Looking after survivors

Thanks to medical breakthroughs and early detection, more and more people are surviving breast cancer and being transferred back to primary care. What kinds of care or services do breast cancer survivors need that differ from other patients? There are guidelines and patient resources in the area, including some from provincial cancer agencies. There’s also the evidence-based breast cancer survivorship tool for primary care physicians, which was published in Canadian Family Physician in May 2020. The tool highlights that family physicians should focus on four areas: knowing what treatment your patient received, managing long-term side-effects of treatment, watching for recurrence, and health promotion and prevention. Understand treatment The first step in taking care of breast cancer survivors is finding out what treatment they had “because that’s going to impact what side-effects or issues they could run in to,” said Dr. Anna Wilkinson, co-author of the breast cancer survivorship tool and assistant professor in the department of family medicine at the University of Ottawa. Even if a patient is arriving at your clinic years after a cancer treatment, ask what treatment they had, because some can have long-term effects. A patient’s tumour pathology dictates their therapy, and side-effects and monitoring needs vary depending on the treatment. Other factors contribute to therapy choice as well. For example, aromatase inhibitors are only given to postmenopausal—not pre- or perimenopausal—women who had estrogen receptor/progesterone receptor positive tumours. Some premenopausal women can safely take aromatase inhibitors if they’ve had treatment to suppress ovarian estrogen production, either via surgery or gonadotropin-releasing hormone (GnRH) agonists. These medications, as well as tamoxifen, have unique side-effect profiles that need to be monitored. A lot of cancer centres now provide organized guidance, or care plans, when a patient is transferred back into primary care, said Dr. Jonathan Sussman, professor of oncology at McMaster University in Hamilton, Ont., and a radiation oncologist at Hamilton Health Sciences Centre. These care plans could include timing of follow-up mammography and links to supportive care services. Dr. Wilkinson and Dr. Catherine Boutet, co-author of the breast cancer survivorship tool, developed Survivor Advisor, an app that provides a custom care plan for patients following their breast cancer treatment. It may be especially useful for the growing number of people who don’t have a family doctor. The app provides reminders about followup screening, information about treatment-based side-effects and surveys about symptoms that could signal a cancer recurrence. The app, produced by Thrive Health, is being piloted at the Ottawa Hospital. Manage consequences Side-effects from treatment can manifest immediately or years after a patient has finished therapy. If a patient had surgery, watch for lymphedema, which could present in one in five people who receive an axillary lymph node dissection, and in some people who had a sentinel node dissection. The majority of lymphedema cases develop within the first year after surgery. Risk factors include obesity and low breast density, according to a 2020 paper by experts at Princess Margaret Cancer Centre in Toronto. Make sure to order a baseline bone mineral density test in women who are postmenopausal and people taking aromatase inhibitors or GnRH agonists. They’re more at risk of bone loss (and fractures) compared to people the same age who did not have breast cancer treatment, Dr. Sussman said. Physicians should monitor these patients’ bone mineral density every two years, and consider bisphosphonate therapy if needed. Watch patients on tamoxifen for signs of venous thromboembolic disease and endometrial cancer, since they have a higher risk for both. Any change in vaginal bleeding should be investigated, Dr. Wilkinson said. A number of breast cancer treatments can impact cardiovascular health. Anthracycline chemotherapeutic agents (epirubicin and doxorubicin) can cause remote issues with cardiotoxicity and a decrease in ejection fraction. “Physicians should consider heart failure in someone who presents with shortness of breath after being treated with these agents, even if it is 20 years after treatment,” Dr. Wilkinson said. Radiation for a left-sided breast cancer can also promote cardiotoxicity. “Sometimes those things are cumulative,” she said. Aromatase inhibitors can also cause hyperlipidemia and physicians should watch lipid levels in patients taking these medications, Drs. Wilkinson and Boutet wrote in their paper. Special considerations The presence of fatigue, cognitive dysfunction and psychological distress is more likely in breast cancer survivors than the general public, and family physicians should monitor their patients for symptoms, Drs. Wilkinson and Boutet noted in their paper. If treating patients for depression or anxiety, note that paroxetine and fluoxetine may reduce the efficacy of tamoxifen, according to tamoxifen’s product monograph. Physicians should ask people who are breast cancer survivors and postmenopausal if symptoms of genitourinary syndrome of menopause (e.g., vulvovaginal atrophy) are bothering them, said Dr. Michelle Jacobson at a Society of Obstetricians and Gynecologists of Canada (SOGC) meeting in June. Dr. Jacobson is an assistant professor at the University of Toronto and an obstetrician-gynecologist at Women’s College and Mount Sinai hospitals in Toronto. While vaginal estrogen or systemic estrogen is a common therapy to treat these symptoms, caution should be used in giving it to breast cancer survivors. Dr. Jacobson noted that the North American Menopause Society’s 2020 position paper and the SOGC menopause guidelines on genitourinary health had guidance on therapies that may help these patients, although evidence on non-hormonal therapies in breast cancer survivors is lacking. She said to reach out to the treating oncologist before prescribing any topical hormone therapy. Watch for recurrence Follow up with breast cancer survivors every six months for the first five years after they finish treatment. The visit should include a clinical breast exam. Patients should get mammograms once a year. Physicians should also be on the alert for new or unusual symptoms that could be cause for concern. “What I say to patients is if they’ve had a new symptom that comes and stays for two weeks or longer, then that’s something you might consider for investigation,” Dr. Wilkinson said. “Sometimes those clinical symptoms can be indicative of metastatic disease but the key is they’re not transient; they’re coming and staying and getting worse over time,” she said. Red flag symptoms could be new pain, particularly bone pain, that can’t otherwise be explained. “That could be a manifestation of the breast cancer recurring in the bone,” Dr. Sussman said. Watch for new, unexplained neurological symptoms, such as headaches or unusual neurological symptoms, because that can be a sign of the breast cancer spreading to the brain. Unexplained gastrointestinal symptoms, particularly significant nausea and weight loss should also be investigated. Unexplained cough is another one to be examined. “Family physicians should never hesitate to get in touch with the treating oncologist if they have any concerns,” Dr. Sussman said. Keep up to date Like with other patients, make sure survivors get routine preventative screening “that sometimes get lost because you’re so busy thinking about the breast cancer,” Dr. Wilkinson said. Prevention of diabetes and cardiovascular disease are also key. Promotion of a healthy lifestyle is just as important for breast cancer survivors as anyone else. Maintaining a healthy body weight, avoiding excess alcohol, avoiding smoking and engaging in regular exercise are all associated with better outcomes generally, and some population studies have suggested they’re associated with better cancer-free survival outcomes as well. Exercise might seem frightening to people who have just completed cancer treatment, but, “I think people who have gone through breast cancer treatment can get back to activity just as much as everyone else would,” Dr. Wilkinson said. Thirty minutes a day of moderate exercise is an appropriate starting goal. Dr. Wilkinson suggests the talk test, where if you’re working hard enough that it’s hard to carry on a conversation, “then that’s probably a good level of exertion.” For many breast cancer survivors, it is their other health conditions that will determine their health in the future. “Those are things that can have a very significant, and in some instances, a more significant impact on someone’s subsequent health, than a breast cancer diagnosis, particularly after early stage breast cancer, which is how most women in Canada are diagnosed,” Dr. Sussman said. “The reality is breast cancer survivors will have better health outcomes if they maintain contact with their primary care provider,” Dr. Sussman said. “Because oncologists are mostly focused on the breast cancer specific survivorship activities—surveillance for recurrence, management of some toxicities—but are not in the position to take on managing health issues unrelated to the breast cancer diagnosis or its treatment. Collaboration with primary care is key to ensuring comprehensive whole-person care.”

Looking after survivors

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