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Coordination of the care of breast cancer survivors between oncology subspecialists and family physicians is critical to achieving optimal health outcomes. Care of survivors includes surveillance for breast cancer recurrence, screening for second malignancies, assessment and management of adverse effects of treatment, and promotion of overall wellness. Adverse effects include hot flushes, depression and anxiety, lymphedema, cognitive impairment, neuropathy, decreased bone health, effects on sexual health, and cardiac dysfunction. Survivorship care plans can help guide care coordination among clinicians. Racial and ethnic disparities also affect outcomes for patients with breast cancer; optimization of survivorship interventions may help address these disparities.

Case 4. Joanna was diagnosed with stage II breast cancer 2 years ago at age 50 years. She underwent partial mastectomy, sentinel lymph node biopsy, chemotherapy, and radiation and started taking an aromatase inhibitor. She has experienced mild neuropathy since chemotherapy. She has significant vaginal dryness related to aromatase inhibitor therapy. She asks about how to manage these current symptoms, prevent recurrence, and stay healthy.

A cancer patient is considered a survivor from the moment of diagnosis, and care should focus on how to promote well-being and optimize survivorship.114 The American Cancer Society (ACS) and the American Society of Clinical Oncology (ASCO) joint guidelines for breast cancer survivorship care include recommendations for surveillance, screening for second malignancies, assessment and management of long-term and late adverse effects, health promotion, and coordination of care.115

Surveillance

Surveillance for recurrence is a main component of breast cancer survivorship. ACS/ASCO guideline recommends a comprehensive history and physical examination every 3 to 6 months during the first 3 years after primary therapy, every 6 to 12 months during years 4 and 5, and then annually.115 The assessments can be performed by any member of the care team (eg, surgeon, medical or radiation oncology subspecialist, family physician) as long as they are comprehensive. Although patients with locally advanced cancer (4+ nodes, tumor greater than 5 cm) should always continue to follow-up with the oncology subspecialist, patients with early-stage cancer may safely continue cancer follow-up care with the family physician after 1 year of oncology care if they prefer and the family physician is comfortable with such a plan.116

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