Incidence and prevalence

Risk factors for breast CA

New Treatments

New medications

Oral Care

New Products

2009:

USA: 1,479,350 new cancer diagnoses (all types)

SC: 22,100 new cancer diagnoses (all types)

USA: 562,340 deaths from cancer

SC: 9,100 deaths from cancer

2012:

USA: 1,638,910 new diagnoses anticipated (all types)

SC: 26,570 new cancer diagnoses (all types)

USA: 577,190 deaths from cancer

SC: 9670 deaths from cancer

*these numbers are slightly higher than last year’s

Breast Cancer (2012)

USA new – 229,060 -2,190 men (1%)

SC new – 3,570

USA incidence/100,000 -120

SC incidence/100,000 -121

USA deaths – 39,920

SC deaths - 660

Oral Cancer (2012)

USA new – 40,250

USA (2009) – 35,700

SC new - ?

USA deaths – 7,850

USA (2009) – 7,600

SC deaths - ?

Decrease in all BC incidence since 2000

7% decrease from

2002-3

› May be related to

reduced use of

hormone therapy

for menopause

Stable 2004-2008

For early stage breast CA

› CA in situ

Stable for white women

Increasing for

African American

Is this a good thing?

› Perhaps more early

diagnoses????

Arizona: 104*

Utah: 108

New Mexico: 109

Mississippi: 110

South Carolina: 120

Oregon, Washington, Vermont: 130

Connecticut: 134

› *per 100,000

1975 -77

All races

› 75%

White

› 76%

African American

› 68%

Today:

All races

› 90% overall,

› 99% for localized

White

› 91%

African American

› 78%

Note: 5-year survival was only 63% in the 1960’s !!!!!

-African American survival rates have not increased at the same rate

as survival of white American women.

10 year = 82%

15 year = 77%

*Remember : a 15 year survivor who dies

this year had her initial diagnosis and

treatment 15 years ago….Sooooo,

advances in diagnosis and treatment

should lead to even longer survival for

women diagnosed this year!

2.5 million

U.S. breast cancer

survivors were

alive in 2010 !

Non-modifiable

› Gender

› Age Long menstrual history

No pregnancies or 1st child

after 30

› Family history:

Genetic

predisposition

Race/ethnicity ?

Lifetime probability of developing breast

cancer = 1 in 8

Probability before age 39 = 1 in 207

Between ages 40-59 = 1 in 27

> age 70 = 1 in 15

Breast Cancer susceptibility gene mutations – BRCA1 and BRCA2

Accounts for 5-10% of all new BCA › Family clusters

› Eastern European Jewish descent

› Males who develop BC

HER2 - a gene gone wild!

All women have the HER2 gene

“Human Epithelial growth factor Receptor 2” = HER2

Normal HER2 receptors help control growth and maintenance of healthy breast tissue.

25% of all breast cancers have an overproduction of HER2 which causes accelerated growth of the tumor.

Newer studies of Latina women:

Links between known BC risk factors are not as clear for Latinas as for non-Hispanic white women

Only common risk is age

Compared to African American women, white women are slightly more likely to develop breast cancer, but less likely to die of it.

African American women tend to have more aggressive tumors. Why this is the case is not known

Women of other ethnic backgrounds

— Asian, Latino, and

Native American — have a lower risk of

developing and

dying from breast cancer than white

women and African

American women

Educational level is the

greatest predictor of unnecessary cancer

death.

Even with racial and demographic data

factored in, lower

education level = higher death rate from

cancer.

Dr. Baker’s perio students?????

Potentially Modifiable:

› Overweight Especially older women

› Hormone exposure HRT – estrogen/progesterone

combos

High dosage BCP

› Couch potato

› Nighttime work* Exposure to light

› Alcohol > 1 drink per day

› Smoking – tobacco exposure* NEW research in this area

Limited evidence, but suggestive

To Decrease Risk:

› Breastfeeding

› Healthy weight

› 4-7 hours / week of physical

activity

› 7-9 servings / day of fruits

and veggies

› Limit alcohol consumption to

less than one drink per day,

2-4 per week.

Body weight and

activity level

› impacts both

risk of disease

and survival

rates.

Surgeries

Chemotherapy

Radiation

Most women undergo a

combination of these

Mastectomy with Lymph Node Dissection › With chemotherapy and/or radiation

Mastectomy with Terminal Node Biopsy › Newer technique

› Fewer complications!!! – more later

Lumpectomy + Radiation › With or without chemotherapy

Range of motion

› If muscles or nerves were lost or damaged in

surgery

Poor circulation in arm on affected side

Lymphedema

› Risk increases with increase in number of

lymph nodes removed.

swelling of the soft

tissues of the arm and

or hand

accumulation of

lymphatic fluid and

damaged drainage

system

5-40% of BC survivors

will have some degree

of lymphedema

Lymph nodes and

vessels are often removed during

mastectomy

If the arm is injured or inflamed, lymph can

accumulate and is not

able to drain normally

This condition can persist

for long periods of time

and may become infected.

Injury to affected side after:

› mastectomy with

lymph node dissection

› Radiation treatment

that results in scarring

of lymphoid area

Lymphedema compression bandage

Do’s:

› Use protective gloves for gardening or

cleaning

› Use oven mitts

› Use mild soaps and moisturizers

› Avoid insect bites (use non-drying repellants)

› Use an electric razor

› Rest the arm in an elevated position

› Control blood sugar levels if you are diabetic

Don’ts:

› Carry a heavy shoulder bag

› Use hot tubs or saunas

› Apply heat or vigorous massage to affected arm

› Have BP taken on affected arm

› Have blood draws or injections on affected arm

› Have tattoos or piercing of affected area.

Sentinel node biopsy and dissection › Requires high level of surgical skill

› Radioactive dye injected into tumor prior to surgery

› Dye drains into lymph nodes – sentinel is first node in line

› Surgeon uses a special instrument to track the flow of the dye

› Sentinel node removed and checked under microscope – if clear – no further nodes removed

› If sentinel is positive for CA, further nodes removed and checked a few at a time.

Evista (raloxifine)

› estrogen receptor blocker

Novaldex (tamoxifen)

› estrogen receptor blocker

Both are given to women in high risk

families

› Tamoxifen is also used to prevent recurrence

of BC, but Evista is only used to prevent a first occurrence

IV chemo drugs:

Adriamycin*

Cytoxen

Taxol* / Taxotere

› made from bark of the Pacific yew tree

› may cause allergic reactions

Herceptin

› For HER2 positive cancers

Oral drugs:

Tamoxifen

Xeloda

Avastin

Arimidex

*Known oral side effects

Zofran

› Wonderful for nausea

› Expensive – must justify for some insurance

companies

Procrit

› stimulates bone marrow to make red blood cells.

› used to treat anemia caused by

chemotherapy. Helps with energy levels.

Neupogen, Neulasta

› Stimulates bone marrow to produce neutrophils

Tamoxifen (older, but still common)

› Blocks estrogen receptors

› Provides some protection against osteoporosis

Arimedex (newer)

› Aromatase (estrogen pre-curser)

› More effective than tamoxifen at preventing

recurrence

› No protective action for bones

Patients should receive a complete oral evaluation, debridement and oral hygiene instructions BEFORE chemotherapy begins.

-Eliminate potential sources of infection / inflammation

-Rough or sharp surfaces should be smoothed.

When patients call… Attempt to schedule within 24 hours. › Patients often do not have much time

between a diagnosis of cancer and the beginning of treatment.

› “Put on your happy face; chances are that this person is having a worse day than you are.” Susan Calderbank, DMD

› YOU can make a difference!!

Consult with the oncologist.

Ask for current blood counts. Patient may be immunosuppressed › Premedication may be necessary.

Attempt to schedule 1 day before chemo day - this is when the patient should be strongest.

Do not schedule when the office will be crowded. › First patient in the morning

Nadir:

Approximately 10 days after

each treatment, the

patient’s blood counts are at

their lowest levels.

This period is called the

nadir.

If the white cells are

affected, the patient will be

most susceptible to infection

at this time

Neupogen/Neulasta help!!!!

Xerostomia

pH changes: more acidic

Fragile, friable tissues

› Generalized “mucositis”

Susceptible to candidiasis

› And other opportunistic infections

Dysgeusia = bad taste

xerostomia

pH changes

Oral environment

becomes more

acidic

Combined with

xerostomia

= Increased caries

oral mucositis: ALL mucosa of the oral

cavity is inflamed.

Changes may be subtle in appearance, but still significant to the patient.

Ulcers may or may not be visible.

Patients will report that the mouth feels “raw” or “scalded”

Candidiasis:

Xerostomia and pH changes alter the oral flora.

The patient’s immune system is suppressed by chemotherapy.

May not present classic appearance

Complications: Oral changes caused by chemotherapy

increase risk of mucositis, candidiasis, gingivitis, periodontitis and caries.

Destruction of blood cells during

chemotherapy places the patient at greater risk for infection.

Infection in the mouth can easily

become systemic in an immunosuppressed patient.

RINCINOL™ P.R.N., THE FIRST

BIO-ADHERENT NON-PRESCRIPTION MOUTH

RINSE FOR ORAL PAIN RELIEF

Non-prescription Aloe Vera based site

specific gel

no alcohol and no Benzocaine

Finally!

G U M Expanding floss:

soft and does not cut

G U M Sensitive Care TB

Xerostomia Xeropthalmia

Lubricant Eye drops

› Refresh

› Refresh PM

Avoid irritants:

› Smoke

› Chlorine

And nose care too…..

…especially at night.

Nose dryness leads to

mouth breathing

Negative effects of chemotherapy will

resolve partially or totally…..eventually

› Xerostomia and delicate tissues may take some time

For survivors of Head/Neck cancer,

effects of radiation therapy are

permanent.

Breast Cancer survivors have some long-

term effects

Chemotherapy for breast cancer will

bring on early and

sudden menopause.

Maintenance drugs

for breast cancer

keep the patient in a

hormone deprived

state. Survivors have

hormone levels of a

much older woman

To menopause and beyond!!!

Loss of estrogen contributes to other health problems such as osteoporosis

Long-term use of bisphosphonate medications for osteoporosis is associated with osteonecrosis of the bone (ONJ).

Rx names:

Fosamax, Actonel,

Boniva

*Reclast (IV)

Patients who have had

› IV bisphosphonates

or

› long term oral

bisphosphonates

are not good

candidates for tooth

extraction or

implants

Prevention and

maintenance is

key!!!

American Cancer Society, Cancer Facts and Figures 2009, www.cancer.org

American Cancer Society, Cancer Facts and Figures 2011, www.cancer.org

American Cancer Society, Cancer Facts and Figures 2012, www.cancer.org

Breastcancer.org

U.S Dept. of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, Three Good Reasons to See a Dentist Before Cancer Treatment, March 2011.

U.S Dept. of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, Head and Neck Radiation Treatment and Your Mouth, March 2011.

U.S Dept. of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, Chemotherapy and Your Mouth, Dec.2010.