Half of Five-Year Survivors of Breast Cancer Are Not Receiving Recommended Post-Surgery Mammograms
NCCN guidelines recommend annual mammograms to detect disease recurrence, but according to the study’s findings, women — even those who had adequate health insurance — were less likely to have their once-a-year mammogram as they became long-term survivors.
“This lack of imaging follow-up represents a missed opportunity for identifying recurrent or new breast cancers among a high-risk patient subgroup,” Benjamin O. Anderson, M.D., FACS, vice chair of the NCCN Guidelines Panel for Breast Cancer, said in a statement. Anderson is professor of surgery and global health medicine at the University of Washington and Fred Hutchinson Cancer Research Center.
“Of equal importance, this finding illustrates that our health care system can fail to track sizable groups of cancer patients after completion of treatment,” he said. “The NCCN guidelines for survivorship delineate the quality-of-life issues that patients must address, which together with tests like follow-up mammograms should be a coherent and integrated survivorship plan.”
In the retrospective study, more than 27,000 patients were followed for a median 2.9 years after breast cancer surgery. The study excluded those who underwent bilateral mastectomies, since they do not need mammograms. After 65 months, 4,790 patients remained in the study cohort.
One year after cancer surgery, 13 percent of women did not undergo any breast imaging. As time went on, that number continued to increase. Five years after surgery, 19 percent of women went the year without imaging. In total, only 50 percent of the patients who were followed for five or more years had at least one mammogram per year.
The researchers on the study also found that African-American survivors were less likely than Caucasian survivors to get their yearly mammograms. This is particularly a point of interest since black women die of breast cancer at a higher rate than white women, and recurrence is a major driver for this.
According to the American Cancer Society, between the years 2009 and 2013, for every 100,000 people, 29.6 African-Americans died of the disease, compared to an average of 21 people per 100,000 in Caucasians. Limited access by black women to genetic testing could be a factor, according to the NCCN, but further research is needed to better understand why this disparity exists.
“The use of regular mammograms to detect a return of breast cancer before any symptoms appear is associated with better overall survival,” said Kathryn Ruddy, M.D., M.P.H., director of cancer survivorship for the Department of Oncology at the Mayo Clinic Cancer Center, in a release.
Ruddy was the lead author on the study and a member of the NCCN Clinical Practice Guidelines in Oncology Panel for Survivorship.
“Therefore, clinicians need to make sure that their patients are fully aware of the role these annual mammograms play in screening for new breast cancers as well as for local recurrences. Creating and implementing survivorship care plans with clear follow-up instructions may help ensure that more survivors adhere to recommended screening schedules,” she said.
Immunotherapy Combination Shows Promise, Side Effects Ensue in Colorectal Cancer Subgroup
The combination regimen – approved by the Food and Drug Administration in August 2017 – is intended to treat patients with dMMR/MSI-H) metastatic colorectal cancer, who progressed following treatment with chemotherapy. At the Oncology Nursing Society (ONS) Annual Congress, Brutcher, who is a nurse as Emory Winship Cancer Institute, emphasized the importance of knowing the differences between side effects from immunotherapy compared with chemotherapy.
She also noted the nurse’s role in recognizing these differences. “The main thing for me is that the concern should be knowing the difference between (side effects) from immunotherapy and from chemotherapy,” Brutcher said in an interview with CURE. “With triaging and being the nurses taking care of the patients, identifying the different between the symptoms and their management is important.”
In the ongoing, multi-cohort, phase 2 CheckMate-142 study – designed to evaluate the efficacy and safety of nivolumab-based therapies in metastatic colorectal cancer – the combination use of nivolumab plus ipilimumab demonstrated promising results, including high objective response rates, durable clinical benefits, encouraging survival and a manageable safety profile.
Despite improved outcomes, the researchers also found that side effects with checkpoint inhibition often affected the dermatologic, gastrointestinal, pulmonary, renal, endocrine and hepatic systems in patients.
“I try to separate the concept of chemotherapy destroying cells as a pain, so it is broad spectrum; and immunotherapy is more focused, but it can focus in on organs,” Brutcher explained.
During a median follow-up of 13.4 months, 73 percent of patients reported to have experienced a treatment-related side effect, including 32 percent who experienced grade 3/4. The most common side effects included diarrhea (22 percent), fatigue (18 percent) and pruritus, or itching (17 percent).
Side effects of any grade occurred early, with median time to onset in the first 12 weeks of therapy.
In the trial, select treatment-related side effects were managed using protocol-specified algorithms. For example, immune modulatory medications, including corticosteroid treatment and immunosuppressive agents, were used to manage these select treatment-related side effects in 22 to 56 percent of patients based on protocol-specific algorithms for organ-specific side effects. Management with protocol-specific algorithms resulted in resolution of the majority of treatment-related side effects.
In addition, the majority of patients treated with immune modulatory medications had resolution of their select TRAEs, including all pulmonary effects.
In total, 13 percent of patients discontinued treatment due to any-grade treatment-related side effects, most commonly because of autoimmune hepatitis (2 percent), and acute kidney injury (2 percent), and 10 percent because of grade 3/4 side effects.
Dose delays caused by select treatment-related side effects occurred in 29 patients; however, combination use of the combination was resumed in 25 of those patients. Fourteen patients did experience additional side effects after resuming therapy with the regimen.
Although side effects do occur, it is key for patients to be aware of their potential occurrence, and to be sure to contact a health care professional when they do. Brutcher also reminds patients that these side effects should not limit patients to live their everyday lives.
“The favorable benefit-risk profile of the nivolumab plus ipilimumab combination provides a new treatment option for patients with previously treated dMMR/MSI-H mCRC,” she added. “Patients get so much information at once and it is such a whirlwind, it is important for nurses to just pull back to the very basics, and say, ‘Remember, this shouldn’t ruin your life. And if in doubt (about an adverse effect), call.’”