Australian Survivorship Centre A Richard Pratt Legacy

Cancer survivorship information for professionals

Follow-up of survivors

Breast cancer five-year survival rates recurrence and mortality (e.g. through Five- and 10-year survival are high for people whose cancer is the use of adjuvant chemotherapy, (Australia) detected early. They are among the aromatase inhibitors, tamoxifen and surgical removal of ovaries). Genetic In 2004, five-year survival for women highest five-year survival rates. profiling advances may help to further with breast cancer was 87.7% and increase the effectiveness of treatment 10-year survival was 79.4%. Advances in treatment over recent and reduce late effects from treatment. years have reduced psychological and Potential issues for survivors physical morbidity (e.g. through the Follow-up includes scheduling regular use of sentinel lymph node biopsy, and reviews and ensuring cancer survivors are Survivors may experience many different breast-conserving surgery versus radical aware of the risks of late effects associated issues after completing treatment: physical, mastectomy) and reduced the risk of with their breast cancer treatment. emotional, psychosocial and practical. Survivorship care ideally addresses all of these issues. The four main aims of care during the survivorship phase, as detailed by the Institute of Medicine’s report (see Hewitt et al. 2006) ‘From cancer patient to cancer survivor: lost in transition’, are: • surveillance for cancer spread, recurrence or second primary • coordination between specialists and primary care providers to ensure that all of the survivor’s health needs are met (incl. health promotion, immunisation, screening for cancer and non-cancerous conditions, and the care of concurrent conditions) • intervention for consequences of cancer and its treatment (e.g. problems such as lymphoedema and sexual Australian Cancer Survivorship Centre A Richard Pratt Legacy

Follow-up of breast cancer survivors

dysfunction, symptoms including There is no evidence that follow- been shown to be associated with increase and , psychological distress up more frequent than the minimal in time to diagnosis, increase in or experienced by cancer survivors and review schedule confers any survival deterioration in health-related quality of life. their , and concerns related benefit or increase in quality of life. It is important that follow-up is coordinated to employment and insurance) New symptoms: advice for survivors and that survivors are not required to • prevention and detection of new attend excessive appointments. cancers and recurrent cancer. Cancer survivors may wait to discuss some symptoms if they know a surveillance/ Guidelines included in the Victorian Surveillance for cancer spread, follow-up appointment is scheduled. Government’s patient management Advise the cancer survivor to contact their framework (breast tumour stream) recurrence or second primary doctor if they notice a breast change or recommend that follow-up should be cancers any other symptom that concerns them by a multidisciplinary team, although Most recurrences are detected in the between follow-up appointments. not all disciplines need to be involved in the longer term follow-up. five years after diagnosis, although Advise the cancer survivor you are treating recurrence can occur more than 20 to contact you if they experience: The guidelines recommend that the team, in years after the initial diagnosis. consultation with the GP, decides on who will • unexplained persistent changes in coordinate follow-up. Responsibility needs For women who have had mastectomy, general condition (loss of weight, to be agreed between the designated lead the majority of recurrences will be loss of appetite, loss of energy) detected by clinical examination alone. For clinician, GP and cancer survivor, and an • persistent unexplained pain or discomfort. women who have had breast-conserving agreed survivorship care plan documented. surgery, a significant proportion will be Coordination between specialists The plan should identify who should be notified detected by regular mammography. if the patient does not attend for follow-up. and primary care providers Which patients? The GP has a key role in follow-up. Follow-up may be performed by the All patients who have been treated for specialist or GP. Follow-up by GPs has not breast cancer should be followed up.

Follow-up of women with early breast cancer

Method Years 1 and 2 Years 3–5 After 5 years

History and examination Every 3–6 months Every 6–12 months Every 12 months

Mammography of the ipsilateral Every 12 months* Every 12 months Every 12 months breast (if breast conserving therapy) and contralateral breast^

Chest X-ray Only if clinically indicated on suspicion of recurrence Bone scan, CT, PET or MRI** scans, blood count, biochemistry and tumour markers

^ Consider ultrasound in addition to mammography Source: Adapted from National Breast and for younger women, women with dense breasts Centre (NBOCC) 2010. Follow-up and those whose initial breast cancer could care for women with early breast cancer. A guide not be detected by mammography for general practitioners. NSW: NBOCC.

* First mammogram 12 months post diagnosis Note: this schedule may change, due for example to the detection of recurrence or the development of other illnesses. ** Use of MRI may be considered in specific high-risk groups The schedule needs to be tailored to individual situations. Symptoms should be fully investigated if they arise. Australian Cancer Survivorship Centre A Richard Pratt Legacy

Follow-up of breast cancer survivors

Intervention for consequences of For survivors and their partners, there may evaluation of cardiac function as well cancer and its treatment be relationship effects from cancer and as advice about other cardiovascular its treatment, including difficulties over risk factors (e.g. smoking, alcohol, Late effects of breast cancer treatment changed roles, fear of recurrence and lack of exercise, poor diet). Note to cancer survivors: late effects from the survivor’s fear of being a burden. • Remind survivors of the need to avoid cancer treatment are generally uncommon Survivors who go through and injury to the upper limb and to be alert and often rare. Do not assume that you beyond cancer treatment without for any arm changes, to help to reduce will get a late effect if you had a treatment partners or close family and friends the risk of lymphoedema. Lymphoedema described here. Please speak to your may experience great loneliness. may occur years after treatment. doctor if you have any concerns about • Women and their families with late effects from your cancer treatment Further information related to late effects BRCA may be referred Late effects can occur as a consequence • Women who have received treatment to a familial cancer clinic for advice of surgery, chemotherapy, hormone known to increase the risk of cardiac about prevention and screening. toxicity should receive long-term periodic therapy and radiotherapy. • Younger women have particular needs if affected by menopause, if they require Late effects of breast cancer treatment contraception, and in coping with changes to sexual function. Refer to fertility and Late effect Cause/association menopause specialists and sex therapists who understand cancer care among Fatigue Association with cancer treatment is not clear; may younger patients if appropriate. occur in association with depression and anxiety • Depression, anaemia, pain and Cardiac toxicity Anthracycline-containing regimens, trastuzumab hypothyroidism can all contribute to • Appears to be dose-dependent (esp. in combination with doxorubicin or epirubicin fatigue and can be treated. It should be • May appear during or shortly after treatment plus cyclophosphamide), paclitaxel, taxane noted that some SSRIs (e.g. paroxetine, or months to years after treatment ends fluoxetine) can decrease the efficacy of tamoxifen so other antidepressants should Lymphoedema Surgical axillary dissection or radiotherapy or both be considered. Venlafaxine has no or minimal effect on tamoxifen metabolism Premature menopause Chemotherapy, ovarian ablation, tamoxifen, aromatase inhibitors and has also been shown to be an effective intervention for hot flushes. Endometrial cancer, stroke, blood clots Tamoxifen • Women at risk of accelerated reduction Depression and anxiety Association with treatment is not well understood of bone mineral density due to chemotherapy should have their BMD checked every two to four years. Advise Pain Surgery, chemotherapy and radiotherapy about bone density loss prevention Impaired sexual functioning or sexual discomfort Related to impaired body image due to surgery such as weight-bearing exercise and • May also be associated with ageing Systemic therapy (esp. chemotherapy) leading smoking cessation. Consider preventive • May especially affect younger survivors to premature menopause/vaginal dryness treatment with calcium and vitamin D supplementation, and bisphosphonates Impaired fertility Chemotherapy for women with osteoporosis, fractures or high rates of bone loss. Ovarian ablation • Enquire about mood and whether the Accelerated loss of bone density, fracture risk Ovarian failure following chemotherapy (esp. high-dose corticosteroids, aromatase inhibitors) survivor feels they are coping. Assess survivor’s level of distress/depression. Impaired cognitive functioning Association with treatment is not well understood Psychological distress generally declines May be associated with adjuvant chemotherapy over time. Psychosocial interventions (e.g. support group, cancer education) Dissatisfaction with cosmetic result Mastectomy (with or without reconstruction) may be effective for women. Support and change in appearance Breast-conserving surgery (smaller effect) groups and/or contact with a fellow survivor through a service such as Cancer Second primary cancer Treatment for original cancer, including Connect (contact via the Cancer Council • May be associated with the individual’s increased risk of cancer in areas exposed to Helpline on 13 11 20) may be helpful. underlying predisposition (e.g. BRCA ) radiation, increased risk of leukaemia due and therefore not a late effect of treatment to use of some adjuvant chemotherapy Australian Cancer Survivorship Centre A Richard Pratt Legacy

Follow-up of breast cancer survivors

Prevention and detection of new guidelines for Australian adults, on which regarding screening for bowel cancer. There cancers and recurrent cancer advice to survivors can be based. is insufficient evidence for population-based screening for ovarian cancer; however, Survivors need appropriate screening for Follow-up care should include counselling women who are at potentially high risk other cancers at recommended time intervals. about improved diet, maintaining a should be referred to a familial cancer clinic All women who have ever been sexually active healthy weight, smoking cessation and for assessment and management. Survivors should commence having Pap tests between increasing physical activity as these may have mammography as part of their follow- the ages of 18 and 20 years, or 1 to 2 years help to prevent secondary, recurrent or up and do not need to respond to invitations after commencing sexual activity, whichever a new primary breast cancer. They may from the Australian Government’s breast is later. In some cases screening for cervical also reduce many of the psychosocial cancer screening program (BreastScreen). consequences of cancer treatment. cancer may be appropriate before 18 years of age. Women over 70 years of age who have Don’t neglect other aspects of primary Advise survivors (unless there are health had two normal Pap tests in the past five years health care. Where indicated, monitor reasons that indicate otherwise) to do at do not require further Pap tests. If a woman survivors’ cholesterol, blood pressure least 30 minutes of moderate-intensity over 70 years has never had a Pap test, or and blood glucose. Survivors should physical activity on most, preferably all, requests a Pap test, they should be screened. have regular dental examinations and be days. The NHMRC has produced dietary Patients over 50 years should be counselled counselled on routine sun protection.

Further information Board. Institute of Medicine (IOM) NBOCC survivorship website. and National Research Council This overview was prepared of the National Academies. Rosenbaum E et al. 2007. Everyone’s guide to cancer with reference to: Kroenke C et al. 2005. Weight, survivorship. Missouri: Andrews Australian Government Department weight gain, and survival McMeel Publishing. of Health and Ageing 2005. after breast cancer diagnosis. Stull V et al. 2007. Lifestyle National physical activity guidelines Journal of Clinical Oncology interventions in cancer survivors: for Australians. Canberra: 23(7) (March 1): 1370–8. designing programs that meet Australian Government. Lemieux J et al. 2007. Medical, the needs of this vulnerable and Australasian Menopause Society psychosocial, and health-related growing population. Journal (AMS) 2008. Early menopause quality of life issues in breast of Nutrition 137: 243S–8S. due to chemotherapy. Available cancer survivors. In Ganz P (ed) 2007. Cancer survivorship today Thewes B et al. 2004. The from AMS website. and tomorrow. New York: Springer psychosocial needs of breast Australian Institute of Health Science+Business Media. cancer survivors: a qualitative study and Welfare, Cancer Australia & of the shared and unique needs Australasian Association of Cancer Loprinzi C et al. 2000. Venlafaxine of younger versus older survivors. Registries 2008. Cancer survival in management of hot flashes Psycho-Oncology 13: 177–89. and prevalence in Australia: in survivors of breast cancer: Also see: cancers diagnosed from 1982 to a randomised control trial. 2004. Cancer Series No. 42. Cat. Lancet 356: 2059–63. National Comprehensive Cancer

No. CAN 38. Canberra: AIHW. Metropolitan Health and Aged Care Network. This US site provides consensus-based guidelines Cousins M 2007. Persistent pain Services Division (MHACSD) 2006. developed by expert groups, after breast cancer surgery. Patient management framework. and other clinical resources. Available from Australian Centre Breast tumour stream: breast for Health Research website. cancer. Victorian Government Department of Human Services. Grunfeld E et al. 1996. Routine follow up of breast cancer in primary care: National Breast Cancer Centre 2001. Australian Cancer Survivorship Centre randomised trial. British Medical Clinical practice guidelines for the A Richard Pratt Legacy Journal, 313:665–9 (14 September). management of early breast cancer (2nd edn). Canberra: NHMRC. Hewitt M, Greenfield S, Stovall E (eds) 2006. From cancer patient to National Health and Medical Australian Cancer Survivorship Centre cancer survivor: lost in transition. Research Council 2003. Dietary Committee on Cancer Survivorship: guidelines for Australian Locked Bag 1, A’Beckett Street Improving Care and Quality adults. Canberra: NHMRC. Victoria 8006 of Life. National Cancer Policy Email: [email protected] www.petermac.org/cancersurvivorship