Today, Friday September 29 at 1:00 PM ET, we are opening up the AMA in THIS POST for your questions to Allison Asante PA-C., Physician Assistant in Gynecologic Oncology at Northwell Hospital, All questions that you have for Allison should be posted as a reply to THIS original post.
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Good Afternoon everyone. I'm so happy to be here today! My name is Allison Asante. I use they/them pronouns. I am a physician assistant and have been practicing in Gynecologic Oncology for a little over 10 years. I work in a practice affiliated with Lenox Hill Hospital where we perform surgery, chemotherapy and survivorship care.
Here's our first question. How often should women with high risk for recurrence receive PET/CT or other scans? Why are some doctors not prescribing them? (#Merma on HU)
Surveillance scans and frequency can certainly be different with different providers. When you look at the guidelines for survivorship and surveillance – there have been no trials that look directly at the different ways we do surveillance in uterine cancer to really know the best way. In my practice - generally we get imaging with CT scans every 6 months for patients at high risk for recurrence for the first two to three years.
What we do know is that a physical exam and patient’s symptom review is over 80% accurate at diagnosing a recurrence in uterine cancer. Its important to note that even when providers do routine imaging with surveillance – a patient’s symptoms are what lead to finding the recurrence somewhere between 40-80% of the time. How you feel as the patient is truly the most important indicator of your cancer status. The decision to get imaging should be a decision you and your provider make together based on your recurrence risks. That being said – there was a large literature review that showed imaging only found at most 20% of recurrences in uterine cancer patients without any symptoms. Most recurrences in patients without symptoms are found on physical exam. So I would say many people, like my practice do routine surveillance imaging, but it has not been proven to be beneficial in improving outcomes for uterine cancer patients.
We have another question that's a good follow-up to the first one. After initial diagnosis, which type of scans are best to use for follow-up surveillance?
This also can vary based on your exact clinical situation and recurrence risk. Most of the time in uterine cancer CT scans are sufficient. In certain cases, or to clarify an abnormal CT result we may also order a PET scan.
A member of our support group wrote: I have a fairly severe chemo-induced neuropathy in both my feet. I also developed foot drop in my right foot. I have been dealing with this for two years. Any recommendations for some relief?
I'm sorry to hear that. Peripheral neuropathy can be one of the most debilitating chemotherapy side effects. My first suggestion would be physical therapy for gait training to make sure you feel safe walking. The physical therapy team may also recommend an orthopedic device to help with the drop foot that can help you feel more stable when walking. There have been small studies that show exercise, acupuncture and scrambler therapy (a type of electrical TENs therapy) may be beneficial for people with chemotherapy induced neuropathy. There have not been enough dedicated large studies for me to say that definitively any of these work. In my experience with patients I have seen people have improvement with both physical therapy and acupuncture. I do not have experience with the scrambler therapy yet. There are medications to help if you have pain from neuropathy too. You should also be careful to keep your feet safe from injury when you do not have normal sensation. Make sure to wear well fitted sneakers, not walk barefoot, inspect your feet for injuries at least once a week, and avoid extremes of temperature.
What a great question! There is no exact size where we consider treatment for lung nodules. In my practice we look a lot at initial size of the nodule and then the rate of growth. From doing many Chest scans on patients with cancer I've noticed many patients may have small (usually less than 1.5 centimeter) nodules in their lungs that can be incidental findings. If the nodule is continuing to grow we watch it very carefully. Typically if the nodule increases in size by 50% and is over a centimeter we will do an intervention. It is not an exact science and changes a bit from patient to patient. Typically if we are concerned we will perform a PET/CT to see if the nodule is active or a biopsy if that is possible.
Please remember to refresh your screens to see the latest answers. Here's another question: Besides diet, exercise and regular gyn exams, is there advice or a protocol for post-treatment patients who are at high risk that may help to prevent a recurrence? Kathy_SHARE
I think the best way to decrease recurrence risk is to take the treatment your cancer team may recommend after surgery. The main point of adjuvant treatment with chemotherapy and/or radiation is to decrease recurrence risk. One other way to decrease recurrence risk is to maintain or decrease your weight. Most uterine cancers are estrogen responsive. Being overweight is a risk factor for uterine cancer because our fat cells produce estrogen as well. A study that came out in May of this year showed that people who gained weight after their uterine cancer diagnosis did have an increased risk of recurrence compared with patients who maintained or lost weight. This risk was most noticeable in people who had endometrioid cell type, which is the most common cell type of uterine cancer.
Why isn't maintenance medication automatically prescribed after the first occurance of grade 3 endometrial cancer? Rather than just after a recurrence? @FierceFriend
This is a another great question and a definite point of discussion in gyn oncology right now. We have not had enough dedicated trials in uterine cancer, especially focusing on maintenance medication. For people with serous uterine cancer that are Her2 positive we can give Herceptin as a maintenance treatment. Grade 3 endometrioid adenocarcinoma is a cell type I agree the dedicated research is lacking. One thing our practice does is add an aromatase inhibitor like letrozole for maintenance in ER+ patients who have had a recurrence or are at high risk for recurrence. Again, this has not been proven to decrease the recurrence risk. The thought behind using them is that it should help prevent recurrence the same way it does in breast cancer with minimal side effects.
Particular to your situation - I do not know of any dedicated studies looking just at maintenance after initial diagnosis for grade 3 endometrioid adenocarcinoma. Why certain things are studied versus not studied is a complicated topic with many influential factors. Federal funding and public awareness are lacking in people with uterine cancer. Because most people with uterine cancer have such a good prognosis, I feel those with higher recurrence risks get left behind. I wish all gynecologic cancers had the same funding and awareness that came with breast cancer.
When a patient has a recurrence of an er+ pr+ her2- endometrial cancer, do you use cdk4/6 inhibitors and an aromatase inhibitor? How long do patients have progression free survival with this treatment?
I have not used this regimen yet personally but I think it has great promise in er+ uterine cancer as it has had effects in breast cancer. Studies on this combination have seen a 10-30% response rate and 5-9 month progression free survival. The big advantage of this treatment is the relatively good side effect profile compared to most chemotherapy regimens.
What do you recommend for patients that struggle with chemo related brain fog (cancer related cognitive decline)? Do you refer your patients to an Occupational Rehabilitation?
Another tough chemo side effect. My cancer center just had occupational rehab added as a resource so I have not utilized it yet but I plan to! The brain fog does seem to improve when chemotherapy is finished, but often does not resolve completely. I notice my patients who also went through surgical menopause, or are 70+ complain about this more. I generally recommend lifestyle modifications - like doing a crossword/puzzle to work on your focus, avoiding multitasking, writing down to do list when short term memory is compromised etc. I have also referred patients rarely to neurologists or psychiatrists who have benefitted from medications typically used in dementia or ADHD to help with focus.
Why and how certain things are researched I find to be frustrating and mystifying. We see these types of research gaps in many types of cancer. You will notice in almost every response I am noting something I use in practice that has not been shown to work in a study. I do think maintenance treatments are coming for uterine cancer - my best guess would be that they will be a combination of immunotherapy and hormonal agents. There is currently maintenance medication in serous uterine cancer patients who are HER2+. We use Herceptin both with their chemotherapy and then after as maintenance.
Here's another from a support group member: Does changing to a plant based diet really make a difference once you’ve gotten cancer? Does it actually prevent occurence?
Diet and cancer is another area where we simply have not had enough dedicated research. In the studies that exist currently, they have not shown that any diet will decrease you cancer recurrence risk. There have been studies that show a decrease in overall mortality (death) in people who eat plant based or Mediterranean diets so I still think there is a benefit of eating this way, even if it has not been proven in cancer specific trials.
Exercise has been shown to improve outcomes in most stages of cancer treatment and remission. The more active people can be before diagnosis, during treatment and after have been shown to improve cancer outcomes. I think the data can be a bit confusing here as generally speaking patients who can exercise during/after treatment are also going to be the "healthiest" subset of patients. However in breast cancer survivors, exercise has been shown to decrease chances of death from breast cancer and other types of cancer. Studies have shown exercise can improve mental health and quality of life during treatment as well. Most studies use "moderate aerobic activity" as the exercise - which I would compare to a fast walk, slow jog, swimming etc. I don't know of a dedicated trial in decreasing uterine cancer recurrence risk, but given the number of other health benefits I still suggest it.
What alternate and traditional therapies do you suggest for side effects from chemotherapy? Pain in bones, peripheral neuropathy, hair loss, exhaustion, sleep disturbances, lack of appetite, things tasting funny, vision changes.
In the theme of the last question - exercise has been shown to decrease pain, fatigue and sleep disturbances during chemotherapy. For bone pain other than moving I generally recommend NSAID pain medication like tylenol or ibuprofen. If the bone pain is caused by Neulasta or similar medications to keep your white cells up Claritin can be helpful too. Acupuncture and Acupressure massage are things I have seen really help patients with most chemotherapy side effects. Aromatherapy can also be used for focus and sleep. For appetite and taste changes I recommend more frequent "snack" sized meals every 2-3 hours rather than 3 meals a day. If you have a metallic taste- using citrus fruit or a sour candy before eating can help. Other things I have seen help are not eating/drinking anything out of a can and changing to paper or plastic plates and utensils. For hair loss, cold capping can decrease or prevent the hair loss from chemotherapy. Many patients report their scalps are tender when they first lose their hair - I have seen improvement using lavender with moisturizer to soothe the scalp. Guided imagery and meditations can help too - I have patients who have used it to imagine their surgery going well, their cancer cells being killed by the chemo etc. Some of my patients utilizing Vitamin B6 and Glutamine supplements to try to prevent neuropathy (Again, not proven to work).
Thank you so much for all this great information, Allison - we are really appreciative of your time and expertise! And thank you everyone who joined us. This whole post will be pinned so you can read it anytime.
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