ACS/ASCO Breast Cancer Survivorship Care Guideline
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. 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 clinicians and others in the care of women who have survived breast cancer.
Key recommendations are summarized/reproduced here. Most of the evidence was not sufficient to warrant designation as strong evidence-based recommendations.
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; 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.
- 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; 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.
- 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.
- Signs of recurrence: Educate and counsel all women about the signs and symptoms of local or regional recurrence.
- 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, endometrial] or age ≤ 60 years with triple-negative breast cancer).
- Endocrine treatment impact, symptom management: Counsel patients to adhere to adjuvant endocrine (antiestrogen) therapy.
Screening for Second Primary Cancers
- Cancer screening in average-risk patients: 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.
Assessment and Management of Physical and Psychosocial Long-Term and Late Effects of Breast Cancer and Treatment
- Body image concerns: Primary care clinicians should (a) assess for patient body image/appearance concerns; (b) offer the option of adaptive devices (eg, breast prostheses, wigs) and/or surgery when appropriate; and (c) refer for psychosocial care as indicated.
- Lymphedema: (a) Counsel survivors on how to prevent/reduce the risk of lymphedema, including weight loss for those who are overweight or obese; and (b) refer patients with clinical symptoms or swelling suggestive of lymphedema to a therapist knowledgeable about the diagnosis and treatment of lymphedema.
- Cardiotoxicity: (a) Monitor lipid levels and provide cardiovascular monitoring, as indicated; and (b) educate survivors on healthy lifestyle modifications, potential cardiac risk factors, and when to report relevant symptoms (shortness of breath or fatigue).
- Cognitive impairment: (a) Ask patients about cognitive difficulties; (b) assess for reversible contributing factors and optimally treat when possible; and (c) refer patients with signs of cognitive impairment for neurocognitive assessment and rehabilitation, including group cognitive training if available.
- Distress, depression, anxiety: (a) Assess patients for distress, depression, or anxiety; (b) conduct a more probing assessment for patients at a higher risk of depression (eg, young patients, those with a history of psychiatric disease, and patients with low socioeconomic status); and (c) offer in-office counseling and/or pharmacotherapy and/or refer to appropriate psycho-oncology and mental health resources as clinically indicated.
- Fatigue: (a) Assess for fatigue and treat any causative factors for fatigue, including anemia, thyroid dysfunction, and cardiac dysfunction; (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; and (c) counsel patients to engage in regular physical activity and refer for cognitive behavioral therapy as appropriate.
- Bone health: (a) Refer postmenopausal survivors for baseline dual-energy x-ray absorptiometry (DEXA) scan; 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 agonist, and women who have chemotherapy-induced premature menopause.
- Musculoskeletal health: (a) Assess for musculoskeletal symptoms, including pain, by querying patients at each clinical encounter; and (b) offer one or more of the following interventions based on clinical indication: acupuncture, physical activity, and referral for physical therapy or rehabilitation.
- 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; (b) offer interventions, such as acetaminophen, nonsteroidal anti-inflammatory drugs, physical activity, and/or acupuncture, for pain; (c) refer to an appropriate specialist once the underlying etiology has been determined (eg, lymphedema specialist, occupational therapist); (d) assess for peripheral neuropathy and contributing factors by asking patients about their symptoms; (e) offer physical activity for neuropathy; and (f) offer duloxetine for patients with neuropathic pain, numbness, and tingling.
- Infertility: Refer survivors of childbearing age who experience infertility to a specialist in reproductive endocrinology and infertility as soon as possible.
- Sexual health: (a) Assess for signs and symptoms of sexual dysfunction or problems with sexual intimacy; (b) assess for reversible contributing factors to sexual dysfunction and treat when appropriate; (c) offer nonhormonal, water-based lubricants and moisturizers for vaginal dryness; and (d) refer for psychoeducational support, group therapy, sexual counseling, marital counseling, or intensive psychotherapy when appropriate.
- 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.
- Information: Primary care clinicians (a) should assess the information needs of the patient related to breast cancer and its treatment, side effects, other health concerns, and available support services; and (b) provide or refer survivors to appropriate resources to meet these needs.
- Obesity: (a) Counsel survivors to achieve and maintain a healthy weight; and (b) counsel survivors if overweight or obese to limit consumption of high-calorie foods and beverages and increase physical activity.
- 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; (b) aim for at least 150 minutes of moderate or 75 minutes of vigorous aerobic exercise per week; 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.
- 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.
- Smoking cessation: Counsel survivors to avoid smoking and refer survivors who smoke to cessation counseling and resources.
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.
- 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.
- Inclusion of family: Encourage inclusion of caregivers, spouses, or partners in usual survivorship care and support.
The article was supported in part by the Centers for Disease Control and Prevention.
Corinne R. Leach, PhD, MS, MPH, of the American Cancer Society, is the corresponding author of the Journal of Clinical Oncology and CA: A Cancer Journal for Clinicians articles.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.