Breast cancer survivors face potentially significant impacts of cancer and its treatment and deserve high-quality, comprehensive, coordinated clinical follow-up care.
Carolyn D. Runowicz, MD, (left) Corinne R. Leach, PhD, MS, MPH, and colleagues
The American Cancer Society (ACS) and ASCO have issued a Breast Cancer Survivorship Care guideline, published jointly in the Journal of Clinical Oncology and CA: A Cancer Journal for Clinicians.1,2 The guideline recommendations were formulated by a multidisciplinary expert work group and are based on a systematic review of the literature through April 2015. The guideline aims to assist primary care and other clinicians in the care of women who have survived breast cancer.
Carolyn D. Runowicz, MD, of Herbert Wertheim College of Medicine, Florida International University, Miami, is the lead author of both articles, and Corinne R. Leach, PhD, MS, MPH, of the American Cancer Society, is the corresponding author of both articles.
Key recommendations are summarized/reproduced below. Level of evidence is defined as follows: I = meta-analyses of randomized controlled trials; IA = randomized controlled trial of breast cancer survivors; IB = randomized controlled trials based on cancer survivors across multiple cancer sites; IC = randomized controlled trials not based on cancer survivors but on the general population experiencing a specific long-term or late effect; IIA = nonrandomized controlled trials based on breast cancer survivors; IIB = nonrandomized controlled trials based on cancer survivors across multiple sites; IIC = nonrandomized controlled trials not based on cancer survivors but on the general population experiencing a specific long-term or late effect; III = case-control study or prospective cohort study; 0 = expert opinion, observational study (excluding case-control and prospective cohort studies), clinical practice, literature review, or pilot study; 2A = National Comprehensive Cancer Network clinical practice guidelines.
Surveillance for Breast Cancer Recurrence
History and physical: Primary care clinicians should (a) individualize clinical follow-up care based on age, specific diagnosis, and treatment protocol and as recommended by the treating oncology team (level of evidence = 2A); and (b) ensure that the patient receives a detailed cancer-related history and physical examination every 3 to 6 months for the first 3 years after primary therapy, every 6 to 12 months for the next 2 years, and annually thereafter (level of evidence = 2A).
Screening for local recurrence or new primary breast cancer: (a) refer women who have received a unilateral mastectomy for annual mammography on the intact breast and, for those with lumpectomies, an annual mammography of both breasts (level of evidence = 2A); and (b) do not refer for routine screening with magnetic resonance imaging of the breast unless the patient meets high-risk criteria per ACS guidelines (level of evidence = 2A).
Laboratory tests and imaging: Do not offer routine laboratory tests or imaging, except mammography if indicated, for the detection of disease recurrence in the absence of symptoms (level of evidence = 2A).
Signs of recurrence: Educate and counsel all women about the signs and symptoms of local or regional recurrence (level of evidence = 2A).
Risk evaluation and genetic counseling: (a) Assess the patient’s cancer family history; and (b) offer genetic counseling if potential hereditary risk factors are suspected (eg, women with a strong family history of cancer [breast, colon, ovarian, endometrial cancer] or age ≤ 60 years with triple-negative breast cancer; level of evidence = 2A).
Endocrine treatment impact, symptom management: Counsel patients to adhere to adjuvant endocrine (antiestrogen) therapy (level of evidence = 2A).
Screening for Second Primary Cancers
Cancer screening in average-risk patient: Primary care clinicians should (a) screen for other cancers as they would for patients in the general population; and (b) provide an annual gynecologic assessment for postmenopausal women on selective estrogen receptor modulator therapies.
Physical and Psychosocial Long-Term and Late Effects
Body image concerns: Primary care clinicians should (a) assess for patient body image/appearance concerns (level of evidence = 0); (b) offer the option of adaptive devices (eg, breast prostheses, wigs) and/or surgery when appropriate (level of evidence = 0); and (c) refer for psychosocial care as indicated (level of evidence = IA).
Lymphedema: (a) Counsel survivors on how to prevent/reduce the risk of lymphedema, including weight loss for those who are overweight or obese (level of evidence = 0) and (b) refer patients with clinical symptoms or swelling suggestive of lymphedema to a therapist knowledgeable about the diagnosis and treatment of lymphedema (level of evidence = 0).
Cardiotoxicity: (a) Monitor lipid levels and provide cardiovascular monitoring, as indicated (level of evidence = 0); and (b) educate survivors on healthy lifestyle modifications, potential cardiac risk factors, and when to report relevant symptoms (shortness of breath or fatigue; level of evidence = I).
Cognitive impairment: (a) Ask patients about cognitive difficulties (level of evidence = 0); (b) assess for reversible contributing factors of cognitive impairment and optimally treat when possible (level of evidence = IA); and (c) refer patients with signs of cognitive impairment for neurocognitive assessment and rehabilitation, including group cognitive training if available (level of evidence = IA).
Distress, depression, anxiety: (a) Assess patients for distress, depression, and/or anxiety (level of evidence = I); (b) conduct a more probing assessment for patients at a higher risk of depression (eg, young patients, those with a history of prior psychiatric disease, and patients with low socioeconomic status, level of evidence = III); and (c) offer in-office counseling and/or pharmacotherapy and/or refer to appropriate psycho-oncology and mental health resources as clinically indicated (level of evidence = I).
Fatigue: (a) Assess for fatigue and treat any causative factors for fatigue, including anemia, thyroid dysfunction, and cardiac dysfunction (level of evidence = 0); (b) offer treatment or referral for factors that may impact fatigue (eg, mood disorders, sleep disturbance, pain, etc) for those without an otherwise identifiable cause (level of evidence = I); and (c) counsel patients to engage in regular physical activity and refer for cognitive behavioral therapy as appropriate (level of evidence = I).
Bone health: (a) Refer postmenopausal survivors for baseline dual-energy x-ray absorptiometry (DEXA) scan (level of evidence = 0); and (b) refer for repeat DEXA scans every 2 years for women taking an aromatase inhibitor, premenopausal women taking tamoxifen and/or a gonadotropin-releasing hormone (GnRH) agonist, and women who have chemotherapy-induced premature menopause (level of evidence = 0).
Musculoskeletal health: (a) Assess for musculoskeletal symptoms, including pain, by querying patients at each clinical encounter (level of evidence = 0); and (b) offer one or more of the following interventions based on clinical indication: acupuncture, physical activity, and referral for physical therapy or rehabilitation (level of evidence = III).
Pain and neuropathy: (a) Assess for pain and contributing factors for pain using a simple pain scale and comprehensive history of the patient’s complaint (level of evidence = 0); (b) offer interventions, such as acetaminophen, nonsteroidal anti-inflammatory drugs, physical activity, and/or acupuncture, for pain (level of evidence = I); (c) refer to an appropriate specialist once the underlying etiology has been determined (eg, lymphedema specialist, occupational therapist, etc; level of evidence = 0); (d) assess for peripheral neuropathy and contributing factors by asking patients about their symptoms (level of evidence = 0); (e) offer physical activity for neuropathy; and (f) offer duloxetine for patients with neuropathic pain, numbness, and tingling (level of evidence = IB).
Infertility: Refer survivors of childbearing age who experience infertility to a specialist in reproductive endocrinology and infertility as soon as possible (level of evidence = 0).
Sexual health: (a) Assess for signs and symptoms of sexual dysfunction or problems with sexual intimacy (level of evidence = 0); (b) assess for reversible contributing factors to sexual dysfunction and treat when appropriate (level of evidence = 0); (c) offer nonhormonal, water-based lubricants and moisturizers for vaginal dryness (level of evidence = IA); and (d) refer for psychoeducational support, group therapy, sexual counseling, marital counseling, or intensive psychotherapy when appropriate (level of evidence = IA).
Premature menopause/hot flashes: Offer selective serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, gabapentin, lifestyle modifications, and/or environmental modifications to help mitigate vasomotor symptoms of premature menopausal symptoms (level of evidence = IA).
Information: Primary care clinicians (a) should assess the informational needs of the patient related to breast cancer and its treatment, side effects, other health concerns, and available support services (level of evidence = 0); and (b) provide or refer survivors to appropriate resources to meet these needs (level of evidence = 0).
Obesity: (a) Counsel survivors to achieve and maintain a healthy weight (level of evidence = III); and (b) counsel survivors if overweight or obese to limit consumption of high-calorie foods and beverages and increase physical activity (level of evidence = IA, III).
Physical activity: Counsel survivors to engage in regular physical activity consistent with ACS guidelines and specifically to: (a) avoid inactivity and return to normal daily activities as soon as possible (level of evidence = III); (b) aim for at least 150 minutes of moderate or 75 minutes of vigorous aerobic exercise per week (level of evidence = I, IA); and (c) include strength training exercises at least 2 days per week and emphasize strength training for women treated with adjuvant chemotherapy or hormone therapy (level of evidence = IA).
Nutrition: Counsel survivors to achieve a dietary pattern that is high in vegetables, fruits, whole grains, and legumes, low in saturated fats, and limited in alcohol consumption (level of evidence = IA, III).
Smoking cessation: Counsel survivors to avoid smoking and refer survivors who smoke to cessation counseling and resources (level of evidence = I).
Care Coordination/Practice Implications
Survivorship care plan: It is recommended that primary care clinicians consult with the cancer treatment team and obtain a treatment summary and survivorship care plan (level of evidence = 0, III).
Communication with oncology team: Maintain communication with the oncology team throughout the patient’s diagnosis, treatment, and post-treatment care to ensure care is evidence-based and well-coordinated (level of evidence = 0).
Inclusion of family: Encourage inclusion of caregivers, spouses, or partners in usual survivorship care and support (level of evidence = 0).
The authors concluded: “Breast cancer survivors face potentially significant impacts of cancer and its treatment and deserve high-quality, comprehensive, coordinated clinical follow-up care. Primary care clinicians must consider each patient’s individual risk profile and preferences of care to address physical and psychosocial impacts.”1,2 ■
Disclosure: The article was supported in part by the Centers for Disease Control and Prevention. For full disclosures of the study authors, visit jco.ascopubs.org.
The recent publication of the American Cancer Society (ACS)/ASCO breast cancer survivorship care guideline is a tremendous contribution to the literature and should provide a roadmap for providers who care for patients with a history of breast cancer for years to come.1,2 The guideline, reported by ...