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Survivorship Care After Curative Treatment for Breast Cancer

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Survivorship Care After Curative Treatment for Breast Cancer SURVIVORSHIP CARE Survivorship Care after Curative Treatment for Breast Cancer Knowledge Summary SURVIVORSHIP CARE Survivorship Care after Curative Treatment for Breast Cancer INTRODUCTION after diagnosis. ¬ Breast cancer treatment is a long-term process and women Breast cancer survivors are patients who have entered the who complete treatment remain at risk of recurrence, long- postreatment phase after the successful completion of breast term treatment-related toxicities and long-term psychoso- cancer therapy with curative intent; longer-term endocrine cial issues related to breast cancer and its treatment. therapy and/or targeted therapy may continue during survivor- ship care. Globally, breast cancer survival rates are increasing, Core components of survivorship care after creating a new generation of survivors in need of ongoing care curative treatment and counseling. Evidence suggests that a significant number ¬ Essential components of follow up care for breast cancer of people with a cancer diagnosis have unmet information- patients after curative treatment include monitoring for al, psychosocial and physical needs which can be effectively breast cancer recurrence, managing long-term treat- addressed through survivorship care interventions. ment-related complications and providing psychosocial care Survivorship care services include treatment of long-term specific to survivor issues. complications, surveillance for cancer recurrence, and coun- ¬ Well established referral systems, communication and seling on prevention strategies, such as lifestyle modifications. coordination of care are essential to help patients transition Other issues include early menopause, body image concerns, from oncology care to follow up care. sexual health and psychosocial issues related to breast cancer ¬ Information about survivorship support should be included in and its treatment. Long-term treatment-related complica- awareness and education programs for health professionals, tions include lymphedema and other upper limb dysfunctions, patients, families and caregivers. pain, fatigue, insomnia and bone health concerns. Increased ¬ Treatments can affect reproductive health and other wom- risk of cardiovascular complications occurs with some cancer en’s health issues. The psychosocial impact of treatment treatments (see Table 1). should be anticipated and addressed. Common challenges associated with survivorship care include Health system and workforce capacity fragmentation of services when a patient transitions from ¬ A survivorship care team should ideally consist of physicians, active oncology treatment to postreatment follow up care. nurses, social workers, psychologists, spiritual counselors, Breast cancer survivors can have unique treatment-related volunteers, traditional healers and religious leaders, with complications, including lymphedema (tissue swelling caused close communication and links to pharmacists. If palliative by the build-up of excess lymph fluid) and reproductive health, care is provided by community volunteers or family mem- body image and sexual health concerns. Delivering high-quality bers, training should be provided. survivorship and supportive care can enhance patients’ long- term health by managing concerns related to cancer treat- ¬ Ensure health care providers are properly trained in the ment and survivorship. It is essential that health professionals assessment and management of long-term treatment-re- be able to recognize, diagnose and treat long-term complica- lated toxicities and long-term psychosocial aspects of care tions of breast cancer treatment, including psychosocial is- for breast cancer survivors, including the use of culturally sues that require intervention or referral for support services. sensitive patient–provider communications. In low-resource settings, the challenges for survivors can be ¬ Engage survivors and community representatives to ensure significant: recurrence rates are higher, treatment modalities health care providers are trained in culturally sensitive cause greater morbidity and the psychosocial effects of cancer patient–clinician communication skills that focus on pa- and its treatment can be profound. Return to daily work and tient-centered care. family life can be complicated and cancer survivors deserve ¬ Emphasize the advantages of survivorship services after informed, quality health care during this transition. treatment, in addition to information about detection and diagnosis of breast cancer and available treatments, in community awareness and patient and family education KEY SUMMARY programs. Breast Cancer Survivors Resource-stratified pathways across the ¬ Patients who receive curative treatment for early stage continuum of care breast cancer should have their needs assessed with appro- priate follow up care after treatment (often referred to as ¬ Follow a defined resource-stratified pathway to allow for survivorship care). coordinated incremental program improvement across the continuum of care based on outcome goals, identified barri- ¬ Breast cancer survivors make up a growing percentage of ers and needs and available resources. breast cancer patients in low- and middle-income coun- tries (LMICs). In high-income countries (HICs), almost 90% of all women diagnosed with breast cancer are alive 5 years 2 Survivorship Care after Curative Treatment for Breast Cancer POINTS FOR POLICYMAKERS: Planning Step 2: Where do we want to be? Set objectives and priorities ¬ Ensure women have access to survivorship support care and OVERVIEW services. ¬ Train health professionals in survivorship care. Preplanning ¬ Establish clear protocols for routine surveillance for recur- ¬ Identify data sources for estimating survivorship needs. rence or second primary breast cancer for survivors, as well ¬ Identify stakeholders, key decision-makers and champions. as counseling services for psychosocial issues. ¬ Identify who will lead in strengthening the survivorship care ¬ Improve awareness among health systems, communities program. and patients and their families regarding the supportive care Planning Step 1: Where are we now? needs of breast cancer patients after curative treatment. Investigate and assess Planning Step 3: How do we get there? ¬ Conduct a self-assessment using standardized tools. Tool- Implement and evaluate kits are available to assess and support survivorship care ¬ Establish a resource-stratified approach to survivorship program development. care for breast cancer survivors as part of long-term breast ¬ Identify structural, sociocultural, personal and financial cancer program planning. Some of the required resources barriers to accessing survivorship care. for survivorship care (e.g., monitoring, patient education) ¬ Assessments should determine who is providing services may already exist or can be implemented at low cost. (e.g., family members, community volunteers, health work- ¬ Implement quality assurance measures and monitor and ers), as well as the population covered by existing services. track supportive care services. ¬ Identify deficiencies in supportive care services, such as access to pain medication (e.g., http://www.who.int/cancer/ palliative/painladder/en/). Survivorship Care after Curative Treatment for Breast Cancer 3 preservation. Women also report treatment-related distress WHAT WE KNOW regarding body changes, including a sense of mutilation, feel- Lymphedema: Lymphedema is a long-term risk of breast ings of self-consciousness, reduced satisfaction with sexual cancer surgery, with different levels of severity associated life and fears of partner rejection. Twenty years after treat- with different types of surgical procedures (i.e., axillary lymph ment, almost 30% of women reported sexual problems. Health node dissection versus sentinel node biopsy). The frequency professionals should be trained in women’s health topics and of lymphedema after axillary node dissection can range from culturally appropriate provider–patient communication strat- 10–50%. This condition can significantly reduce a woman’s egies. Breast cancer care requires a discussion of sensitive quality of life and the management of lymphedema is an women’s health topics, including menopausal symptoms, and essential component of follow up care. Tracking the incidence health professionals should be aware of sociocultural differ- of lymphedema and its level of severity can help inform quality ences in a woman’s understanding of these issues, as well improvement of breast cancer treatment. Free online assess- as her potential preference for female health professionals. ment tools are available, and more-advanced tools can be pur- Patient counseling should be part of supportive care services chased. The effects of lymphedema can be minimized through at all resource levels (see Table 1). patient education and training in limb exercises, range of motion activities, weight lifting, use of compression garments Other complications: Fatigue, insomnia and nonspecific pain and effective weight management. Patient counseling should are often reported by breast cancer survivors after treatment. include instruction on incorrect or unsafe exercises that can Deficits in emotional, cognitive and social functioning have exacerbate lymphedema. Short-term pharmacologic therapies also been reported up to one year after treatment and may may relieve some lymphedema-related symptoms, but long- persist over years in some patients. Therefore, care for breast term pharmacologic therapies (e.g., anticoagulants,
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