Breast Cancer Survivorship in Community Oncology Practice

Breast cancer is the most commonly diagnosed cancer among women. Recent improvements in healthcare, including earlier detection and effective treatment strategies, have significantly improved survival rates. With more than 3.8 million breast cancer survivors in the United States, the 5-year survival rate is 90% and the 10-year survival rate is 80%. Therefore, most patients diagnosed with breast cancer will become long-term survivors. Breast cancer predominantly affects women, with less than 1% of all breast cancers occurring in men, thus much of the information on breast cancer survivorship is geared toward women. Breast cancer survivors frequently experience a number of physical and psychosocial issues that can affect their health and wellbeing. Cancer programs and clinicians need to be prepared to address these long-term effects of cancer and its treatment. The term “cancer survivor” most commonly refers to any person who has been diagnosed with cancer, but the needs of patients with metastatic disease are different from those with curative intent disease. This chapter will review and discuss the essential elements of survivorship care in community oncology practice for breast cancer patients diagnosed with curative intent disease.

Surveillance

The primary goals of surveillance are to watch for recurrence of the original cancer or development of a second cancer. Patients with early-stage breast cancers (tumor <5 cm and fewer than four positive nodes) may follow up with their primary care provider 1 year after their diagnosis, according to the American Society of Clinical Oncology. Crabtree et al. found that there are differing views regarding primary care’s role in cancer survivorship care that includes a “lack of coherence” about the overall concept of survivorship. The authors found that in spite of a growing number of cancer survivors in the United States as well as a shortage of oncologists, some primary care providers believe that care after cancer treatment has ended should continue to be done by the oncology team. Table 13.1 summarizes current surveillance recommendations for breast cancer survivors, as outlined in this section.

Table 13.1

Surveillance Recommendations for Breast Cancer Survivors

Mode of Surveillance	Recommendation
History/physical examination	Every 3–6 months for the first 3 years after primary therapy, then every 6–12 months for the next 2 years, and then annually
Mammography	Mammography should be performed yearly
Pelvic examination	Regular gynecologic follow-up is recommended for all women. Patients who receive tamoxifen therapy are at increased risk for developing endometrial cancer and should be advised to report any vaginal bleeding to their physicians. Longer follow-up intervals may be appropriate for women who have had a total hysterectomy and oophorectomy
Bone density testing	Those at risk for developing bone loss due to medication should be screened with a bone density test every 2 years

Regular assessment with history and physical examination, including a clinical breast examination, remains the mainstay of detecting breast cancer recurrence. The physical examination should be performed by a clinician who is experienced in doing breast examinations and should include examination of the affected breast, if present, as well as the chest wall, the contralateral side, bilateral axillary regions, and the supraclavicular fossas. If lymphedema is present, circumferential measurement of both upper extremities should be done. It is also recommended that palpation of the spine, sternum, ribs, and pelvis for bone tenderness should be routinely performed. Cardiac evaluation, as well as assessment of the lungs and abdomen, and a neurologic assessment that evaluates balance, gait, and sensory and motor function are important as well. Routine gynecologic follow-up is recommended for women who have not undergone total hysterectomy, particularly patients who are prescribed tamoxifen, as they are at increased risk for developing endometrial cancer. Follow-up recommendations for breast cancer survivors are summarized in Table 13.1 .

Imaging

Mammography

Mammography continues to be the imaging standard for breast cancer screening. The use of digital breast tomosynthesis as opposed to full-field digital mammography reduces recall rate and improves sensitivity and specificity. Variability exists in guideline recommendations for surveillance initiation, interval, and cessation. According to the National Comprehensive Cancer Network (NCCN), American Cancer Society, and American Society of Clinical Oncology (ASCO), annual mammograms are recommended for women who have had breast-conserving surgery (partial mastectomy or lumpectomy) and/or radiation. Women who have had a simple, modified radical or radical mastectomy should continue to have a yearly mammogram on the remaining breast.

Magnetic Resonance Imaging Breast magnetic resonance imaging (MRI) is not routinely recommended for surveillance due to insufficient evidence that it is any better than mammography in detecting breast cancer recurrence. However, it can be a useful diagnostic tool, specifically for women with a known BRCA1 , BRCA2 , or other high-risk genetic mutation and/or those who have a strong family history.

Genetics

If not already done by the time of survivorship, women who are at high risk of familial breast cancer syndromes and all men with breast cancer should be referred for genetic counseling. As an alternative to surveillance, women with a personal history of breast cancer and genetic mutation may want to consider bilateral mastectomy, which can be performed at the time of diagnosis or at a later point. The criteria to recommend referral for genetic counseling includes:

Ashkenazi Jewish heritage.
History of ovarian cancer at any age in the patient or any first- or second-degree relatives.
Any first-degree relative with a history of breast cancer diagnosed before the age of 50 years.
Two or more first- or second-degree relatives diagnosed with breast cancer at any age.
A patient or their relative with a diagnosis of bilateral breast cancer.
History of breast cancer in a male relative.

Breast Cancer Tumor Marker Testing and Other Blood Tests

For routine surveillance, it is not recommended to test with CA 15-3, CA 27.29, and CEA tumor markers. In addition, laboratory studies and other radiologic tests have not been shown to be helpful in breast cancer surveillance in asymptomatic patients.

Bone Density Testing

Women with a history of breast cancer may be at increased risk of developing osteoporosis because of their prior cancer treatment, as well as the use of aromatase inhibitors (AIs) for prevention of recurrence in hormone receptor–positive breast cancer in postmenopausal women. NCCN guidelines recommend that women with breast cancer treated with an AI should have a baseline bone density test and then have periodic scans, although the frequency of long-term screening is not specified. ASCO recommends that cancer survivors at risk for developing bone loss due to medication should be screened with a bone density test every 2 years, or more frequently if deemed medically necessary.

Screening for Secondary Cancers

Screening for secondary malignancies related to diagnosis and treatment after breast cancer is an important part of survivorship. A second breast cancer in the opposite breast, or in the same breast for women who were treated with breast-conserving surgery, is the most common occurrence for these patients. Li et al. found that the cumulative incidence of developing second primary cancers after early-stage initial primary breast cancer was 7.43% at 10 years, 14.41% at 15 years, and 20.08% at 20 years. Radiation therapy was also associated with increased risk of secondary cancers. Hormone status has been found to affect one’s risk of secondary malignancy. Women with hormone-positive disease have a decreased risk of developing a secondary primary breast or ovarian cancer, but they have an increased risk of urinary tract cancers, possibly due to hormone use. Smoking history, obesity, and high blood pressure are also risk factors for the development of second primary cancers, underscoring the need for counseling about healthy lifestyle habits. Aside from physical examination and yearly mammograms, there are no recommended screening tests for secondary cancers. Breast cancer survivors should be educated to watch for the following symptoms:

New lumps in the breast
Changes to the skin of the breast, including inflammation and redness
Nipple discharge
Thickening along or near the mastectomy scar
Swollen lymph nodes
New and unexplained pain, especially chest, back, or hip pain
Persistent cough and/or difficulty breathing
Loss of appetite and/or weight loss without trying
New and/or progressive headaches
New or increased seizure activity

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