Primary Care of Breast Cancer Survivors

 

Am Fam Physician. 2019 Mar 15;99(6):370-375.

Author disclosure: No relevant financial affiliations.

With declining mortality rates, the number of breast cancer survivors is increasing. Ongoing care after breast cancer treatment is often provided by primary care physicians. This care includes surveillance for cancer recurrence with a history and physical examination every three to six months for the first three years after treatment, every six to 12 months for two more years, and annually thereafter. Mammography is performed annually. Magnetic resonance imaging of the breast is not indicated unless patients are at high risk of recurrence, such as having a hereditary cancer syndrome. Many breast cancer survivors experience long-term sequelae from the disease or treatment. Premature menopause with hot flashes can occur and is managed with pharmacologic and nonpharmacologic treatments. Vaginal dryness is treated with vaginal lubricants and gels. Because cardiotoxicity from chemotherapy is possible, clinicians should be alert for this complication and perform echocardiography if appropriate. Impaired cognition after chemotherapy is also common; treatment includes cognitive rehabilitation therapy. Patients with treatment-induced menopause develop decreased bone density and should receive dual energy x-ray absorptiometry and pharmacologic and nonpharmacologic therapies. Others experience lymphedema, often best managed with weight loss and complex decongestive therapy. Some women develop chronic pain, which is treated by addressing psychological factors and with appropriate pharmacologic therapy.

There are approximately 300,000 new cases of breast cancer (in situ or invasive) each year in the United States, with about one in eight women having breast cancer at some point in life.1 The annual incidence is 129 per 100,000 for non-Hispanic whites, 126 per 100,000 for non-Hispanic blacks, 100 per 100,000 for Native Americans, 92 per 100,000 for Hispanics, and 91 per 100,000 for Asians.1 Mortality rates have been declining for many years. The current annual mortality rates are 21 per 100,000 for non-Hispanic whites, 30 per 100,000 for non-Hispanic blacks, 14 per 100,000 for Native Americans, 14 per 100,000 for Hispanics, and 11 per 100,000 for Asians.1

Because of the declining mortality rates, most patients with breast cancer survive and require ongoing surveillance for recurrence and management of sequelae from the disease or its treatment. Primary care physicians are often involved in the care of these patients.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Breast cancer survivors should receive a history and physical examination every three to six months for the first three years after treatment, then every six to 12 months for two more years, then annually thereafter.

C

2

Radiologic surveillance after breast cancer treatment should consist of annual mammography of both breasts or the remaining breast.

A

24

Annual magnetic resonance imaging is indicated only in breast cancer survivors at high risk of recurrence (high lifetime risk, strong family history of breast or ovarian cancer, or personal history of Hodgkin disease).

C

9

Nonhormonal treatments should be used to manage hot flashes in breast cancer survivors.

C

2, 9, 12

Primary care physicians should monitor breast cancer survivors for signs and symptoms of cardiotoxicity. Routine echocardiography is not recommended in asymptomatic patients unless they are at high risk of cardiotoxicity.

C

2

For postmenopausal breast cancer survivors without risk factors, dual energy x-ray absorptiometry should be performed at baseline.

C

2

Breast cancer survivors who develop lymphedema should be referred for complex decongestive therapy.

C

2, 4


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Breast cancer survivors should receive a history and physical examination every three to six months for the first three years after treatment, then every six to 12 months for two more years, then annually thereafter.

C

2

Radiologic surveillance after breast cancer treatment should consist of annual mammography of both breasts or the remaining breast.

A

24

Annual magnetic resonance imaging is indicated only in breast cancer survivors at high risk of recurrence (high lifetime risk, strong family history of breast or ovarian cancer, or personal history of Hodgkin disease).

C

9

Nonhormonal treatments should be used to manage hot flashes in breast cancer survivors.

C

2, 9, 12

Primary care physicians should monitor breast cancer survivors for signs and symptoms of cardiotoxicity. Routine echocardiography is not recommended in asymptomatic patients unless

The Authors

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KIMBERLY ZOBERI, MD, MAHCM, is clerkship director and an associate professor in the Department of Family and Community Medicine at Saint Louis (Mo.) University School of Medicine....

JANE TUCKER, MD, is medical director and an assistant professor in the Department of Family and Community Medicine at Saint Louis University School of Medicine.

Address correspondence to Kimberly Zoberi, MD, MAHCM (e-mail: kimberly.zoberi@health.slu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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