapy. By the end of the first treatment period, hot flash scores (frequency × average severity) decreased 50% in the fluoxetine arm versus 36% in the placebo arm. Cross-over analysis demonstrated a significantly greater marked hot flash score improvement with fluoxetine than placebo (P = .02). The results were not adjusted for potential confounding influences, including age and tamoxifen use. The fluoxetine was well tolerated. CONCLUSION: This dose of fluoxetine resulted in a modest improvement in hot flashes.

147 Background: The Institute of Medicine recommends development of cancer survivorship care models that are patient centered. We designed a cross-sectional survey to determine the medical and psychosocial needs and preferences of breast cancer survivors. Methods: We identified a random sample, stratified by age and chemotherapy usage, of 600 women from MN, WI, and IA, ages 18-99, within 1-5 years of diagnosis of stage 0-3 breast cancer and seen at our institution. Results: We received 329 surveys (response rate 55%). Respondents were a mean age of 58 years (range 26-89) and a mean of 3.3 years from cancer diagnosis (range 1.2-5.4). 96% were white and stage distribution was: 15% stage 0, 35% stage 1, 32% stage 2, 15% stage 3, and 3% missing. Treatment included mastectomy (60%), lumpectomy (40%), radiation (61%), chemotherapy (55%) and hormonal therapy (50%). Most common treatment-related sequelae were neuropathy (38%), chest wall or arm pain (27%), and lymphedema (26%). Over half (52%) report worry and 45% report fatigue as a problem in the past week. 74% stated that their medical needs were met, whereas 49% said their psychological and spiritual needs were met (p<0.01). 68% understood the follow-up plan after treatment was complete. Perceived barriers to follow up care were anxiety (30%) and lack of coordination (10%). When queried about post-treatment care, the following aspects were considered important (% of patients ranking ≥7 on scale 0-10: 0=not important, 10=very important): breast/chest wall exam (88%); screening for osteoporosis (71%), colorectal cancer (69%), and heart disease (65%); educational materials (64%); mammography (63%); physical therapy (61%); diet and exercise counseling (60%); and complementary/alternative medicine information (53%). Less important were psychology (44%), gynecology (43%), chaplain services (35%), support groups (32%), social work (20%), and infertility experts (4%). 60% expressed interest in attending a survivorship clinic. Conclusions: This survey provides unique data on breast cancer survivors, and efforts should be made to optimize medical and psychosocial care in line with their needs and preferences. These results will be imperative in designing a wellness and survivorship clinic.

Abstract Aromatase inhibitors (AI) profoundly suppress estrogen levels in postmenopausal women and are effective in breast cancer prevention among high-risk postmenopausal women. Unfortunately, AI treatment is associated with undesirable side effects that limit patient acceptance for primary prevention of breast cancer. A double-blind, randomized trial was conducted to determine whether low and intermittent doses of letrozole can achieve effective estrogen suppression with a more favorable side-effect profile. Overall, 112 postmenopausal women at increased risk for breast cancer were randomized to receive letrozole at 2.5 mg once daily (QD, standard dose arm), 2.5 mg every Monday, Wednesday, and Friday (Q-MWF), 1.0 mg Q-MWF, or 0.25 mg Q-MWF for 24 weeks. Primary endpoint was suppression in serum estradiol levels at the end of letrozole intervention. Secondary endpoints included changes in serum estrone, testosterone, C-telopeptide (marker of bone resorption), lipid profile, and quality-of-life measures (QoL) following treatment. Significant estrogen suppression was observed in all dose arms with an average of 75% to 78% and 86% to 93% reduction in serum estradiol and estrone levels, respectively. There were no differences among dose arms with respect to changes in C-telopeptide levels, lipid profile, adverse events (AE), or QoL measures. We conclude that low and intermittent doses of letrozole are not inferior to standard dose in estrogen suppression and resulted in a similar side-effect profile compared with standard dose. Further studies are needed to determine the feasibility of selecting an effective AI dosing schedule with better tolerability. Cancer Prev Res; 9(2); 142–8. ©2015 AACR.

Background: Care of the gynecologic cancer survivor extends beyond cancer treatment to encompass promotion of sexual, cardiovascular, bone, and brain health; management of fertility, contraception, and vasomotor symptoms; and genetic counseling. Methods: This is a narrative review of the data and guidelines regarding care and surveillance of the gynecologic cancer survivor. We searched databases including PubMed, Cochrane, and Scopus using the search terms gynecologic cancer, cancer surveillance, and cancer survivor and reached a consensus for articles chosen for inclusion in the review based on availability in the English language and publication since 2001, as well as key older articles, consensus statements, and practice guidelines from professional societies. However, we did not undertake an extensive systematic search of the literature to identify all potentially relevant studies, nor did we utilize statistical methods to summarize data. We offer clinical recommendations for the management of gynecologic cancer survivors based on review of evidence and our collective clinical experience. Results: Key messages include the limitations of laboratory studies, including CA-125, and imaging in the setting of gynecologic cancer surveillance, hormonal and non-hormonal management of treatment-related vasomotor symptoms and genitourinary syndrome of menopause, as well as recommendations for general health screening, fertility preservation, and contraception. Conclusions: A holistic approach to care extending beyond cancer treatment alone benefits gynecologic cancer survivors. In addition to surveillance for cancer recurrence and late treatment side effects, survivors benefit from guidance on hormonal, contraceptive, and fertility management and promotion of cardiovascular, bone, brain, and sexual health.

Many women at increased risk for breast cancer would benefit from referral for genetic testing, enhanced screening, preventive therapy or risk-reducing surgery. We present a visual model and a step-wise approach to assist with a personalized risk stratification and management of these women. We present current recommendations with respect to lifestyle behaviors and mammographic screening, and we review the current evidence regarding enhanced screening and risk-reducing therapies. We discuss the usefulness of three risk-assessment tools in determining whether a woman qualifies for genetic testing, enhanced screening or preventive therapy and present four cases to demonstrate the usefulness of this approach in the clinical setting.