In the Journals

ASCO, American Cancer Society issue joint guideline on breast cancer survivorship care

The American Cancer Society and ASCO jointly released a comprehensive guideline on breast cancer survivorship that stresses the importance of regular surveillance, routine laboratory testing and maintaining a healthy lifestyle.

The guideline — geared toward primary care providers and other clinicians who treat survivors of breast cancer — marks the first time the two societies have collaborated on clinical recommendations.

“The new guideline addressed the issues facing women breast cancer survivors as they transition from treatment to survivorship,” Carolyn D. Runowicz, MD, professor of obstetrics and gynecology and executive associate dean for academic affairs at Herbert Wertheim College of Medicine at Florida International University, said in a press release. “The recommendations should result in high-quality survivorship care, with a focus on improving their quality of life and health outcomes.”

The two societies formed a multidisciplinary workgroup composed of experts in primary care, gynecology, surgical oncology, medical oncology, radiation oncology and nursing.

The workgroup identified 237 published articles of research as the evidence base for the guidelines, although only 2% of the articles were considered level I evidence and 7% were considered level IA. Sixty-four percent of the articles were consider level 0; thus, the workgroup stated these recommendations are based on current evidence and consensus expert opinion.

The recommendation includes five key areas:

  • The need for surveillance for breast cancer recurrence;
  • The need for screening for second primary cancers;
  • Assessing and managing long-term and late effects of breast cancer and treatment;
  • Promoting a healthy lifestyle; and
  • Coordinating care and practice implications.

Screening for recurrence, second cancers

Although routine screening for recurrence is not necessary for asymptomatic individuals, the guidelines stress a careful history is necessary to ensure a survivor is asymptomatic, and survivors at higher risk for local recurrence should undergo screening.

Thus, follow-up care should be individualized for survivors based on age, diagnosis and treatment protocol, and survivors should receive a detailed history and physical exam every 3 to 6 months in the first 3 years following therapy, 6 to 12 months in the next 2 years, and annually thereafter.

Women should be counseled to adhere to adjuvant endocrine therapy and be educated about the signs and symptoms of local or regional recurrence, and PCPs should offer genetic counselling if hereditary risk factors are present.

Additionally, women who received a unilateral mastectomy or lumpectomy should undergo annual mammography, whereas MRI should be restricted to high-risk women based on ASCO or American Cancer Society (ACS) criteria.

Routine lab testing and imaging other than mammography should not be offered to asymptomatic women to detect disease recurrence, according to the guidelines.

Further, the guidelines recommend survivors of breast cancer be screened for other cancers in the same manner as the general population. PCPs should provide annual gynecologic assessments for women who are postmenopausal who are taking such selective estrogen receptor modulator agents such as tamoxifen.

Physical, psychosocial management

The workgroup identified several areas of concern regarding the quality of life of survivors of breast cancer.

Because body image and appearance concerns affect 31% to 67% of survivors, the guideline recommends that after assessment, clinicians offer patients adaptive devices (eg, breast prostheses or wigs), appropriate surgery or psychosocial care.

All breast cancer survivors are at risk for lymphedema, which occurs in approximately 40% of the population. Thus, clinicians should counsel patients on preventive measures to reduce their risk, and refer them to physical or occupational therapists or lymphedema specialists if there are symptoms present.

Clinicians also should monitor lipid levels and check for other potential cardiotoxicities, as well as educate survivors on lifestyle modifications and potential cardiac risk factors.

Likewise, clinicians should ensure their patients are not experiencing cognitive difficulties and/or distress, depression and anxiety. If those conditions exist, physicians are recommended to treat them optimally and to recommend further counsel with specialists.

To maintain bone health, clinicians should refer postmenopausal survivors for a baseline dual-energy x-ray absorptiometry scan followed by repeat scans every 2 years for those taking an aromatase inhibitor, premenopausal women taking tamoxifen and/or a gonadotropin-releasing hormone antagonist, and women with chemotherapy-induced premature menopause.

Other factors clinicians should regularly assess in survivors of breast cancer include fatigue,

musculoskeletal symptoms, pain and neuropathy, infertility, and issues with sexual dysfunction or intimacy problems. If a women experiences premature menopause, she should receive serotonin norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, gabapentin or lifestyle/environmental modifications to mitigate vasomotor symptoms.

Healthy behaviors

Clinicians are recommended to offer survivors information related to their breast cancer and treatment, side effects and support services.

Gary Lyman

Gary H. Lyman

Additionally, the guideline recommends physicians counsel survivors on healthy weight, weight loss options, exercise and diet, as well as a recommendation for regular physical activity and smoking cessation, if applicable.

Co-management of care

PCPs and oncologists should consult to provide summaries and create a survivorship care plan for each individual. Family members of the survivor should be included in the care strategy and be counseled on their role as support for the patient, according to the guidelines.

“I believe that this broad set of recommendations will provide optimal health outcomes for the increasing number of breast cancer survivors,” Gary H. Lyman, MD, MPH, an oncologist in the breast cancer program of the Seattle Cancer Alliance and professor in the school of medicine in the division of medical oncology at University of Washington, said in a press release. “This joint guideline initiative will also serve as a framework for future fruitful collaborations between ACS and ASCO across the spectrum of cancer care and survivorship.” – by Anthony SanFilippo

Disclosure: Runowicz reports honoraria from; consultant/advisory roles with; and travel, accommodations and expenses from Audio Digest, Hologic, Pfizer and UpToDate. Lyman reports research funding from Amgen. Please see the full study for a list of the other workgroup members’ relevant financial disclosures.

The American Cancer Society and ASCO jointly released a comprehensive guideline on breast cancer survivorship that stresses the importance of regular surveillance, routine laboratory testing and maintaining a healthy lifestyle.

The guideline — geared toward primary care providers and other clinicians who treat survivors of breast cancer — marks the first time the two societies have collaborated on clinical recommendations.

“The new guideline addressed the issues facing women breast cancer survivors as they transition from treatment to survivorship,” Carolyn D. Runowicz, MD, professor of obstetrics and gynecology and executive associate dean for academic affairs at Herbert Wertheim College of Medicine at Florida International University, said in a press release. “The recommendations should result in high-quality survivorship care, with a focus on improving their quality of life and health outcomes.”

The two societies formed a multidisciplinary workgroup composed of experts in primary care, gynecology, surgical oncology, medical oncology, radiation oncology and nursing.

The workgroup identified 237 published articles of research as the evidence base for the guidelines, although only 2% of the articles were considered level I evidence and 7% were considered level IA. Sixty-four percent of the articles were consider level 0; thus, the workgroup stated these recommendations are based on current evidence and consensus expert opinion.

The recommendation includes five key areas:

  • The need for surveillance for breast cancer recurrence;
  • The need for screening for second primary cancers;
  • Assessing and managing long-term and late effects of breast cancer and treatment;
  • Promoting a healthy lifestyle; and
  • Coordinating care and practice implications.

Screening for recurrence, second cancers

Although routine screening for recurrence is not necessary for asymptomatic individuals, the guidelines stress a careful history is necessary to ensure a survivor is asymptomatic, and survivors at higher risk for local recurrence should undergo screening.

Thus, follow-up care should be individualized for survivors based on age, diagnosis and treatment protocol, and survivors should receive a detailed history and physical exam every 3 to 6 months in the first 3 years following therapy, 6 to 12 months in the next 2 years, and annually thereafter.

Women should be counseled to adhere to adjuvant endocrine therapy and be educated about the signs and symptoms of local or regional recurrence, and PCPs should offer genetic counselling if hereditary risk factors are present.

Additionally, women who received a unilateral mastectomy or lumpectomy should undergo annual mammography, whereas MRI should be restricted to high-risk women based on ASCO or American Cancer Society (ACS) criteria.

Routine lab testing and imaging other than mammography should not be offered to asymptomatic women to detect disease recurrence, according to the guidelines.

Further, the guidelines recommend survivors of breast cancer be screened for other cancers in the same manner as the general population. PCPs should provide annual gynecologic assessments for women who are postmenopausal who are taking such selective estrogen receptor modulator agents such as tamoxifen.

Physical, psychosocial management

The workgroup identified several areas of concern regarding the quality of life of survivors of breast cancer.

Because body image and appearance concerns affect 31% to 67% of survivors, the guideline recommends that after assessment, clinicians offer patients adaptive devices (eg, breast prostheses or wigs), appropriate surgery or psychosocial care.

All breast cancer survivors are at risk for lymphedema, which occurs in approximately 40% of the population. Thus, clinicians should counsel patients on preventive measures to reduce their risk, and refer them to physical or occupational therapists or lymphedema specialists if there are symptoms present.

Clinicians also should monitor lipid levels and check for other potential cardiotoxicities, as well as educate survivors on lifestyle modifications and potential cardiac risk factors.

Likewise, clinicians should ensure their patients are not experiencing cognitive difficulties and/or distress, depression and anxiety. If those conditions exist, physicians are recommended to treat them optimally and to recommend further counsel with specialists.

To maintain bone health, clinicians should refer postmenopausal survivors for a baseline dual-energy x-ray absorptiometry scan followed by repeat scans every 2 years for those taking an aromatase inhibitor, premenopausal women taking tamoxifen and/or a gonadotropin-releasing hormone antagonist, and women with chemotherapy-induced premature menopause.

Other factors clinicians should regularly assess in survivors of breast cancer include fatigue,

musculoskeletal symptoms, pain and neuropathy, infertility, and issues with sexual dysfunction or intimacy problems. If a women experiences premature menopause, she should receive serotonin norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, gabapentin or lifestyle/environmental modifications to mitigate vasomotor symptoms.

Healthy behaviors

Clinicians are recommended to offer survivors information related to their breast cancer and treatment, side effects and support services.

Gary Lyman

Gary H. Lyman

Additionally, the guideline recommends physicians counsel survivors on healthy weight, weight loss options, exercise and diet, as well as a recommendation for regular physical activity and smoking cessation, if applicable.

Co-management of care

PCPs and oncologists should consult to provide summaries and create a survivorship care plan for each individual. Family members of the survivor should be included in the care strategy and be counseled on their role as support for the patient, according to the guidelines.

“I believe that this broad set of recommendations will provide optimal health outcomes for the increasing number of breast cancer survivors,” Gary H. Lyman, MD, MPH, an oncologist in the breast cancer program of the Seattle Cancer Alliance and professor in the school of medicine in the division of medical oncology at University of Washington, said in a press release. “This joint guideline initiative will also serve as a framework for future fruitful collaborations between ACS and ASCO across the spectrum of cancer care and survivorship.” – by Anthony SanFilippo

Disclosure: Runowicz reports honoraria from; consultant/advisory roles with; and travel, accommodations and expenses from Audio Digest, Hologic, Pfizer and UpToDate. Lyman reports research funding from Amgen. Please see the full study for a list of the other workgroup members’ relevant financial disclosures.