SURVIVORSHIP AND FOLLOW-UP CARE

Cancer casts a long shadow. Anyone diagnosed with cancer lives with the possibility of recurrence. Although many people survive breast cancer and live out a normal lifespan, others do not. That is why each new pain or other symptom may bring forth the fear of recurrence or metastasis until the symptom disappears or is found to be something other than cancer. Learning to live with uncertainty is part of recovery from cancer, and it is different for each individual. Healthcare professionals can help reduce the fear and anxiety associated with cancer survivorship by providing practical information to patients.

Patients should be encouraged to focus on wellness—taking good care of body, mind, and spirit—by eating a healthy diet, getting enough sleep and exercise, paying attention to symptoms, and getting regular checkups. Wellness also includes grieving one’s losses, whether the loss of a breast, loss of a relationship, or loss of the sense of control. It means seeking support when one needs it. Many patients continue with a support group after treatment has ended. Others seek individual counseling and psychological support. Many patients find further healing by helping others who are just starting on their cancer journey.

Survivorship Care Plan

The Commission on Cancer strongly encourages cancer centers to provide a survivorship care plan to all cancer patients. The American Cancer Society and American Society of Clinical Oncology both have published breast cancer survivorship care guidelines.

Breast cancer survivors may face significant short- and long-term effects of cancer and its treatment. To assist each survivor, an individualized care plan should be provided that includes a summary of all treatment, as well as a follow-up care plan. This plan is created in partnership with the cancer survivor to identify and prioritize individual goals. The survivorship care plan should also include information about individual risks, recommended tests and procedures, supportive care, and wellness strategies (ACS, 2022d). (See also “Resources” at the end of this course.)

Symptoms That Require Attention

If breast cancer recurs, it usually happens within the first five years after diagnosis and is most often suspected or discovered by patients themselves. ASCO (2021) recommends that breast cancer patients see their primary care provider immediately if any of the following signs and symptoms occur and/or persist:

Chronic bone pain or tenderness (persistent)
Bone fractures
Skin rashes, redness, or swelling in the breast or arm (persistent)
New lumps in the breasts, under the arm, or in the chest wall
Changes in the shape or size of the breasts
Chest pain and any shortness of breath (persistent)
Pain that is constant, worsening, and not relieved by over-the-counter (OTC) medication
Changes in weight, especially weight loss when not intentional
Headaches that are not relieved by OTC medication
Chronic cough or problems breathing
Abdominal pain
Jaundice (yellowing of skin and eyes)
Changes in vision
Extreme fatigue
Poor appetite
Fevers, night sweats

These symptoms may or may not be a sign of recurrence, but they do call for prompt evaluation.

Routine Follow-Up Care

Two major entities—ASCO (American Society of Clinical Oncology) and NCCN (National Comprehensive Cancer Network)—have issued guidelines for surveillance of breast cancer patients after curative-intent treatment.

ASCO guidelines (2021) include:

History and physical exam every 3–6 months for 3 years, then every 6–12 months for 2 years, then annually thereafter
Annual mammogram starting no sooner than 6 months after radiation therapy is completed
Regular bone mineral-density testing for patients taking AIs
Breast self-exam every month
Continued treatment with endocrine therapy, as directed by oncologist

NCCN guidelines (2022c) mirror ASCO’s, except they recommend a history and physical exam every 4–6 months for 5 years, then annually thereafter.

Both guidelines recommend referral for genetic counseling for familial cancers. Both guidelines do not recommend any other routine laboratory tests or imaging unless abnormalities are detected with history and physical or mammogram because more intense surveillance has not been shown to improve overall survival.

These guidelines do not take into account a patient’s hormone receptor status. This is significant because hormone receptor–positive cancers are slower growing and may take longer to recur.

As the population of cancer survivors grows, additional research may lead to more accurate and specific guidelines.

Health and Wellness Recommendations

Patients recovering from breast cancer are encouraged to follow established wellness guidelines. These include maintaining a healthy weight, exercising, not smoking, and eating a balanced diet.

The following guidelines are encouraged:

Eat a plant-based diet focused on fruits and vegetables, whole grains, and legumes; exclude high-calorie foods and beverages and consume less saturated fat.
Include moderate physical activity for at least 150 minutes or vigorous activity for 75 minutes each week.
Participate in strength-training exercises at least two days per week.
Limit alcohol consumption to 0–1 drink per day, with no more than 7 per week.
Quit smoking or using other types of tobacco.
Follow recommendations for general cancer screening (see below).
(ASCO, 2021)

Other Cancer Screenings

Breast cancer patients must also stay current with screenings for other types of cancer, which may include colorectal, cervical (if cervix is present), endometrial (if uterus is present), and skin cancer, among others. Depending on age and family history, patients should be screened for colon cancer. If detected early, colorectal cancer can be completely cured by surgery to remove polyps. Women should have a Pap smear with HPV testing for detection of cervical cancer as often as directed by their healthcare provider. This is especially important in younger women. Cervical cancer is also highly curable when caught early, but it can be very deadly if not.