Dr. Ann Partridge discusses the four major areas of cancer survivorship and the role of the oncology health care practitioner in optimizing cancer survivorship care.
Back to Symposium Page » and I would like to introduce you to our next speaker, Doctor And Partridge is a professor of medicine at Harvard Medical School and vice chair of medical oncology at Dana Farber Cancer Institute, where she also serves as director of the Adults Survivorship program and leads the program for young women with breast cancer. As a medical oncologist and clinical researcher, she has sought to improve the care and outcomes of patients with cancer by conducting research and by developing innovative clinical programming. Doctor Partridges most substantial research contributions focused on clinical epidemiology of breast cancer and young women. She's established and served serves as P. I for Young Women's Breast Cancer Study, a multi institutional cohort of young women with breast cancer, which enrolled over 1300 women aged 40 and younger. At diagnosis, she's also had a have a team with her team. She has characterized a range of issues of young breast cancer survivors, including the impact of treatment on fertility adherence with hormone. Oh, there are P psychological adaptations to the diagnosis, including impact of treatment on sexual functioning and the factors that play an important role in patient decision making. More recently, she has collaborated to develop and study interventions to improve outcomes and young cancer survivors, and worked with basic investigators to identify molecular differences in tumors found in young patients and potential biomarkers of cancer risk and long term effects. Dr. Partridge serves in leadership roles nationally and internationally. She is co chair of the Breast Committee of the Alliance for Clinical Trials and Oncology. Was chair of the Scientific Program Committee for the 2000 and 18 American Society of Clinical Oncology. ASCO annual meeting co chairs the by Ennio Ehsmoh Eso sponsored breast cancer and Young Woman Conference and served as chair of the Center of for Disease Control and Prevention Advisory Committee on Breast Cancer and Young Woman from 2000 and 10 to 2000 and 17. She has received prior awards and grants, including a Champions of Change award from the White from the White House and Asko Improving Cancer Care Grant, the CDC Carol Friedman Award, the Edward James Binge Junior Award for advancing the Careers of Women faculty, the American Association for Cancer Research Outstanding Investigator Award for breast cancer and that Ellen Stovall award and cancer survivorship from ASCO and the A Clifford Barger Excellent and Mentoring award from Harvard Medical School. After graduating from Georgetown University, Dr Partridge received her medical degree from Cornell University Medical College per student, internal medicine residency at the hospital for the University of Pennsylvania and completed medical oncology and hematology fellowship at Dana Farber Partners. Cancer Care. She's earned a master of public health degree at the Harvard School of Public Health. So welcome, Dr Partridge. Thank you and thanks for having may. I'm delighted to be here with you all today. And as you can see in my background, it's been a beautiful, beautiful day, uh, in the Northeast and New England in particular, watching the foliage. So e hope all of you also are having a beautiful day. I'm going to be talking about cancer survivorship. Andi. How we in particular as caregivers can help to improve the care of our patients through and beyond their cancer diagnosis and treatment. Here we go is my disclosure. Nothing got exciting. So first, let's start with a definition who's a cancer survivor. There are new definitions coming to us from the National Cancer Institute as of last year, and a cancer survivors, an individual who from the time of their diagnosis for the balance of his or her life. There are many types of survivors, including those living with cancer and those free of cancer. It's meant to emphasize ah, population of those with ever a history of cancer, rather than to provide a label that may or may not resonate with individuals. We all know that some people love the term, and some people hate the term. But we've got to call it something and what we typically are referring to. However, with some exceptions, when we think about the caring for individual populations as well a specific modalities air strategies is people who have been through cancer and the treatment and are often living with the aftermath but perhaps not living with the actual disease. That's often the focus we think about. But I think we allow it to encompass other populations as well, which is captain captured in this definition and therefore cancer survivorship spans the journey, the cancer care continuum you can see here outline, and just like treating a person's cancer needs vary between individuals as well as within individuals along the continuum. It's really important to recognize that another huge factor is that in the United States and worldwide, the number of cancer survivors is, of course, growing. And that's a really good thing because it means we're affecting war cures. MAWR treatments, where people can live with chronic disease and live without cancer. After having had a diagnosis as 2019, it's been estimated there at least almost 17 million cancer survivors in the US alone. And that represents about 5% of the population. And it's expected to go up another couple million out over the next, more than a couple of other six million over the next decade. And so this is a growing population that we need to attend to in our in our in our providing our clinics as well as society. This is breaking down the estimated number of cancer survivors in the US by their current age. And you heard from my bio. I focused a lot on the way the adolescent young adults survivor. But the truth is, when you think about the demographics of our population in the United States and the fact that cancer is essentially a disease of aging, the actual population of cancer survivors really is comprised of more older folks. The pie graph here that you can see at least three quarters of it represents people 60 and older. So as we design programs, as we think about who's likely to walk in our clinic as a cancer survivor who we need to manage in the outback of the of the treatment, it's often not that young people, although of course, they represented a substantial minority. It's really older folks, and we need to think about how the help them also to manage their cancer experience. This is showing it broken down by the sight of cancer that people had. Andi. It's not surprising that the groups with the largest number of cancer survivors are the very often treatable as well a screened groups where you're diagnosing really early on dso prostate breast. But you can see that other larger groups exist as well. Even long is a growing cancer survivor group, colorectal gynecologic that he malignancies on. Did you could see that the on the Y axis there? It's the million. So these air large populations and again we have to think about what does do different groups need because, of course, one size doesn't fit all in our provider, Cam. So why does this matter? Let's just step back a second and say, You know, Okay, you wanna hold people's hand, You want to help them emotionally, But But why does it really matter from a health care kind of dollars and cents and why we should spend some time on this in this course and thank you for having me. It matters because if we give appropriate care and good follow up care, we could potentially detect problems that could be prevented, cured or controlled. Improve either morbidity or mortality from those problems. And then on top of that overuse and under use of medical resource is, has been documented in our literature for follow but appears to be quite common in long term survivors. And so, from a societal standpoint, it's important that we understand what's worth doing and what's not worth doing, and continued it to expand the evidence base to inform what we do in our politics. So I got this live from my colleague Antonio Wolf, and he showed this at a talk a few years ago that is called the web of cancer survivorship. And when I thought I thought Oh, that's a complex Web. When I think about cancer survivorship. Sure, these air really important things. You got the economics, you got personal, you got the co morbid, and you've got all these little guys on the side. But when I see something like this, especially when I'm talking to an audience of people who don't just focus on cancer survivorship of focus on either, you know, caring for a lot of patients with different kinds of cancers or one kind of cancer, a primary care doctors where cancer is just, you know, our clinicians, where cancer is just one of the diseases their patients can get, get a little overwhelmed on the humble breast cancer doctor. And this is a little too much for me to be honest. And so I like to simplify. And as you can see here, I think if you take anything away from our discussion today, when I go in and see a patient and I think about these four buckets, when I see people and follow up and I see them through this lens, I almost always get it something that we hadn't otherwise discussed on. I always feel like I've done them due diligence in their survivorship care. So if you have any take home point from today these four things when you see someone and follow up from a cancer, whether you're a primary care doctor, your clinician and a subspecialty area, you're an oncologist or something in that realm. This can help you. So think about this. Use of the four buckets recurrence and new cancers, long term late effects, modifiable health behaviors and coordination of care. And I'll get into each of these buckets, OK, and included in that long term late effects that bucket as the psychosocial. So if you think about that complex web that I just showed you all those things air in here. But they're here in a kind of, I think, less overwhelming, more manageable in your practice way. All right, so let's start with Bucket number one, surveillance, screening and Prevention of Recurrence in new cancers. This is the thing that's on most cancer survivors minds. And as an oncologist, you know, any time a person comes in, you know, in my head it is a back that they have something new and then you're managing the rest, and we're pretty good at this as a rule, especially early on. And the question that comes up for most patients, especially those with solid tumors, is Do I get scanned? How you're gonna watch me, Doc? How am I going to know that I am okay or not to scan? And here I'm thinking about people who have been treated for pure and they have no evidence of disease clinically. But do you look aggressively for signs of early recurrence? So the rationale for screening for recurrent cancer would be to detect asymptomatic disease, right, Because you're gonna look into something that they have a symptom that would improve morbidity or mentality. Ideally, this would lead to additional testing and potential early intervention. It's got to be cost effective for that, for the population and safe in the population. And then it's got to make sense for that individual. So, for example, if a person can undergo the potentially curative thing that would helped, Um, if you found something, then you wouldn't put them through a scan or screen to try and detect that problem just thinking about that. So here's an example of colon cancer we know in colon cancer, and this is from one of the large randomized trials that when you do see EEA and follow up as well a. C T and follow up. And here there were 1200 plus patients randomized with stage one through three disease. If you did one of these modalities and you can see here with curves, either CE A or C T. People did better in the long run in terms of detecting recurrences and detecting recurrences that could be treated with curative intent, which is of course, going to improve their long term outcomes if you could cure them. Alright. They put this together and found that from this study that intensive follow up with either CE A or C T increase the likelihood of detecting recurrent that could be treated with curative intent. They didn't see an advantage in this particular randomized trial for both strategies combined, and then they showed outcomes wise. The absolute difference in the proportion of participants treated with curative intent was approximately 5% in the I T T group in the intention to treat group and 8% in the a valuable subset so you could make a delta and potentially cure 8% more people, right? Doesn't mean you're carrying them all, but you're getting the more of them a good chance. Then of course you're going to say Yeah, maybe we should do that. Obviously, depending on what the society or the insurances are willing to pay eso in colon cancer. But there are guidelines, and based on those and other data, asco in particular, recommended there. Of course, other guidelines that medical history, physical exam, and then and follow up people get C e. A s every 3 to 6 months for five years. It's important to note that in the first five years, the vast majority of recurrences Air Detective, as you can see here And then there's also recommendation for CDs. Fans every three years are actually every year for three years. Um, no recommendation for other image ing during that time. And this is you know, of course, in guidelines you have to weigh all the other data and think about all the other bells and whistles you could add on. So, you know you want to be both physically and patient responsible and at the same time get to that sweet spot where you may actually help someone with the end where the evidence shows it. This is in contrast to breast cancer again, one of the larger populations where we have randomized data that doesn't support doing routine screening for recurrent disease outside of the breast. So this is one of the biggest studies is about 1300 patients randomized in the nineties to intensive surveillance, do drawer versus standard follow up, which included regular mammography, regular history and physical solicitation of symptoms, and then follow up care. And what they found is you can see bold in the yellow. Overall survival was the same, at least statistically, actually, slightly better in the standard. Follow and quality of life was the same. And I would actually argue that if having scanned people on a regular basis with, you know, with metastatic disease, at least that if you had surveyed people about their quality of life between, they're scan and not getting the results. Probably life might have been worse in the group that was being intensively surveilled, but they didn't find that, Um, the other important lesson learns from both that study, another randomized trial and breast cancer survivors, as well as multiple other evidence that are not quite as robust are that most symptoms and are not related to recurrent at least breast cancer survivors. And that's probably true in most of the other solid tumor survivor groups. Most recurrences were heralded by symptoms. So in now, those data on Lee, a minority of the patients were actually detected toe have a recurrence by scans. If they were destined, taboo recurrence, most of it was picked up on symptoms that prompted image ing in between. Finally, lab and radiology test can have significant false positive rates and lead to excess testing and risks from that, as well as the anxiety, of course. And then we also have data, at least in the breast cancer. Well, the patients could be educated by this, so you know they're all taught follow up care, early detection, blah blah, blah. We get that when it comes to breast cancer in the breast. But when it spreads also were in the body, it can take a patient a while to understand that, at least with present day therapies, picking it up a little bit earlier does not appear to improve how people do in the long run. That doesn't mean we can't test it again as we get better therapies coming on. But based on the data that we have today, we do not recommend further evaluation without symptom, prompting that beyond mammogram or breast division. Now let's switch gears to lung cancer, and I highlight lung cancer because when I first got into the business of survivorship and we started to collate together, well, what are all the follow up recommendations for the different groups of different cancer types? At least the big ones that are institution so interesting? You can see here and this was published a few years ago. Look how many guidelines there are for follow up care for lung cancer, and they're kind of close to each other. But they're pretty heterogeneous if you get into the nitty gritty and there's always that kind of heterogeneity when there aren't good data to inform. So people kind of make it up. What is the prudent oncologists? Dio So I I beg of you all keep doing research in this area or put people on studies, refer your patients so we can continue to learn what is the optimal follow up strategy for folks so moving forward Basically, we've gone around and use guidelines that exist. If there's evidence to inform them or spoken to our and and spoken to our leaders and our divisions of different disease groups and come up with what is the prudent oncologists do, at least the Dana Farber based on the evidence? And if there is an evidence, decisions still need to be made. So as I showed you in breast cancer, you can see what the standard recommendations are. And of course, there is decent evidence around this same thing in colon cancer as I just showed you lung cancer, you know, decisions need to be made, and this is what we've come up with. We have recommendations around prostate, many thing People need scans, but generally in patients treated for any D, no evidence of disease. It's really not about the scan. It's about the P S A and the digital rectal, Um, and then and so on and so on. In other diseases, such as human logic malignancies, there are scans and blood work. In Guiyu, bladder test eases disease dependent, but also scans often come in depending on the stage of disease. I think gynecologic malignancies. It's tailored to the disease. Eso you want to know where to look? And CCN also has very nice guidelines and follow up alright. Finally, when we talk about the the current cancer and new primaries in the 21st century, we cannot ignore genetics and we need toe in. Survivors update their family history because, of course, their family history maybe changing in long term follow and revisit genetics. Survivorship care definitely needs to be doing this, and we might want to send people to the genetic counselor for testing barriers to testing. And diagnosis may have diminished over time for a particular disease or a particular gene. We've learned a lot in the last decade or two about genetics and genetic predisposition to cancer. The testing itself is evolving, and then, of course, the patient and the system level indications for testing is evolving. So, for example, in my disease that I focused on breast cancer. If you were a 50 year old woman without a strong breast cancer in your family and not triple negative breast skin genetic testing. Now we have data that suggests that if women have triple negative breast cancer before the age of 60 there's something on the order of a 30 to 35% chance that they might have, ah, hereditary predisposition to getting breast cancer. So when I see those patients and follow up, especially if they have family, that's at risk. I like to make sure that we talk about this very important, because you could not only help them if they have remaining breast tissue and adding more testing an image ing. But you could also help their family members so super important to bring it up in the survivorship space. And it may be that you also just never got two of the patient early on because it wasn't going to change their treatment at that time. All right, now let's switch gears to that second big bucket prevention and management of long term light effects. All right now, there are veritable laundry lists around late effects that could occur short term and long term in our patients from either the disease or the treatment or life in relation to the disease and the treatment like what else can happen to people? So here I also like to take ah kind of broader approach, like step back and take a big picture approach because you could get overwhelmed with little picture. So when I think about patients who have had local therapy, you want to think site specific and field. So if a person had a surgery in the rectal region, let's say they had rectal cancer and they got chemo radiation or they got surgery because it was low interior. They needed it. What do you think about you? Think about local things, paying numbness, lymphedema, restricted motion or weakness. And you want to elicit these things from patient because there's things that can be done. You worry long term about cellulitis, nerve damage, bone fracture, Newman itis, lung fibrosis, particularly in patients who got radiation. There's the all important functional cosmetic or reconstructive changes. And there is a whole field of doctors, particularly surgeons, plastic surgeons, urologic reconstructive surgeons, people out there that are available to help our patients when they have issues. Pa's IA trist. That can help with a lot of the functional issues, and we need toe, elicit the problems from the patients and then refer. It's not us that can provide the service to help them improve heart disease, sarcoma, skin and other second cancers lung, fibrosis, thes air, The more insidious problems we need to have our antennas up when we're seeing patients involved. Remember what their treatment waas and remember when they complain about something, that they may be higher risk for a new problem on shortness of breath in a patient who got mental radiation and recycling might make you a little bit more worried at age 40 than in your regular garden variety. Patient has never been exposed to any of those things. Same thing with their skin. A little change in a mall in a young, healthy person might be a little different in a cancer survivor in terms of getting them into the dermatologist for evaluation. And then, finally, people can experience the systemic effects of site specific treatment. Most notably, things like you get radiated up here. You might have hypothyroidism develop immediately or over time. Ah, person who's had and you, you know radiation to their head clearly is at risk for endocrine off of these, so we need to know these things, and they often occur early on. But we have to also remember that sometimes they can occur later, especially in adult population. So we want to keep that in mind and have a sense of what could happen to our patients. Or at least remember their cancer treatment. If you're seeing them in long term follow up to kind of go back to why they might be higher risk from a systemic, very pay stamp when I also be again don't like to be overwhelmed. I like to take a systems approach kind of like when you were in medical school and I had to learn all the systems or you were in the I C U in training and you know, you had a sick patient Come in. You have to remember all this stuff. If you see someone who's coming in, kind of tired from their cancer or sick, you want to take a step back and take a systems level approach. So I put up the systems here, but I'm going to give you an example to help you think through this. So, for example, ah, person comes in and they are getting a d t for prostate cancer. Okay, androgen deprivation, therapy for prostate cancer and my naive self. I'm not a prostate cancer doctor. When I first started caring for survivors and thinking about them all I remembered from about a D T. Was the fact that it caused, you know, people that lose their mojo loss of libido, erectile dysfunction. But actually, when you step back, if you know about a D T and you should. If you're caring for these people, there's a whole lot more they're at risk for. So if your prostate cancer provide patient comes in and they feel tired or they have shortness of breath, you got to kind of know what kinds of systems could be impacted on this. And he here are the other things that can happen to someone on a D. T. They can have cognitive decline, altered body composition, arterial stiffness, bone thinning and osteoporosis. That's not something they're going to complain about, But God knows you don't wanna have to have enough fracture, metabolic syndrome, fatigue and, of course, the associated cardiovascular morbidity. So this is the kind of patient where you want to maybe get them into. The cardiologists are back to their primary care physician sooner than rather than later. Fatigue is also something you gotta manage. Exercise is something that may help that. So if you don't know what to look for, you're not going to know how to help these patients. Just a good systems level approach can help them. All right, let's focus a little bit, though, on the cardiovascular morbidity and why? Well, we know that a D T could be a problem for people in, you know, men with prostate cancer. In particular, it's been associate with unfavorable metabolic changes. And while to date no randomized trials have perspectively addressed cardiovascular risk of a D. T that have reported out, we do know. And you can see the data here that cardiovascular death in men receiving a D T. Does not appear to be greater in the randomized trials of it. But in men who have had prior, clear cardiovascular events, if they start on a d t, they are much higher risk of having another cardiovascular event within the first six months. So it's not a slam dunk, but hearts are pretty important, and these are things that I would say make sure that patient is getting optimized for their lipids hypertensive issues in with their cardiologists, if they've had an event, and for men who haven't had an event yet. If they have other risk factors, you might wanna work with their primary care physician to make sure that their risks are optimized. Smoking cessation, all the things that they're associate with. Heart disease. We want to be careful of it out, because what do cancer survivors die of if they don't die of the cancer? And for these many early stage detected cancers like breast cancer and colon cancer, the vast majority of people won't die of the cancer. What did they die of? You can see here. This was a very interesting study, published where they looked at non cancer deaths for and follow up time in cancer survivors on Dukan. See here that a lot of others, but what's the biggest bucket cardiovascular disease in the bright red? I want to highlight, though, that there are very preventable things in there. OK, like some of the smoking related things, but heart disease. Okay, so we want to be on that, because that's the number one killer of Americans. Just like it is off. Cancer survivors who don't die of the cancer. Second cancers is a growing problem in cancer survivors. It's been estimated. It's something around one in five new cancer diagnoses are actually happening today in cancer survivors, so that their second time at that rodeo and then finally, while this is not a huge population, suicide is actually more prevalent in cancer survivors, particularly some groups than other groups of patients. And you got groups of our population, and you can see here it does appear to be Maura Tha risk earlier on in the treatment trajectory. But it continues. That's like E don't know if you can see it's the little blue line. That's the second from the top after the gray and obviously death from suicide to run this in any population. But if it's related to their cancer experience and there's a higher risk, especially in a high curable cancer, that's a tragedy. More on that later. Let's get back to heart disease for a second. There are increasing links between cancer and heart disease, first of all, increasing age. Remember cancers, diseases of aging. So it's heart disease. There's a new kid in town called clonal Matip, oasis of indeterminate potential that's called ship, and that's something that you can detect the biomarker that could be detected, not something that were routinely looking for yet. But it's something that's been shown in many people's labs and many clinical epidemiology studies, and we're working on some of that ourselves in our survivors with some some basic laboratory researchers has been associated with higher risk of getting a secondary human logic malignancy or just the primary human logical agency, particularly MDs. But it's also got a very high risk of heart disease in the general population, and it goes up as people age. And so it's. It's the relationship between cancer and cancer treatment and heart disease that's now being worked out in lab in the clinics. There are also shared risk factors for both cancer and heart disease, tobacco, the growing obesity epidemic in our population, physical in activity and then, of course, menopause and women or 80 tianmen. And then finally we people get cancer, and then we give them treatments that may have cardio toxic effects with good intentions. So this is a group that's high risk for heart problems, that we need to be onto them very aware and also referring and supporting as needed. All right, I'm going to switch gears now and talk about some of them or common, but also not easy to talk about in the clinics issues long term late effects that can happen to our survivors of sexual health. It's the elephant in the room. For many people, this is a really important thing for many of our survivors. But it's often something that we don't have time to address and follow up. Or the patient is uncomfortable bringing up for the doctor, the nurse from district uncomfortable bringing it up. And so it's one of those things that I think you got to develop a system to ask you. Either do it yourself or you get somebody to screen because you know treatment depends on the primary problem. It's often multifactorial. I'm here. I'm focusing on women this slide. So for women who've been through cancer treatment, if estrogen replacement therapy is appropriate, you could give it back to them. Obviously, in breast cancer, we don't tend to do that. So you do non hormonal water based lubricants, if possible for vaginal dryness and this brew Nia vaginal Dilip ation can be used for stenosis. Medications can help with libido problems and sex therapy, couples counseling and psychotherapy can be really helpful because, of course, it's not just patient, but it's her whole ecosystem when she's diagnosed with cancer in her body, image issues around. A lot of the cancer is not just breast cancer, and we do know that while a lot of people might say and nothing's gonna help, there actually was a nice small randomized trial conducted by Patty Dan's at U. C. L. A. Where she randomized a small group of breast cancer survivors to usual care versus treatment of their sexual menopausal complaints with assessment, education, counseling and interventions tailored to their complaints. And she actually showed a really nice delta with the A menopausal symptoms as well as the sexual functioning. So treatment works. If you ask people, they'll often endorsed symptoms that you can then either help them with a teaching she and some guidance or referral to a website or to a sexual health counselor. If you're lucky enough to have one near you, Alright, what about for men? As I alluded to earlier those men on E D T. It's E. D that we all worry about. Of course, they can have all the other things. The couple's issues the other stuff, and you might want to get that involved in that. But E D is something that we can refer them to urology or their primary care, depending on who in your area actually takes care of them. But we can also make recommendations so you want to modify the reversible causes, and you can see this here. First line therapy is listed there. There's, you know, the oral agents. There is vacuum devices. Obviously, you generally get urology involved for that couples or sexual therapy. And then you can see there are second line and third line therapies. Obviously, you need a urologist for a lot of that stuff, but they're doing it. And those those guys were out there to help the urology providers. And so if you plug a patient and they don't have to live feeling badly because they can't perform if this is something that's important to them. But it's another thing that if you don't ask, they may not tell you because it's uncomfortable. It's embarrassing. Your wife might tell U. S. So it's really something that we need. Thio are the partner. We really need to speak Thio our patients and all this. It's this kind of thing in a review of systems. And, of course, your survivorship review assistant is going to be different to some degree, then your standard like sick patient with your assistance. All right, Another hot off the presses area that we deal with a lot in the breast cancer world in particular in the prostate cancer world as well. Um, is how do we manage those damn hot flashes that could get in the way of people from tolerating their therapy? Well, this is literally hot off the presses. It was published last year. We've got a lot of therapies, but Occid butin and actually reduces hot flashes. Who would have known? I didn't know that till they published this paper. So they randomized 150 women, uh thio, many of which were on endocrine therapy. And they randomized them to either 2.5 b i D or 5 mg B i. D or a placebo. And the cool thing is that both doses improved weekly hot flash scores and hot flash frequency, and it improved most hot flash related data, daily interference scale measures and actually overall improvement in quality of life because if you're having fewer hot flashes, you actually feel better. Overall, there were more side effects, but they were mostly mild, drying out some difficulty urinating because, of course, are contributing. And it's a bladder problem. I mean, excuse me, is a bladder medication historically, and then some people had some low grade abdominal pain. There were not differences, however, and studied this continuation because of adverse effects. And the 5 mg dose was a little more effective numerically. So. If you're someone's having real problems, you might start there and go down. Or or if they're worried about the side effects or having you might start a 2.5. So that's really good news. And there's actually a case report that it works for men to with a D T. And so, while not a large randomized trial for the men, why not try it if they're suffering from hot flashes and see if they can tolerate the side effects? So a new option for our patients with hot flashes. And to put this all into context, I got this slide from Charles Liu Frenzy who's done a ton of this work at the Mayo clinic to help manage the hot flashes for women with breast cancer in particular, there are now lots of options for our patients. They're not perfect. Some people don't want to take a med to tolerate a med. We understand that. But if people do need it to get the benefits of a judgment or you know not even a judgment treatment for disease that they have, then often we can help them and choose the right one for their disease status. In the interest of time, I won't get into that. But there's really nice work out there by Dr Luke Frenzy and others kind of helping people decide which drug is right for which person, which which situation. All right, another very burdensome symptom in a large group of patients are those aroma taste inhibitor My al Jas Um, John Hershman, out of Columbia just ran this beautiful randomized trial through swaths of acupuncture. So I just alluded to some people don't want to take a medication to deal with the side effects of the medication. This is a nice natural therapy. Acupuncture people get randomized in the study, too. True acupuncture, sham acupuncture versus a weightless control they were treated, as you can see here. And there was even I follow up, period where they weren't getting anything anymore. But they still assess them to look for durability of the acupuncture effect, if there was any. And what she presented a few years ago now was that it worked. Everything worked. Everybody got a little better. There's always a placebo effect. But the true acupuncture had the biggest Delta. Sham also had some, but not as much as true, and Waitlist had the least effect. So true acupuncture was clearly the winner here. There were much improvement in pain on, and you can see here from the worst pain and many other measures. It was sustained over the 12 weeks beyond the initial treatment period. Who knows how long it would be? And we fucked about whether people would need boosters and how long you need to keep doing it on. It was seen on multiple additional pain and stiffness measures and toxicity is minimal. So the real issue with acupuncture is, is it available when your insurance pay for it in the patient, afford it on what they buy into it? But I always tried this now, especially for patients who are willing and who are able to access it, because I think it's a nice adjunct to our follow up care and management of symptoms. All right, so this is a busy slide. There are many, many other things when I showed you those lists and we talked about second malignancies and heart disease and lung cancer, bladder cancer and problems after treatment, you know there are many, many unanswered questions, and we need to continue to grow the evidence base. There are recommendations from asking and others about how we should be following cardiac and bone health in our survivors, so I would refer you to those for secondary malignancies. There's lots of things we don't know but definitely have a low threshold. But looking into any symptoms. And if screenings appropriate for that malignancy, for example, lung cancer survivors, If they're long term survivors and they're still smoking, we now do screening CTS and those people, of course. Um, what about some high high risk groups like lymphoma treated people with mantle radiation or Hodgkin's disease with mantle radiation women who were treated at a young age? You don't have to do a randomized trial, sometimes to show that something is likely to help. This is an example of that Andrea Ing and colleagues of the Dana Farber. They put 148 woman women on a surveillance study where they basically said you had Chester radiation before the age of 35 your higher risk for breast cancer. All the epidemiologic data was coming out showing that, and they followed these women with an annual Marie and mammogram for only three years on what they found was ultimately, 29% of those who ended up having abnormal abnormality had a malignancy. Sensitivity from the emery was 63%. Sensitivity from the mammogram was 68% but when you put them together, 95% sensitivity and ultimately all but one of the patients had of the image detective. Malignancies were pre invasive or small, and all were no negative. So these were detecting disease that could be difficult to treat in women. That was clearly earlier, even though than you would expect, even though you don't have a control arm with that kind of sensitivity. So this is something we do routinely without randomized control data but to say in a high risk population, it's prudent to do that, which I think it's quite reasonable. I like Thio liking it, too. You know, you don't have to do a randomized controlled trial of the parachute, right? It doesn't always work, but, ah, parachute. Better than having no parachute. We're not going to test it anyway. There are many ongoing studies that air reporting out now things like looking at a sin hih bitters or other types of cardiac medications to prevent cardiac complications of cancer treatment, low dopes, tamoxifen and other preventative agents in our Hodgkin's survivors who got radiation. So stay tuned because these things are ongoing and hopefully we'll have more information for that. All important, not just screening but prevention of those late effects more directly for our teams of survivors. All right, one area that's also had a lot of press and a lot of attention lately, as I alluded to earlier. There is a way patients that pull on our heartstrings is fertility preservation. And here's where I think again, kind of like sexual health. If you don't ask, they may not tell you, especially our young patients who might be caught up appropriately in the, um I'm gonna live or die. But if you have a highly treatable cancer or even a decent chance of surviving or even if you're gonna be living with disease, fertility really does matter to our patients who haven't completed their families. And sometimes it's about helping them breathe the losses. But often we can do things to help them to preserve their fertility. Should they be in a place where they're comfortable trying to have a future biologic child? For men, it's sperm. Cryopreservation is the mainstay, but there are also strategies in order to get the sperm, sometimes in sick patients. For women, the embryo cryopreservation has been a mainstay now, almost a decade ago, who cite cryopreservation became mainstream in the standard of care and an option because we got better at the freeze thaw techniques. And then finally, most recently, ovarian suppression with Groh agonists through treatment has kind of made it to prime time. And we stand breast cancer survivors, and I'm gonna show you those data. So this was published in and full disclosure. I'm part of this research team. Um, this was a meta analysis looking at a number of randomized trials to see whether or not ovarian suppression through site a toxic chemotherapy would improve the likelihood of of fertility and prevention of premature menopause and premenopausal patients going through treatment. You can see these are the studies that were included pretty robust, random honest trial, some negative, some positive. What they showed in the meta analysis was that, yes, indeed, there was an improvement in the rates of Amen Arria. At two years, there was less. Amen Arria at Oh, sorry, this is that one year, um, in the g r H group, and it was similar at two years. And in the meta analysis approach, you could see that everybody leaned towards and the overall group at the bottom, trying that diamonds lean towards generate. Jagan's being better in terms of preventing ovarian insufficiency, at least at one year. What about pregnancies? We'll have you focus on the fact that they are very small numbers, but it did appear to be a small but statistically significant improvement in rates of pregnancies and the G R H group compared to the control group. But no, most of the patients who got pregnant were under 40. That's not shocking, But you know what they're talking to a 41 year old and she's interested in fertility preservation. This may not be the way to go. Most of them were, er, negative. But that's because many people with er positive disease aren't getting pregnant and short term follow because there are hormonal therapy. But it did appear that there were more pregnancies on the same thing In the meta analysis group MAWR January age agonists treated patients had babies after breast cancer compared to the control group. Again look very small numbers that 10% versus 5%. So you have to take it a little with Ukraine and most of us, you know, say, use the blueprint or one of the other generate agonists as kind of. If you can't do the other more tried and true things or you're not up for it or you can't pay for it or something like that because that's still on issue in many situations. For many patients, the important thing also is that it appeared to be safe, so there was no signal that getting ovarian suppression with Jnr age Agnes through treatment worsened how people do in the long run. In fact, we now know that in the er positive setting, it's been shown long term to improve how people do in the long run, all things being equal and overall survival was awash. Actually, people seem to do a tiny bit better in the nards treated group, but nobody quite believes that. All right, so that's including New York positive. So then the question comes up, especially in a breast cancer population. Is it safe to get pregnant, want those hormones fuel the fire and increase my risk of cancer recurrence? Well, this is data from another retrospective analysis of a prospective registry that suggests, no, it's quite safe. And the outcomes for those who became pregnant after a breast cancer whether that breast cancer was here a positive or er negative, were the same. You didn't do any better. You didn't do any worse. Eso Is it safe to get pregnant after our breast cancer? There's no clear adverse effect based on the data that we have. The conventional wisdom is to wait to get through the highest risk of recurrence in the ER negative setting in the ER positive setting to get some endocrine therapy under your belt. There is no data suggest harm in a pregnancy sooner, especially although you would want to wait at least 6 to 12 months to kind of get all kinds of chemo out of your system. And ultimately, the decision to get pregnant is a very personal one, dependent on both the patient and the loved ones, as well as her residual risk. Because even though it doesn't improve how someone does in the long run or worse in it, they still may be at risk of recurrence, regardless of whether they have a pregnancy. And that risk is sometimes high. And that's a calamity toe. Have a recurrence, especially during pregnancy or with young Children. Anyway, we are testing prospectively, the safety of interrupting endocrine therapy for breast cancer survivors in the positive trial. This is a Phase two study where we're looking at interrupting indifferent therapy. We enrolled 512 patients in this. They come off, they try and have a pregnancy, they get back on, and we're looking at disease, reproductive and psychosocial outcomes. Stay tuned on that we fully accrued as of last year, and we look forward to those data to inform er patient care in the future. And you know a related note for these young patients who want fertility after cancer. We know that survivors of all cancers often experience whatever age they are, but particularly the young adults and a roller coaster of emotions. And that's something that we need to attend to. You can see some of the common emotions here, Um, common emotions and symptoms and are survivors will overlap so you can see depression, fatigue, cognitive dysfunction, the kind of three sides of the same coin on, and we need to be able to kind of tease it out in order to both help people Thio intervene to help and figure out which is the dominant or is something going on with all of these? We know that these air prevalent depression it occurs in about 14% of survivors. Some studies suggest a little higher in patients with a history of cancer. Some studies suggest not fatigue is clearly higher Cognitive dysfunction a bigger problem in our survivors. Um, it's something that we need to also pay attention to and refer as appropriate. Um, mental path, as I alluded to, is a big issue the extreme is that suicide ality. But we know that just regular depression and anxiety is associate with symptom distress, maladaptive coping, premature mortality and cancer death. And then we talked about that. Increased rates of suicide ality. So ideally, they'll be screening in your clinic. Or at least when you asked that how you doing and the person breaks down or seems very flat trying to screen and getting them in to see a mental health provider if they're willing or get their loved ones to be more involved to help, um, reassured treatment refers. Appropriate. Of course. Many of us do treat our clinics for lower level anxiety and depression, and there are guidelines to inform how to support patients through this and then the other symptoms. I just alluded Thio the fatigue and things like that. Um, you can see here treatment considerations for each of those main things that seem toe overlap in many patients depression. You could go with meds. You could go with cognitive behavioral therapy and psycho therapies. Fatigue. Exercise actually seems to be the best, and that's good and good for you. More on that later. But other things can help with that as well and then cognitive dysfunction a tough nut to crack these often, Patients don't have to hide testing that positive on the neuro psych tests, but sometimes they do. And of course, there's cognitive rehab for those people. But for many others, it's really about kind of retraining their brains a little bit, being patient, making lists, not trying to multitask. Sometimes it's about removing treatments that might be just too cumbersome, like hormonal treatments. And you have to weigh the pros and the cons. And then exercise may also be helpful here. So what about exercise? Isn't the panacea for all that ails of cancer survivor? Well, not completely, but it actually can be quite helpful on a number of factors. And this is a man analysis that looking at the relationship between exercise and fatigue, and you can see that those who did especially supervised exercise had clear improvements in their fatigue and this meta analysis. And, of course, the harms of exercise air pretty low. So let's move on to one of those last big buckets. Improving health behaviors. Can we capitalize on the teachable moment of having a cancer history and help people toe live better and thrive in their survivorship. Well, one of the big areas is energy balance. That's about weight and exercise. And we know that the risk of weight gain, obesity and metabolic syndrome is very clear in patients with breast, colorectal and prostate testicular myeloma, pediatric cancer survivors. And this not only is a risk factor for getting the disease, but patients are more likely or some of the diseases patients are more likely to gain the weight. And in some of these diseases, it's been shown to potentially affect their cancer outcomes. And then, of course, weight gain and metabolic syndrome has an impact on cardiovascular and overall mortality. So again, fortunately, we kind of have fixes for this. They're tough, but regular physical activity, diet and attention to diabetic and cardiovascular risk factors, of course is going to help. And that is also associated with lower risk of both cancer recurrence and death in many populations. So we need to pay attention to that. This is an example from the Nurses Health Study, where patients and follow up who exercise had not only lower risk of total death, but they had a lower risk of recurrence and breast cancer death. So it's good and good for patients. And the critical thing is, how do we help them to get to exercise and programs and studies air working on How do we help people in this arena? What about diet, where there's nice data coming from a lot of different cancer types, particularly colon cancer, has been really important for this. A Western diet has been associated with people doing worse with stage three colon cancer than a prudent diet, as you can see here, and other data suggests that their ah hike lice emmick load would be particularly risky. Western diets like the diet, the eggs, the bacon, the toast, prudent die. It's more of a Mediterranean hi and good proteins and low and dad. Five pats in vegetables and fruit. Um, and the winds died in breast cancer was a low fat diet where patients also lost weight, and there appeared to be an improvement in how people did with regard to relapse free survival. This is a messy study, but there was a signal here. There was statistically significant, so low fat might have let to weight loss not so clear whether or not the low fat itself was the actor, But this is something we also think about with our patients. In contrast, the well study. When we gave people high fruits, vegetables and fiber in breast cancer survivors but didn't change their actual caloric intake, there was no doubt tha there was no improvement. So how do we put this all together? Well, fortunately, the American Cancer Society has done this for us and looking at the preponderance of evidence you can see hear their recommendations. You know, if someone's overweight or obese, you wanna help them toe limit their high calorie foods and beverages, increased physical activity and promote weight loss through better diet you could see listed here. And there are great guidelines out there in terms of physical activity. You want to get people back and moving your physical therapy fizz, ia trist, reconstruction or whatever you need to help people to move. And then you want them to aim to get 150 minutes per week, just getting a little bit sweaty a little bit, you know, breath. You don't have to be running marathons or scaling mountains, and you are also especially for older people want to use strength training at least two days a week because I didn't talk about this. But you didn't. You know another big risk factors people as the ages falls and especially if they fall and break a hip because they're osteo product, that strength training can help them prevent falls and also prevent those hip fractures in the end. Alright, what about those modifiable health behaviors in summary? Well, first, you want to help them to drop or decrease the things that are not so great for them. The tobacco, the higher higher amounts of alcohol, a little bits. Okay, on average on, Do you want to help them maintain or increase the things we just talked about? It's kind of common sense, but we know, for example, smoking cessation, that if the doctor tells a person to quit and makes them deal with the patient, they're more likely to quit than if you know somebody else's just telling them like, you know, the husband, wife or partners just squawking at them to quit. So patients do take this seriously, and it can be a teachable moment. And of course, there are also evidence based counseling ways to help support people who want to do something better, like smoking or tobacco cessation. Alright, The last big bucket. How can we do all this and get through our day? Do this effectively and efficiently. How do we best coordinate and communicate? This is a really tough nut to crack and a lot of us have been working on this. In our programs are practices or institutions nationally and we've come up with this treatment summary and survivorship care plan document, which is kind of a cool thing. It's a roadmap. And if you land in a foreign country and someone gives you a road map that you can read, you're more likely to get from a to B. Probably not everybody needs it because they might have a driver, but it's also reassuring toe have it, and some people might fall through the cracks. If they don't get that road map, they might miss something. Some people might not be able to read the roadmap and therefore it doesn't matter to them. So this whole treatment summary and survivorship care plan. If you use that analogy of the map, it helps some people, but it's not gonna help all but it can certainly help to communicate standard and tailored needs for an individual. And there are new tools, APS and patient facing portals and APS that can help the patient for whom it may be valuable and or help them to not miss something that might be important or help them to communicate with their provider or vice versa. Help for you to communicate with their provider. That's not the cancer care doctor who knows what do and follow a potentially about what to pay attention to him. What not to. If the patient goes back to either a community provider, a PCP or someone with less knowledge about these things or who is busier, it's a go to tool. It's really nice that there's actually a clinician app for the big cancers brought to us by the American Cancer Society, where you can like if you're seeing a patient involved and you want to know what's the minimum, I need to dio what's kind of the basics I need to do to get through this patient visit and get it. Those four big buckets, you can dial it up and say, Oh, head neck cancer. This is what I need to think about. So this is a really cool app that I'd refer you to if you want a tool in clinic. And how do we try and put this all together with their survivorship programs at many large cancer centers and small cancer centers? And it's interesting because they've really changed from a survivorship program. Focus on that. Get that treatment summary to people in the last year. You can see the new requirements say, You know, we like that we like that treatment. So I book, really, we want you to have a program, and in that program you got to be focused on addressing the needs of cancer survivors, either for direct care or consultation services, either on site or by referral. And you can see the list of things that you can do in your program and support groups and services. And you know that care plan things a good thing to do. But it's not required anymore because now it's hard to make that happen, and it's not exactly necessary for every. So we still try and do it because I think it's better to have a road map, but we don't sweat it too hard when we can't get it to a patient or they're not interested. But we use the road map to guide the care as a tool, but not the end all be all so. In conclusion, enormous progress has been made, and yet many challenges and opportunities remain in optimizing cancer, survivorship care, awareness of what does help our patients and good communication with them and their other providers are both critical factors. So thank you for your attention today, and I hope that we made you more aware than you already were and will help to communicate around your patients with their other providers for what they need in their survivorship care and with increased focus on the importance of the survivorship phase of care, I think we can help our patients. Thank you very, very much. Thank you, Dr Partridge. It looks like we have several questions that came in, but we we are out of time. So what I'm going to do is send you these questions by email. And if any one of you else have questions for Dr Partridge, you could center those two up through her email, and it's and underscore Underscore Partridge at D F C I. Dana Farber cancer institute dot harvard dot e d u. I want to thank you, Dr Partridge, for your very informative talk. I'm really glad that you covered this topic because cancer survivorship is such an important part of a patient's treatment trajectory. Because we all know that our patients are going are living longer these days because of the advances and cancer therapies and new treatments that are coming out. And you covered a lot of topics the whole spectrum of issues that these patients can experience as survivors and pointed out a lot of number of trials that are pertinent to the overall quality of life for these survivors. So thank you so much for joining today. We really enjoyed your talk. My pleasure. Thank you. And for all of you who would like Thio stay on and learn more. There is a non CE symposium hosted by BMS on a treatment option for patients with AML right after this, in 4. 30 to 5. 30 Pacific standard time. And in order to access the link to that offering, just scroll down where you see the comforts agenda and you will see the link for it regarding obtaining your CEO. I just want to remind you all that there will be an email sent out next week. They eat, sent to your email that you registered to the conference with and your nurse practitioners will need to take a quiz and make at least a 70 in order to get the credit. The evaluation is going to prompt you to take the test if you are an MP and I want to thank I want to think scripts, conference services for coordinate this wonderful and informative conference. There was a lot of work on the back end with the planning Committee and the broadcast company as well, so I would like to make sure that they get recognized as well. Carlin, Denise, Patty, Laura, Kathy, Katie Donna's gotten Justin and last but not least thank you all the attendees for your participation in the symposium. It wouldn't be possible without your participation. And we're so happy. We had such a good turnout this year with our first virtual offing, and we were able Thio, have you the attendees from different states come and join us, and I hope that you can join us all next year in person on November 5th. 26 2021 at the Marriott Mission Valley Hotel in San Diego. Thank you all. Have a good night.