This document discusses various aspects of cancer disease management beyond treatment. It notes that worldwide over 14 million new cancer cases were diagnosed in 2015, making it the second leading cause of death globally. Cancer incidence and mortality rates are higher in less developed countries. The document then focuses on the Indian cancer scenario, noting that breast, cervical and oral cancers are the most common types in India. It emphasizes that effective cancer treatment requires managing psychosocial needs and stresses the importance of a multidisciplinary care team. The document highlights challenges cancer patients face and stresses the importance of support throughout the entire patient journey from diagnosis to recovery.

1. !
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Disease!!!!!
management!beyond!
treatment!

2. Cancer,!Cancer,!cancer..!
• Worldwide,14.1!million!cancer!cases!
were!newly!diagnosed,!with!>8!million!
deaths!and!32!million!five=year!
prevalent!cases.!
• !57!per!cent!of!new!cases,!65!per!cent!of!
deaths!and!48!per!cent!of!five=year!
prevalent!cases!of!cancer!are!es4mated!
to!occur!in!less!developed!countries.!!

3. Cancer,!Cancer,!cancer..!
• In!2015,!it!became!the!second!leading!cause!
of!mortality!globally,!killing!approximately!
8.8!million!people,!which!translates!to!one!in!
six!deaths!worldwide.!!
• Globally,!malignancies!of!the!lung,!prostate,!
colorectal,!stomach!and!liver,!in!that!order,!
are!the!most!common!types!in!men,!with!
breast,!colorectal,!lung,!cervix!and!stomach!
cancers!most!prevalent!among!women.!

4. Indian!scenario!
• In!India,!nearly!2.5!million!people!are!living!with!
a!diagnosis!of!cancer.!
• Incidence!rate!of!cancer!is!more!in!females!as!
compared!to!males.!
• In!the!urban!areas!of!country,!the!ageEadjusted!
incidence!of!cancer!ranges!from!107.8!to!
142.0/100,000!for!women!and!from!92.1!to!
126.1/100,000!for!men.!
!
• Overall,(breast,(uterine(cervix(and(oral(cavity(
are(the(three(most(common(sites(of(
malignancies,(accoun8ng(for(about(34(per(cent(
of(>1(million(cases(diagnosed(each(year.(

9. “Cancer!is!no!simple!disease,!and!
effecMve!treatment!is!not!just!about!
killing!rogue!cells!with!radiaMon!and!
chemotherapy.!It!is!about!healing!the!
human!being.”!
Cancer'Care'for'the'Whole'Pa/ent:'Mee/ng'Psychosocial'
Health'Needs!by!The!Na4onal!Academies’!Ins4tute!of!
Medicine!

10. Curing!or!healing!
“Healingisadynamicprocessofrecovery,repair,
restoration,renewal,andtransformationthat
increasesresilience,coherence,andwholeness.”
!!!!!!!!!!!!!WayneJonas,MD,SamueliInstituteforInformationBiology'

11. Differences!between!Healing!!
Versus!Curing!Cancer!
!
!
• Curing'addresses'the'disease.'
• 'Healing'is'not'about'absence'of'disease.'Even'when'
curing'is'not'possible,'there'is'opportunity'for'healing.'
• 'Healing'comes'from'an'individual’s'core'and'can'be'
accessed'regardless'of'internal'or'external'
circumstances.'
• 'As(disease(may(contain(disconnect,(disharmony,(and(
dismemberment,(healing(involves(connec8on,(
harmony,(and(remembering.(

12. • Cancer!has!both!social!and!economic!implicaMons!in!India.!
• The!s4gma!associated!with!cancer!is!known!to!leave!a!
psychosocial!impact!that!alters!the!health!seeking!
behaviour!of!the!pa4ent.!!
• The!prolonged!treatment!oLen!impoverishes!the!
household.!!
• The!mortality!rate!due!to!cancer!is!high,!at!sixty!eight!
percent!of!the!annual!incidence.!
• !Fewer!than!thirty!percent!of!Indian!pa4ents!with!cancer!
survive!five!years!or!longer!aLer!diagnosis.!!
• This!rate!is!much!lower!than!many!developed!naMons.!!
• Five!year!survival!rates!in!South!Korea!and!Japan!are!sixty!
eight!percent!and!sixty!percent,!respecMvely.!

13. Coming!in!early..!

14. Breast!cancer!pa4ents!face!challenges!
throughout!the!journey!of!!!
• diagnosis,!
• !treatment,!
• !postEtreatment,!
• !and!recovery.!!

15. Mano’s!story!
• When!I!opened!the!door,!my!doctor!
didn’t!ask!if!I!was!with!anybody,!she!
didn’t!ask!me!to!sit!down.!…!You!can!
imagine!my!shock:!I’m!standing!at!the!
door!and!this!doctor!is!telling!me!that!
I’ve!got!cancer.!What!do!you!do?!!
• My!father!was!only!round!the!corner.!I!
could!have!rung!for!somebody!to!
come.!It!would!have!taken!two!
minutes.!But!I!wasn’t!given!the!
opportunity.!!

16. IniMal!reacMons!
• Shock!and!Denial!
• Anxiety!and!Fear!
• Guilt!and!Shame!
• Anger!and!Resentment!
• Sadness!and!Depression!
• Powerless!and!overwhelmed!

18. Breaking!the!news…!
• Physicians!lack!proper!training,!breaking!bad!news!can!lead!to!
nega4ve!consequences!for!pa4ents,!families,!and!physicians.!
• !A!ques4onnaire!was!used!to!determine!whether!a!didac4c!
program!on!delivering!bad!news!was!needed!for!doctors.!
• !Results!revealed!that!:!
• 91%!of!respondents!perceived!delivering!bad!news!as!a!very!
important!skill,!
• But!only!40%!felt!they!had!the!training!to!effec4vely!deliver!
such!news.!
• (We(need(to(review(of(different(approaches(to(delivering(bad(
news(and(advocate(for(training(physicians(in(a(comprehensive,(
structured(model.(

19. Debbie!darling..!
• It!is!important!to!note!that!people!oaen!
require!informaMon!about!services!at!the!
beginning!of!their!cancer!journey.!!
For!something!like!cancer,!which!
seems!to!be!fast!in!development!
and!with!treatment,!having!an!
awareness!of!what’s!out!there!
before!you!actually!need!it!is!
important.!!

21. Support!at!every!stage…!
• Before!and!during!the!treatment,!the!cancer!care!
team!should!explain!to!the!pa4ents!and!their!families!
about!their!chances!of!recovery,!treatment!benefits!
and!disadvantages,!the!availability!of!psychological!
services,!social!support!and!pallia4ve!care,!and!the!
es4mated!total!costs!.!!
• Stressing'the'importance'of'effec/ve'communica/on'in'
holis/c'cancer'care,'the'Australian'Na/onal'Breast'
Cancer'Centre'has'published'guidelines'on'informa/on'
provision'and'counseling'for'breast'cancer'pa/ents'and'
developed'a'na/onal'communica/on'skills'training'
strategy'to'train'health'professionals.'

22. • Suicide(is(most(common(in(the(first(3(
months(aEer(someone(is(diagnosed(with(
cancer.(!With!an!overall!risk!twice!that!of!
the!general!popula4on,!this!risk!can!be!as!
much!as!13!4mes!the!average!suicide!risk!in!
those!newly!diagnosed!with!cancer.!
• 'Suicidal(idea8on—defined!by!the!CDC!as!
"thinking!about,!considering,!or!planning!
for!suicide”—occurs!in!almost(6(percent(of(
people(with(cancer.!!

23. Care!beyond!cure!
• Cancer!therapy!along!with!mere!treatment!
also!encompasses!management!of!pain!and!
psychological!trauma.!Hence!it!is!!!!!!!!!!!!!!!!!!!!!!!
oLen!referred!to!as!care!beyond!cure.!.!
• A!cancer!pa4ent!is!oLen!undergoing!
extreme!mental!trauma!and!stress!coupled!
with!apprehension!and!uncertainty.!The!
experience!is!worsened!by!the!financial!
distress!of!the!long!term!treatment!and!the!
disrup4on!to!normal!life.!
(Neron,!2009).!!

24. You!didn’t!budget!for!cancer.!No!one!
budgets!for!cancer.!

25. The!good!physician!treats!the!disease;!the!great!
physician!treats!the!paMent!who!has!the!disease.!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!William'Osler'
'

26. The!most!valued!qualiMes!in!a!doctor!
were:!
• Knowledge!(51%),!!
• Honesty!(44%),!
• Humanity!(43%),!
• Availability!(32%),!
• Experience!(31%),!
• Humility!(19%),!
• Sympathy!(18%),!
• others!(3%).!!
Although!the!most!important!quality!was!always!knowledge,!there!
was!a!marked!difference!between!sexes:!women!valued!humanity!
more!than!honesty!(Chi!square!p=0.001)!while!men!believed!
honesty!(Chi!square!p=0.001)!and!experience!(Chi!square=!0.01)!
were!more!important!than!humanity.!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Ernesto(Gil(Deza(et(al(Journal(of(clinical(Oncology((2013(
“Medicine'is'an'art'whose'
magic'and'crea/ve'ability'
have'long'been'recognized'as'
residing'in'the'interpersonal'
aspects'of'pa/entLphysician'
rela/onship.”!

27. Recognize!the!importance!!
of!a!mulMdisciplinary!team!!in!!
cancer!care.!
• In!fact,!under!the!Na4onal!Health!Service!in!
England,!it!is!mandatory!for!the!cancer!care!
team!to!comprise!designated!breast!
surgeons,!breast!care!nurses!(BCNs),!
pathologists,!radiologists,!and!oncologists!.!
• Such!a!mul4disciplinary!approach!has!also!
been!adopted!by!the!Swedish!Medical!
Center!and!the!Japan!Cancer!Ins4tute!
hospital’s!breast!oncology!center!.!
• !The!efficacy!of!the!MDT!is!shown!by!the!
reduc4on!in!mortality!in!a!region!of!
Scotland!aLer!the!introduc4on!of!MDT!.!

28. Role!of!nurses!
• Serving!as!a!core!member!of!MDT,!a!
dedicated!breast!specialist!nurse!
speaks!to!her!pa4ent!before!and!aLer!
surgery.!
• !For'instance,'in'Singapore,'breast'care'
nurses'are'specially'trained'to'aOend'
to'and'care'for'breast'cancer'survivors,'
in'addi/on'to'the'surgical'oncologist,'
providing'both'preLopera/ve'
counselling'and'postLopera/ve'
rehabilita/on'.'

29. FOGSI!JHPEIGO!Samarth!
!iniMaMve!
• 70%!!healthcare!in!private!
• Private!dependent!on!semi!trained!
or!untrained!paramedical!staff.!
• Private!nursing!colleges!churning!
out!para!medics!without!prac4cal!
training.!
• Samarth!ini4a4ve!will!help!in!skill!
assessment!before!employing!and!
the!ones!employed!can!undergo!a!
two!week!structured!!skill!
enhancement!programme!.!

30. Decision!making!for!LOA..!
For'/by'Lana'
• My!decision!was!made!–!I!was!going!to!have!
the!DIEP!Flap!procedure!and!I!was!actually!
excited!about!it!!My!breasts!were!going!to!
feel!normal,!have!a!normal!body!temperature,!
have!minimal!scarring,!have!the!original!
nipples!and!the!bonus…a!flat!tummy!!!!!Who!
would!have!thought!that!this!situa4on!could!
have!such!a!posi4ve!outcome?!

31. • Pa4ents!who!par4cipate!in!their!fight!for!!
recovery!along!with!their!health!care!team,!!
will!improve!the!quality!of!their!lives!and!!
may!enhance!the!possibility!of!recovery.!
!!!!!!!!!!!!!!!!!!!!Dr.'Harold'Benjamin,'Founder'of'The'Wellness'Community'

32. Support!in!decision!making!for!!
surgery!

34. Angelina!Jolie!effect..!
• Celebrity!disclosures,!revela4on!of!
her!BRCA!status!and!her!decision!for!
a!prophylac4c!mastectomy,!can!
influence!pa4ents’!behaviour!
leading!to!important!effects!on!
antudes!towards!screening.!!
• Organisa4ons!should!assist!pa4ents!
appropriately,!but!at!the!same!4me!
should!consider!the!available!
resources,!and!should!interface!with!
journalists!and!the!social!media!in!
order!to!guarantee!the!validity!of!
the!informa4on.!

35. Regret!about!surgical!decisions!among!early=stage!!
breast!cancer!paMents:!Effects!of!the!congruence!!
between!paMents'!preferred!and!actual!decision=!
making!roles.!
!• EarlyNstage(breast(cancer(pa8ents(generally(receive(
either(a(mastectomy(or(a(lumpectomy,(either(by(their(
own(choice(or(that(of(their(surgeon.(Some8mes,(there(
is(regret(about(the(decision(aEerward.((
• The!first!is!that!women!who!take!a!dominant!or!
collabora4ve!role!in!decision!making!about!the!surgery!
express!less!regret!aLerward.!The!second!is!that!
congruence!between!preferred!role!and!actual!role!
predicts!less!regret.!We!also!explored!whether!disease!
stage!moderates!the!rela4onship!between!role!
congruence!and!decisional!regret.!
Wang'AW'Pub'Med'2018'

36. Decision!Making!!

39. What!Angelina’s!doctor!didn’t!!
tell!her?!
• “New!evidence!shows!that!even!a!faulty!BRCA1!gene,!as!
Jolie!has,!may!require!epigeneMc!modificaMon,!or!
‘silencing,’!before!cancer!progresses.”!In!layman’s!terms,!
this!means!that!a!physiological!change!is!required!to!
acMvate!the!gene.!
• Vitamin'D'levels'play'a'huge'role'in'protec/ng'women'from'
cancers'of'all'kinds.''
• We!now!know!that!the!risk!of!breast!cancer!is!cut!in!half!
in!women!with!adequate!levels!of!vitamin!D.!
• The(nutri8on(a(girl(gets(at(cri8cal(8mes(in(her(life,(
par8cularly(as(a(fetus(and(during(puberty,(greatly(
influence(the(expression(of(genes(like(BRCA1.(
• Daily!intake!of!fruits!and!vegetables!also!lowers!your!risk!of!
breast!cancer.!!
In!an!blog!called!“What!Doctors!Didn’t!Tell!Angelina!
Jolie”2!journalist!Lynn!McTaggart!points!out!

41. Components!of!Adhbhut!Matrutva!!
Antenatal!care!
Diet!and!Nutri4on!
Yoga!and!exercise!
Music!&!meditaMon!
Cosme4c!care!
Immuniza4on!!
Bonding!with!your!!
baby!and!doctor!
Post!partum!care!
Preconcep4on!counselling!
Birth!preparedness!

42. Follow!Up!
• RecommendaMons!of!rouMne!post=cancer!
treatment!care!for!all!survivors,!in!areas!such!as!
expected!short=term!and!long=term!effects!of!
therapy,!post=treatment!monitoring!for!toxicity!
and!recurrence,!psychosocial!and!employment!
needs!as!well!as!prevenMve!lifestyle!
modificaMons.!!
• A'systema/c'review'of'studies'by'the'Ins/tute'of'
Medicine'(US)'has'shown'that'psychosocial'
interven/ons'in'breast'cancer'can'improve'quality'
of'life'and'reduce'symptoms'of'mental'illness.'

43. !
Managing!Physical!Side!Effects!
!

44. !
!Pain!and!pain!management!
!• 71.7%(of(pa8ents(reported(pain((Weruska((
(((((Alcoforado(Costa(2017)(
• Chronic!pain!is!one!of!the!most!distressing!and!disabling!symptoms!
experienced!by!cancer!pa4ents!and!survivors.!
• Knowledge!of!pain!and!its!effects!on!cancer!survivors!is!s4ll!limited!
due!to!the!small!number!of!studies,!and!thus!it!is!oLen!leL!
unrecognised!and!untreated!.!
• Pain!is!not!only!caused!by!4ssue!damage!produced!by!the!cancer!
itself!but!can!also!be!caused!by!treatmentErelated!toxic!or!
trauma4c!damage!to!peripheral!and!central!neural!structures,!
resul4ng!in!longElas4ng!or!even!late!onset!neuropathy.!
• !Pain!may!persist!aLer!treatment!or!may!emerge!several!months!or!
even!years!aLer!treatment!has!been!completed.!This!is!described!
as!post=cancer!pain!syndrome.!
Pain!compromises!the!quality!of!life!of!paMents!with!breast!
cancer,!parMcularly!those!with!advanced!stages!of!the!disease.!

45. !
Cancer=related!faMgue!
!
• !Majority!of!pa4ents!experience!cancer=
related!FaMgue!(CRF)!during!cancer!
treatment,!and!it!can!have!a!profound!
impact!on!both!physical!and!
psychosocial!func4oning.!!
• What!is!less!clear!is!why!some!pa4ents!
recover!quickly!from!CRF!while!for!
others!it!develops!into!a!chronic!state.!!
• There!is!a!need!to!understand!the!
mediators!of!CRF!including!pain,!mood!
state!and!inflammatory!processes,!in!
order!to!design!suitable!interven4ons.!

46. Lymphedema!

47. Lymphedema!
• Significant!difference!between!the!groups!of!
paMents!with!and!those!without!lymphedema!with!
respect!to:!
• !!!Older!age!(0.016),!
• !!!BMI!greater!than!30!(0.007),!!
• !!!Hard!work!(0.004),!
• !!!Ipsilateral!dominant!arm!(0.021),!
• !!!History!of!injury!(0.001)!!
• !!!Infec4on!(0.001)!to!the!ipsilateral!arm,!
• !!!Posi4ve!lymphadenopathy!(0.020),!!
• !!!Advanced!stage!of!cancer!(0.009),!!
• !!!Posi4ve!human!epidermal!growth!factor!receptorE2/neu!receptor!(0.001),!
• !!!Level!III!axillary!dissec4on!(0.001),!
• !!!Lack!of!informa4on!about!BCRL!and/or!not!following!prophylac4c!advice!(0.001).!!
!
Meanwhile,!mul4ple!logis4c!regression!analysis!showed!only!old!age!
(0.005),!history!of!injury!(0.016),!celluli4s!(0.033),!level!III!axillary!
dissec4on!(0.011),!lack!of!informa4on!about!BCRL,!and!not!following!
prophylac4c!advice!(0.012)!to!have!a!significant!rela4on!to!
lymphedema.!
Mar/jn'M'Stuiver'et'al'BMJ'2017'

48. !
Sleep!disturbances!
!
• Sleep!problems!affect!most!pa4ents!during!chemotherapy.!
• Many!breast!cancer!survivors!experience!disturbed!sleep,!
and!a!subset!meets!the!criteria!for!insomnia.!
• The!problem!may!be!preEexis4ng!or!may!result!from!the!
cancer!and!its!treatment.!Hot!flashes!and!pain!affect!sleep!
efficiency!and!quality!and!contribute!to!CRF!and!day4me!
dysfunc4on.!
• !Sleep!problems!have!been!associated!with!CRF,!
depression,!and!poorer!overall!QOL.!
• !Some!of!the!effect!of!pain!on!CRF!reportedly!was!mediated!
by!sleep!disturbance,!but!pain!also!had!a!direct!effect!on!
CRF.!

49. !
Psychological!distress!
!
• Mood!disturbances!and!fa4gue!frequently!coEoccur,!and!mood!
disturbance!may!amplify!the!percep4on!of!fa4gue.!
• May!have!preEexis4ng!fa4gue!that!may!accompany!depression!or!
anxiety.!
• Among!pa4ents!with!newly!diagnosed!breast!cancer!(n!=!236),!!
• 27%!reported!a!previous!depression,!
• 11%!currently!met!criteria!for!major!depression,!
• 10%!met!criteria!for!postEtrauma4c!stress!syndrome.!
• These!diagnoses!were!associated!with!marked!func4onal!
impairment!compared!with!women!who!did!not!have!a!diagnosis!
of!depression!or!postEtrauma4c!stress!disorder!(PTSD).!!
• !56%!of!the!women!with!major!depression!who!were!on!
anMdepressants!sMll!met!criteria!for!major!depression.!

50. Exercise!and!breast!cancer!!
survival!
• Physical!ac4vity!enhancement!
involves!the!use!of!some!form!of!
exercise.!!
• Interven4ons!include!various!
modes,!intensity,!and!4ming!of!
exercise!ac4vi4es,!such!as!walking,!
cardiovascular!and/or!flexibility!
training,!and!resistance!training.!
• !Exercise!interven4ons!have!
included!both!supervised!and!homeE
based!programs.!

51. !
Psychosocial!and!psychological!!
distress:!assessment!and!treatment!
intervenMons!
!
• Across!all!diagnoses,!cancer!pa4ents!are!at!significantly!increased!risk!for!
psychological!symptoms!.!
• Distress!is!a!broad!construct!including!a!wide!con4nuum!of!emo4ons!related!to,!
among!others,!symptoms!of!depression,!anxiety!and!adjustment!disorder!.!
• Overall,!distress!in!cancer!pa4ents!is!oLen!reported!to!be!above!30%!.!!
• The!prevalence!of!depressive!symptoms!varies!between!10!and!25%!,!and!a!
significantly!increased!risk!for!hospital!admission!for!depression!has!been!
reported.!!
• Anxiety!symptoms!vary!between!10!and!30%!.!
• High!levels!of!comorbid!symptoms!of!anxiety!and!depression!have!been!
reported!and!gene4c!risk!factors!for!both!have!been!shown!to!correlate!
strongly!.!!
• However,!symptoms!of!anxiety!and!depression!may!also!occur!independently!
and!progress!quite!differently!aLer!a!cancer!diagnosis.!This!process!remains!
almost!unexplored!in!cancer!survivors.!

52. FerMlity!PreservaMon!
• With!recent!advances!in!assisted!reproduc4ve!technology!(ART),!
women!newly!diagnosed!with!cancer!increasingly!are!pursuing!
fer4lity!preserva4on!(FP)!before!chemotherapy!or!radia4on.!!
• Oocytes/ovarian!4ssue!can!be!frozen!(through!vitrifica4on)!if!the!
pa4ent!does!not!have!a!partner.!!
• Alterna4vely,!oocytes!may!be!fer4lized!with!a!partner’s!sperm!and!
the!resul4ng!embryos!(usually!day!5!or!day!6!blastocysts)!vitrified.!
• !These!frozen!oocytes!or!embryos!can!be!thawed!and!used!to!affect!a!
pregnancy!in!cancer!survivors!aLer!clearance!by!their!oncologists!to!
conceive.!

53. Is!ferMlity!preservaMon!a!safe!!
opMon!for!breast!cancer!survivors?!
• Many!women!of!reproduc4ve!age!who!are!newly!
diagnosed!with!cancer!have!not!yet!started!their!
families,!whereas!others!have!not!completed!their!
families.!
• Previously,!the!majority!of!these!women!would!
remain!childless.!

54. Is!ferMlity!preservaMon!a!safe!!
opMon!for!breast!cancer!survivors?!
• !Although!spontaneous!pregnancy!is!some4mes!
possible!aLer!treatment,!fer4lity!poten4al!in!the!
majority!of!these!women!will!decline!as!a!result!of!
the!gonadotoxic!nature!of!some!of!the!most!effec4ve!
chemotherapeu4c!agents,!first!and!foremost!
alkyla4ng!agents.!
• !The!immediate,!longEterm!effect!is,!almost!
uniformly,!diminished!ovarian!reserve,!and!in!many!
cases,!premature!ovarian!insufficiency.!

55. FerMlity!preservaMon!
• The!most!commonly!diagnosed!muta4ons!in!
pa4ents!with!breast!cancer!are!found!
in!BRCA1!and!BRCA2,!which!are!present!in!10%!
of!pa4ents!<!40!years!of!age.!
• !By!using!preimplanta4on!gene4c!diagnosis!
(PGD),!a!biopsy!of!cells!from!the!blastocyst!(day!
5!embryo)!can!be!done!to!analyze!DNA!for!the!
cancer!gene!muta4on,!which!allows!future!
transfer!of!an!unaffected!embryo!and!preven4on!
of!inheritance!of!the!muta4on!by!the!offspring.!!
• Although!this!process!can!take!several!weeks!to!
complete,!PGD!is!possible!for!pa4ents!who!
undergo!either!adjuvant!therapy!or!NAT.!

56. !“We!do!everything!we!can!to!cure!you,!but!
treatments!can!affect!your!body!in!serious!
ways,”!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Kevin'Browne,'Deputy'Chief'Nursing'Officer.'

62. !!
Work!parMcipaMon!!
among!cancer!survivors!
!
• Research!on!employment!and!workErelated!issues!has!
convincingly!shown!high!mo4va4on!among!cancer!
survivors!to!return!to!work!aLer!primary!treatment!has!
been!completed.!!
• Approximately!twoEthirds!of!cancer!pa4ents!either!
con4nue!working!aLer!their!diagnosis!of!cancer!or!
return!to!work.!!
• Aside!from!the!obvious!financial!benefits!associated!with!
(return!to)!work],!cancer!survivors!also!experience!work!
as!a!means!of!maintaining!their!personal!iden4ty,!a!
sense!of!normalcy,!social!rela4onships,!selfEesteem,!selfE
worth,!social!roles,!life!sa4sfac4on!and!quality!of!life.!

63. !!
Work!parMcipaMon!!
among!cancer!survivors!
!
• However,(the(process(of(returning(to(work(
is(a(difficult(one(for(many(survivors(due(to(
chronic(physical,(emo8onal(and(
occupa8onal(problems.((
• Cancer(survivors(are(more(likely(to(be(
unemployed(than(their(peers(in(the(
general(popula8on,(and(they(have(an(
increased(risk(of(early(re8rement(.(

64. Holis4c!Needs!aLer!Treatment!
!
• Following!treatment,!breast!cancer!pa4ents!
may!suffer!from!physical!side!effects!such!as!
lymphedema,!postEmastectomy!pain!
syndrome,!and!postEchemotherapy!cogni4ve!
impairment!.!!
• There!may!also!be!a!persistent!fear!of!cancer!
recurrence.!It!is!hence!impera4ve!that!doctors!
and!pa4ents!work!together!to!develop!a!
personalized!followEup!care!plan!for!the!
coming!months!and!years,!so!as!to!maintain!
good!health,!manage!side!effects,!and!monitor!
for!cancer!recurrence!in!both!the!na4ve!site!
and!in!other!parts!of!the!body!

65. Cancer!survivors/fighters!
/winners!
• !It!defines!someone!as!a!cancer!survivor!from!the!4me!of!diagnosis!
to!her!demise,!regardless!of!whether!the!cancer!is!cured,!ac4ve,!or!
untreatable.!
• !It!seeks!to!change!the!pa4ent’s!perspec4ve!from!that!of!a!passive!
vic4m!to!an!ac4ve!survivor.!
• !However,!it!is!worth!poin4ng!out!that,!while!this!concept!serves!to!
create!a!sense!of!belonging!among!cancer!pa4ents,!some!pa4ents!
may!feel!uncomfortable!being!labeled!as!survivors,!especially!as!it!
forces!them!to!focus!on!their!disease!as!a!centric!theme!in!life.!!
'
Such'sen/ments'are'echoed'by'authors'including'Diana'Fields'in'her'autobiography'

66. Camilia!frank!

67. Each!paMent!is!different?!
• As!each!pa4ent!at!different(stages(of(breast(
cancer(faces(varying(difficul8es(and!is!
surrounded!by!her!own!unique!circumstances,!
there!is!a!need!to!individualize!a!holisMc!
recovery!package!for!every!pa4ent!based!on!
periodic!holis4c!needs’!assessment.!
• !This!is!a!set!of!recognized!assessment!tools!
that!allows!pa4ents!and!their!healthcare!
professionals!to!reflect!on!their!needs!and!
explore!how!best!these!could!be!achieved.!It!is!
hoped!that!pa4ents!will!be!able!to!bewer!selfE
manage!living!beyond!breast!cancer!.!

68. !
Survivorship!skill=set!
!
1.!Get!Back!to!Wellness:!Take!Control!of!Your!
Survivorship!
2.!!Exercise!for!Wellness:!Customized!Exercise!
3.!!EmoMonal!Health!and!Well=Being:!From!
Pa4ent!to!Survivor!
4.!!NutriMon!Beyond!Cancer!
5.!!Medical!Management!Beyond!Cancer:!
What!You!Need!to!Know.!
6.!!Moving!Beyond!Treatment:!Next!Steps!
Towards!Survivorship!

69. Strategies(to(reduce(the(burden(of(
breast(cancer((
• Raising!general!public!awareness!on!the!breast!cancer!
problem!and!the!mechanisms!to!control!as!well!as!
advocaMng!for!appropriate!policies!and!programmes!
are!key!strategies!of!popula4onEbased!breast!cancer!
control.!!
• Many!low=!and!middle=income!countries!face!now!a!
double!burden!of!breast!and!cervical!cancer!which!
represent!top!cancer!killers!in!women!over!30!years!
old.!!
• These!countries!need!to!implement!combined!
strategies!that!address!both!public!health!problems!in!
an!effecMve!and!efficient!way.!

71. Obesity!and!risk!of!Malignancy!

73. GeneMc!counselling!
• Pa4ent!with!hereditary!breast!cancer,!the!
management!may!vary!in!gene4c!tes4ng.!!
• In!hereditary!breast!cancer!pa4ents!with!
abnormal!BRCA1!or!BRCA2!gene!muta4ons,!
other!female!rela4ves!may!also!be!at!risk!of!
developing!not!just!breast!cancer,!but!also!
ovarian!and!other!cancers.!
!!!!Other!inheritable!gene!mutaMons!such!as!!
• TP53!in!families!with!LiEFraumeni!syndrome,!
• Checkpoint!kinase!2!(CHEK2),!!
• AtaxiaEtelangiectasia!mutated!(ATM),!
• EEcadherin!(CDH1),!!
• Serine/threonine!kinase!11!(STK11),!
• Partner!and!localizer!of!BRCA2!(PALB2),!
• Phosphatase!and!tensin!homolog!(PTEN)!
!although!rare,!have!been!shown!to!increase!the!
risk!of!!early!onset!breast!cancer!.!

74. Males!too!need!to!be!on!alert?!
• Males!are!not!as!suscep4ble!as!females!for!breast!cancer,!those!with!a!posi4ve!family!
history!have!a!greater!chance!of!contrac4ng!breast!cancer,!compared!to!other!males!in!the!
general!popula4on!.!!
• Therefore,!the!family!members!of!breast!cancer!pa4ents!with!suscep4bility!genes,!both!
male!and!female,!may!need!to!be!counselled!with!respect!to!the!risks!of!developing!cancers!
associated!with!relevant!gene4c!muta4ons.!!
• Besides!gene4c!tes4ng!and!counselling,!psychosocial!support!may!also!be!offered!to!such!
families.!
• !It!should!be!noted!that!women!with!posi4ve!family!histories!of!breast!cancer!tend!to!have!a!
heightened!sense!of!anxiety!.!!
• Appropriate!gene4c!educa4on!and!counselling!would!thus!enable!family!members!to!fully!
appreciate!the!inherent!uncertainty!and!implica4ons!behind!gene4c!tes4ng.!

75. !
PrevenMon!
!
• Control!of!specific!modifiable!breast!
cancer!risk!factors!as!well!as!effec4ve!
integrated!preven4on!of!nonE
communicable!diseases!which!
promotes!healthy!diet,!physical!ac4vity!
and!control!of!alcohol!intake,!
overweight!and!obesity,!could!
eventually!have!an!impact!in!reducing!
the!incidence!of!breast!cancer!in!the!
long!term.!

76. !
Early!detecMon!
!
• Although!some!risk!reduc4on!might!be!
achieved!with!preven4on,!these!
strategies!cannot!eliminate!the!
majority!of!breast!cancers!that!develop!
in!lowE!and!middleEincome!countries.!!
• Therefore,!early!detec4on!in!order!to!
improve!breast!cancer!outcome!and!
survival!remains!the!cornerstone!of!
breast!cancer!control!(Anderson!et!al.,!
2008).!

77. !
Mammography!screening!
!
• Mammography!screening!is!the!only!
screening!method!that!has!proven!to!be!
effec4ve.!!
• Although!there!is!evidence!that!organized!
popula4onEbased!mammography!screening!
programmes!can!reduce!breast!cancer!
mortality!by!around!20%!in!the!screened!
group!versus!the!unscreened!group!across!all!
age!groups,!in!general!there!appears!to!be!a!
narrow!balance!of!benefits!compared!with!
harms,!par4cularly!in!younger!and!older!
women.!

78. !
Breast!self!examinaMon!(BSE)!
!
• There!is!no!evidence!on!the!
effect!of!screening!through!
breast!selfEexamina4on!(BSE).!
• !However,!the!prac4ce!of!BSE!
has!been!seen!to!empower!
women,!taking!responsibility!
for!their!own!health.!!
• Therefore,!BSE!is!recommend!
for!raising!awareness!among!
women!at!risk!rather!than!as!
a!screening!method.!

79. !
Clinical!Breast!ExaminaMon!(CBE)!
!• Research!is!underway!to!evaluate!CBE!as!a!lowEcost!approach!to!
breast!cancer!screening!that!can!work!in!less!affluent!countries.!
• !Promising!preliminary!results!show!that!the!ageEstandardized!
incidence!rate!for!advancedEstage!breast!cancer!is!lower!in!the!
screened!group!compared!to!the!unscreened!group!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Sankaranarayanan,!2011.!
!
!

80. A!largeEscale!analysis!of!nearly!150,000!women!published!in!
The'Lancet!in!2002!found!that!for!every!12!months!of!breasyeeding!
(either!with!one!child!or!spread!over!mul4ple!children),!the!risk!of!
breast!cancer!decreased!by!4.3!percent.!
!
In!2009!study!of!more!than!60,000!women!published!in!the!
Archives'of'Internal'Medicine!found!that!women!with!a!family!history!
of!breast!cancer!reduced!their!risk!of!genng!the!disease!before!
menopause!by!nearly!60!percent!if!they!breasyed.!
!
2017!Journal'of'the'Na/onal'Cancer'Ins/tute!found!that!women!of!
African!ancestry!have!an!especially!high!risk!of!developing!the!
aggressive!and!hardEtoEtreat!forms!of!breast!cancer!called!estrogen!
receptorEnega4ve!and!tripleEnega4ve—and!the!risk!actually!goes!up!
when!a!woman!gives!birth—but!breasyeeding!negates!this!risk.!
!
Breast!Feeding!and!!
Risk!of!Breast!Cancer!

81. In!utero!environment!and!!
breast!cancer!
• The!majority!of!
evidence!suggests!
that!various!sources!
of!excess!estrogen!
correlate!to!future!
breast!cancer!
development.!

82. In!utero!environment!and!!
breast!cancer!
• !In!addi4on,!maternal!
macroE!and!
micronutrient!balance!
appear!to!play!a!role!in!
genomic!regula4on,!
and!preliminary!data!
suggest!that!specific!
superfoods,!such!as!
blueberries,!have!a!
protec4ve!epigene4c!
effect.!

83. In!utero!environment!and!!
breast!cancer!
• !Iden4fying!the!influence!
of!environmental!
toxicants,!hormonal!
exposure,!maternal!
nutri4on,!and!maternal!
disease!on!fetal!
epigene4cs!may!have!
poten4al!for!
development!of!new!
therapeu4c!approaches!
for!the!preven4on!of!
breast!cancer.!

84. Danish!Study!
• With!the!use!of!a!very!large!collec4on!of!school!health!
records!combined!with!effec4ve!followEup,!we!found!that!
high!birth!weight,!early!age!at!peak!growth,!high!stature!
at!14!years!of!age,!low!BMI!at!14!years!of!age,!and!high!
growth!rate!in!childhood!—!parMcularly!around!puberty!
—!were!all!independent!risk!factors!for!breast!cancer.!
• Overall,!our!results!provide!evidence!that!factors!
influencing!fetal,!childhood,!and!adolescent!growth!are!
important!independent!risk!factors!for!breast!cancer!in!
adulthood.!
• !Therefore,!the!exposures!or!condi4oning!processes!during!
these!periods!are!of!par4cular!importance!in!rela4on!to!
adult!breast!cancer.!

85. Breast!cancer!registry!
• Develop!cancer!registries!and!
health!informa4on!systems!that!
collect!standardised!data!which!
is!comprehensive!and!accurate,!
so!that!decisionEmakers!can!
make!informed!and!evidenceE
based!policy!decisions!
Na4onal!Cancer!Registry!Program!
reports!on!4me!trends!in!cancer!
incidence!rates!(1982–2010)!from!13!
PBCRs!(Bangalore,!Bhopal,!Chennai,!
Delhi,!Mumbai,!Barshi,!
Thiruvananthapuram,!Dibrugarh,!
Kamrup!Urban!District,!Imphal!West!
District,!Ahmedabad!Rural!District!

86. • A!weekly!30!minute!exercise!program!tailored!
for!the!needs!of!cancer!survivors!
•!Training!in!relaxaMon!and!stress!management!
•!Group!discussion!and!support!
•!Resources!for!addiMonal!informaMon!

89. !
Complementary!Medicine!
!
• Many!people!use!complementary!and!alterna4ve!
medicine!(CAM)!while!they!are!on!conven4onal!
treatment.!
• !In!Singapore,!due!to!its!mul4cultural!popula4on,!
the!wide!array!of!CAM!encompasses!tradi4onal!
Chinese,!Malay,!and!Indian!medicine,!health!
supplements,!acupuncture,!yoga,!and!Ayurvedic!
massage.!A!crossEsec4onal!study!revealed!that!
the!use!of!CAM!is!highly!prevalent!among!cancer!
pa4ents!in!Singapore!.!!

90. !
Complementary!Medicine!
!
• Such!prac4ce!has!also!been!reported!in!China!with!the!use!of!
Tradi4onal!Chinese!Medicine!(TCM)!.!An!integra4ve!approach!
between!Western!treatment!and!CAM!could!benefit!pa4ents!
in!providing!increased!overall!wellEbeing!during!breast!cancer!
treatment,!by!improving!the!side!effects!from!conven4onal!
treatment!and!enhancing!treatment!outcomes.!However,!in!
order!for!these!benefits!to!be!delivered,!it!is!important!for!
trust!to!be!established!between!the!Western!doctor!and!the!
pa4ent,!so!that!the!pa4ent!is!forthcoming!in!telling!her!
doctor!what!treatment!she!is!receiving.!This!aids!the!Western!
doctor!to!ascertain!whether!the!CAM!would!interfere!with!
the!conven4onal!treatment,!so!as!to!prevent!treatment!delay!
and!poten4ally!dangerous!drug–drug!interac4ons!between!
CAM!and!chemotherapeu4c!or!radiotherapeu4c!agents.!

91. • On!the!contrary,!par4cularly!in!Asia,!where!family!plays!a!
greater!role!in!healthcare!decisions,!some!pa4ents!may!
find!it!stressful!and!confusing!when!overEanxious!family!
members!interfere!with!every!aspect!of!their!daily!life,!
including!their!diet!and!habits.!!
• To!avoid!such!situa4ons,!the!American!Society!of!Clinical!
Oncology!recommends!that!caregivers!have!an!open!
communica4on!with!the!cancer!pa4ent!and!give!assurance!
that!he!or!she!would!be!a!central!part!of!all!discussions!
and!decisions!.!!
• They!should!also!strive!to!involve!the!pa4ent!and!maintain!
a!sense!of!normalcy!by!helping!her!stay!engaged!with!the!
world!beyond!cancer.!

92. !
Spiritual!Care!
!
• Pa4ents!may!find!solace!and!assurance!
from!the!knowledge!that!a!higher!power!
exists.!
• !The!mo4va4onal!teachings!involved!in!
many!different!religions!help!to!keep!their!
hopes!high,!diver4ng!awen4on!away!from!
themselves!to!the!religious!rituals!or!
beliefs.!!
• Moreover,!religious!groups!can!also!offer!
community!support!and!solidarity!.!!

93. !
Spiritual!Care!
!
.!For!both!religious!and!nonE
religious!individuals,!nurseE
counseling!service!and!voluntary!
organiza4ons!support!can!also!
help!to!reduce!distress!associated!
with!breast!cancer!diagnosis!and!
treatment!!

94. !
RecreaMon!
!
• Pa4ents!are!likely!to!be!on!longEterm!
leave!while!recovering!from!treatment.!
Some!pa4ents!may!inevitably!feel!a!
sense!of!emp4ness!following!a!sudden!
break!from!their!hec4c!work.!As!such,!
recrea4on!becomes!an!important!means!
to!“kill!4me”!and!preoccupy!them.!
• !Some!forms!of!recrea4on!include!
watching!drama,!going!on!excursions!or!
trips,!engaging!in!music!therapy,!pet!
therapy,!or!art!therapy.!

95. !
RecreaMon!
!
• !Randomized!controlled!trials!
conducted!on!cancer!pa4ents!have!
shown!that!music!and!art!therapy!
are!effec4ve!in!reducing!emo4onal!
distress!and!enhancing!
psychological!wellEbeing.!