ASCO and the American Cancer Society (ACS) have jointly published a breast cancer survivorship care guideline, aimed at assisting primary care physicians (PCPs) in caring for female breast cancer survivors without evidence of disease but who need to be watched for recurrence and who may experience long-term side effects unique to their experience with breast cancer. The guideline, “American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline,” was published online in Journal of Clinical Oncology in December 2015.1
This document marks the first time the two societies have collaborated on developing a comprehensive survivorship guideline. With a 5-year breast cancer survival rate of approximately 90%,2 addressing survivorship care and monitoring needs is becoming increasingly important in this large population of cancer survivors.
Dr. Gary H. Lyman
According to Dr. Lyman, the guideline “covers a whole range of issues” relating to physical and emotional after-effects for survivors and incorporates important elements of health promotion. “This guideline is long overdue,” he said.
Dr. Carolyn D. Runowicz
Surveillance for Breast Cancer Recurrence
According to the guideline, “patients should undergo regular surveillance for breast cancer recurrence, including evaluation with a cancer-related history and physical examination, and should be screened for new primary breast cancer. Data do not support performing routine laboratory tests or imaging tests in asymptomatic patients to evaluate for breast cancer recurrence.”1
Individualized clinical follow-up care should be provided to breast cancer survivors based on age, specific diagnosis, and treatment protocol. This means patients should receive a detailed cancer-related history and physical exams every 3 to 6 months for the first 3 years after primary therapy, decreasing to every 6 to 12 months for the following 2 years, and then annually thereafter. Patients who have undergone a unilateral mastectomy should be referred for annual mammography on the intact breast, and for those who underwent lumpectomy, an annual mammography on both breasts. The recommendations are against ordering an MRI unless a patient has a high risk.
Screenings for Second Primary Cancers
PCPs should screen average-risk breast cancer survivors for cancers as they would for patients in the general population, and they should provide an annual gynecologic assessment for postmenopausal women on selective estrogen receptor modulatory therapies.
PCPs need to screen for other cancers such as colon, lung, or cervical cancers, as appropriate. PCPs also need to screen for breast cancer in the contralateral breast, especially when patients have not undergone a prophylactic mastectomy. Genetic counseling may also be recommended, Dr. Runowicz said.
Managing Long-Term Side Effects of Breast Cancer Treatment
Long-term side effects—those that may occur up to decades after the primary treatment—are an increasing concern because breast cancer survivors are a growing population with complex needs. The guideline addresses many of the common side effects survivors may face, including lymphedema, cardiovascular disease, cognitive impairment, distress, depression, anxiety, bone health, and fatigue, among others. The impetus is to have PCPs become more cognizant of these effects and the correlation to prior breast cancer treatment, not just the patient’s lifestyle.
“If someone is 15 or 20 years cancer free, complaints of fatigue may not be attributed to the cancer treatment,” Dr. Lyman said. “A complete work-up is recommended.”
Also, some patients may not associate cognitive issues with previous cancer treatment but rather can think it may be dementia or Alzheimer’s disease, he said. Identifying potential side effects before they become a larger problem is crucial.
The guidelines recommend that patients be counseled to improve their overall health, including smoking cessation and healthy weight management/physical activity.
“In addition to hopefully reducing the risk of breast cancer recurrence, the guideline should help improve the overall health of the patient,” Dr. Lyman said.
“Exercise and developing a healthy lifestyle is critical,” Dr. Runowicz said.
Moving forward, Dr. Lyman sees a “more coordinated, organized set of recommendations for survivorship.” This includes how communication should flow between the oncology care team and patients, family, and PCPs. “After cancer treatments are finished, we need to ensure patients’ subsequent care over the following years and decades is optimal,” he said.
These guidelines “provide a roadmap for our patients, and it helps them become partners in their overall health care,” Dr. Runowicz said.