Insights from Cleveland Clinic’s Breast Cancer Survivorship Program

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma programs. Today, I'm happy to welcome Dr. Halle Moore, who's the director of the Cleveland Clinic Taussig Breast Cancer Program. She's here today to discuss breast cancer survivorship. Halle, tell me a little about your role here at Cleveland Clinic.

Halle Moore, MD: Sure. Hi, Dale. Thanks for having me. I direct our Medical Oncology Breast Cancer Program and I co-direct the Cleveland Clinic Comprehensive Breast Cancer Program. I've also been very involved with our survivorship program since its onset.

Dale Shepard, MD, PhD: Excellent. Maybe you could share with us some background about the Cleveland Clinic Breast Cancer Survivorship Program.

Halle Moore, MD: Our formal program started about 12 years ago, but really survivorship care is something that breast cancer specialists had been providing well before that. The National Cancer Institute includes in the definition of a cancer survivor, individuals from the time of their cancer diagnosis through the balance of their lives. Survivorship is not just one set time point in cancer care, but really incorporates the entire experience after a cancer diagnosis. But compared to routine oncology services, our survivorship services deal largely with the issues that prevail following the initial cancer treatment in the absence of active cancer. I think of it as a focus on health maintenance rather than disease treatment.

In our program here at the Cleveland Clinic, we try to anticipate, assess for, and facilitate management and prevention of a variety of health concerns that may be associated with either the cancer itself or the cancer treatment. A key feature of our program is that it's really integrated into the usual care of our patients, starting from their initial diagnosis and provided by the same caregivers that have treated them throughout their more active treatment.

Dale Shepard, MD, PhD: Maybe you could describe who are the members of the team? What does this look like in terms of the program? Who normally would see the patients for survivorship?

Halle Moore, MD: The real champions of our survivorship program are our nurse practitioners. These are the ones who conduct the formal survivorship visits and provide a care plan, give information on health maintenance, activities lifestyle, and really get into the details of assessing for ongoing issues, toxicities related to treatment or symptoms related to the cancer or its treatment, and can facilitate appropriate referrals.

The physicians are also very involved with survivorship and survivorship care planning, especially when thinking about, for instance if we see a patient with new diagnosis, they're a young patient, we have to think about survivorship right away. If they're interested in future fertility, we're going to be much more helpful to them if we make appropriate referrals before we start treatment, rather than waiting until treatment is over. Similarly with genetic risk assessment, this is something that we need to address early on.

All of our providers, the surgeons, the medical oncologists, radiation oncologists, are thinking about survivorship very early on. Our plastic surgeons are anticipating who's going to be at risk for lymphedema and may offer different procedures in terms of their plastic surgery that will help to reduce or prevent lymphedema.

So really all of our oncology providers, our care coordinators who are involved in the education and management of many of these patients symptoms, and then we have a whole referral network with physical therapists, occupational therapists, our psychosocial support group, just many resources for our patients. It's not just one simple visit for survivorship, it's really a whole network of teamwork and referrals.

Dale Shepard, MD, PhD: Now, how do you typically incorporate patients who may have had surgery as their primary therapy and maybe didn't have a medical oncology component per se? Are they followed within the survivorship program by medical oncology side, or do they stay with the surgery side, or how have you worked that into the program?

Halle Moore, MD: Well, it's very much individualized, but for patients that really don't need to see a medical oncologist, for instance, somebody who's had a mastectomy for a noninvasive cancer, we have the opportunity for survivorship care in our medical breast clinics. We have internal medicine-trained specialists who work in our breast center and see individuals who are at high risk for developing breast cancer, maybe never had a diagnosis of breast cancer, but they also see patients who are breast cancer survivors and need some sort of continuing follow up. So we have that option as well.

Dale Shepard, MD, PhD: I guess the other thing that would come to mind would be we certainly see a lot of patients here on main campus, but we have a large presence in common cancers, like breast cancer in our regional practices, so how does a survivorship ... What does that look like in the regional practices?

Halle Moore, MD: Yeah. In some of the practices, we don't have the availability of the nurse practitioners to provide these visits, although in some we do. For those that don't, oftentimes the care coordinators are providing the formal survivorship visit in conjunction with the providing physician. But each of our areas has developed a plan for how to provide a formal survivorship visit. Then many of the other survivorship issues are administered by either the nurse practitioners or the physicians who are following those patients after their initial treatment.

Dale Shepard, MD, PhD: That's great. It sounds like pretty much everyone can get some survivorship coverage in some way.

Halle Moore, MD: Right, and we've tried to put together a list of the resources that are available so that providers can have a place to go to, to see who is the sexual health expert or who is good for dealing with neuropathy, so that we don't expect every provider to be an expert at managing every consequence of cancer and its treatment. However, we do expect all of our patients to have access to appropriate referrals.

Dale Shepard, MD, PhD: That's great. Halle, certainly we provide great clinical care. When we think about moving forward, research is certainly important. What has happened within the survivorship program from a research standpoint?

Halle Moore, MD: One of my particular areas of research interest is in the prevention of infertility, which can be a consequence of a breast cancer treatment. We led a national trial, and that was through the SWOG Research Network, looking at trying to suppress ovarian function during chemotherapy as a means to reduce the long-term risk of premature menopause and improve the chances for future pregnancy. Indeed, we found that this technique did work and it's something that we can routinely offer our patients.

Within our own program, we've also looked at patient-reported symptoms in our survivorship population to try to better identify the needs of our survivors. We have found some of the most prevalent sentiments were menopausal symptoms, but perhaps the most bothersome symptom that we saw was neuropathy. Actually, in the population that we surveyed, that was about a third of the patients had symptoms consistent with neuropathy.

We also noticed a high prevalence of overweight and obesity among our breast cancer survivors and a higher body mass index was also associated with a higher prevalence of a number of other health conditions, such as depression, hypertension, diabetes. These are really important observations that can lead us to areas of need for management and our survivors. Then on a happier note, we found that patients who reported regular exercise had lower rates of neuropathy symptoms, less fatigue, fewer sleep issues and anxiety. That's a pretty straightforward intervention that we can encourage for our patients.

Also along those lines, we've done some work in collaboration with investigators at Case Western Reserve University and with a community gathering place to look at a community-based exercise intervention. We've done a couple of studies, one in African-American breast cancer survivors and one in older breast cancer survivors, to try to get at reducing some of the disparities in these populations.

Dale Shepard, MD, PhD: That's great. For these exercise interventions for instance, these are patients who are currently undergoing treatment or in the survivorship phase, or both?

Halle Moore, MD: Yeah, those particular studies involve patients who had completed surgery and any planned chemotherapy and radiation. Some were still on endocrine therapy, but they were off of the most acute treatments.

Dale Shepard, MD, PhD: Well, that's great. That means that you have the opportunity to talk to people and actually make a suggestion that they can act upon instead of maybe, oh, I had a history of doing something. That's great to hear. Do we have any other ongoing research that you'd like to promote?

Halle Moore, MD: We are involved in a number of ongoing projects. We're participating in some of the national studies, one that's looking at an intervention to prevent cardiac toxicity, and that actually is in patients with advanced breast cancer. Survivorship needs aren't limited to patients with early-stage cancer. Our regional practices are participating in a study of a weight loss intervention for obese women with early breast cancer. Our surgeons are conducting some really innovative research in the treatment and prevention of lymphedema.

Then one other project that I'm excited about, in conjunction with some of our colleagues who study hematologic malignancies, is we're looking at something called CHIP, or clonal hematopoiesis of indeterminate prognosis. Among other populations, the breast cancer survivorship population is being studied. We know that genomic sequencing can identify clonal hematopoiesis in healthy individuals, and this is more common as one ages. It also appears to be more common in solid tumor malignancy survivors. Our understanding of the implications of having this clonal hematopoiesis is an area of active research. There has been associations with an increased risk not only of hematologic malignancies, but also of cardiovascular disease. So we are trying to study our survivorship population to better understand these risks and hopefully lead to some prevention strategies.

Dale Shepard, MD, PhD: When we think about this, you've been at it for a long time and you've mentioned that for a dozen years now we've been having a program, and most places would have, as you mentioned, breast cancers is a very commonplace to have survivorship programs, but what kind of advice would you give in terms of things that you might think we're doing well that other programs might not be currently offering or things that they might be able to do to enhance their programs for the sake of patients?

Halle Moore, MD: Yeah. My advice for somebody trying to build their program would be to really build on what you're already doing. You're taking care of patients, and this is just an extension of that. Rather than just focusing on the cancer, also focus on the whole patient. By assessing what their needs are, assessing their entire health history, you can easily determine where they may need referrals. The more you do it, the more you'll learn who the appropriate people, are and whatever your system is, you can find those people who are interested in promoting the health and survivorship for your patients.

Dale Shepard, MD, PhD: You just talked about how breast cancer programs might be able to enhance what they're doing, but what about other solid tumors? There's other diseases that might want to think about either starting or enhancing a program. Where's the best place to start? What kind of things should they be thinking about?

Halle Moore, MD:
It's always nice to have a champion and someone who's going to organize for survivorship to be done in a somewhat methodical way. We were lucky enough to have a nurse practitioner who took this on as a champion and developed a template and a questionnaire. Now you can find these templates often through various groups, through ASCO, through even our medical records often have templates for survivorship visits and have the opportunity to provide places to ask patients about their symptoms related to whatever treatment they may have had.

I think the key to getting started is to schedule patients back for follow-up, not just say, "Okay, you're done with treatment. You can go ahead and follow up with your primary care doctor," but to actually see the patients back and continue to manage them, or at least have informal conversation with them about what kind of issues they might expect to have, who they should go to for what problems, and to assess for any ongoing effects of the treatment so that you can get those patients to the help that they need.

The key is really making sure that you have some sort of follow-up opportunity to assess what's going on for these individuals and get them the appropriate care that they need.

Dale Shepard, MD, PhD: Having done a lot of these survivorship visits, one thing as physicians we always like is that, "Oh, one more thing," as you walk out the door. There's clearly patients who will have things that they really want to have addressed in a survivorship meeting that we may not initially think about. Is there anything you might be able to pass along about specific things we want to really key in on and make sure that we cover that we may not realize initially?

Halle Moore, MD: Yeah. It may depend a little bit on the type of treatment that that individual has had. For instance, men with treatment for prostate cancer may have hormonal issues similar to what women experience for breast cancer, patients who've had surgery for colorectal cancer may have issues related to their ostomies. I think really knowing the disease and knowing what the common problems are is very important, and to also not be afraid to ask about problems that they might be having, even if you're not the expert on managing that problem. You probably have the skills to get that person to somebody who is more expert in managing that problem.

Dale Shepard, MD, PhD: Well, Halle, you've given us some great insight on survivorship programs, and I appreciate it. Thanks for joining us to discuss this important topic.

Halle Moore, MD: Thank you, Dale.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real time updates from Cleveland Clinics Cancer Center experts on our Consult QD website, at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.