Improve breast cancer survival through knowledge, behaviors, coordination
Although significant progress has been made in breast cancer care, challenges and opportunities remain in cancer survivorship.
“There are a growing number of breast cancer survivors. It is estimated that there will be more than 18 million cancer survivors in the U.S. alone by 2022, of whom 22% are expected to be female breast cancer survivors,” Ann H. Partridge, MD, MPH, founder and director of the program for young women with breast cancer and director of the adult survivorship program at Dana-Farber Cancer Institute, said during a presentation at the 2019 Miami Breast Cancer Conference.
Survivorship spans the cancer trajectory, and needs vary for each patient.
Partridge recommended clinicians focus on four major areas: recurrence and new cancers, long-term and late effects, modifiable health behaviors and coordination of care.
“Every time I see a survivor during follow-up, I focus on these four areas,” Partridge said. “I guarantee that by focusing on these key areas, clinicians will pick up on something that they had not picked up on before with each patient.”
Recurrence risk a key challenge
The risk for recurrence is a key challenge in cancer survivorship, she said.
Geurts and colleagues found in a 2017 study of 9,342 patients from the nationwide population-based Netherlands Cancer Registry that breast cancer recurred in 20% of patients over a 10-year period, and the risk was highest in the second year after diagnosis.
According to American Cancer Society statistics, 5-year survival rates are 99% for women with cancer in the breast only, 86% with cancer in the regional lymph nodes and 27% with cancer that has spread to a distant part of the body. The society noted that survival rates are about 9% lower for black women compared with white women, and that early detection remains crucial to prevent breast cancer deaths.
Screening tools include mammography and MRI, which Lehman and colleagues evaluated for detection of cancer in the contralateral breast after an initial breast cancer diagnosis.
Their 2007 study included 969 women with a recent diagnosis of unilateral breast cancer and no clinical or mammographic evidence of contralateral disease.
MRI of the contralateral breast led to biopsy for 121 women (12.5%), 30 of whom were diagnosed with contralateral breast cancer, Partridge said.
“Following these data, the American Cancer Society came together on recommendations for MRI breast cancer screening as an adjunct to mammography,” she said. “The society stated that the evidence is insufficient to recommend for or against MRI screening, and that clinicians should decide on their own on how to follow nonhigh-risk patients.”
New cancer risk
Another challenge of cancer survivorship is the risk for new primary disease, Partridge said.
According to a 2020 study by Li and colleagues, the cumulative incidence of developing second primary cancers after early-stage initial primary breast cancer was 7.43% at 10 years, 14.41% at 15 years and 20.08% at 20 years.
The researchers used data from the SEER registry to evaluate 250,764 women aged 20 to 80 years with early-stage breast cancer who survived at least 5 years.
They found that the majority of second primary cancer cases comprised breast cancer (43.27%), followed by gastrointestinal cancer (14.28%), lung cancer (10.58%), female genital tract cancers (9.65%), skin cancer (4.84%), cancers of the central nervous system (4.4%), leukemia (4.14%), urinary tract cancers (3.94%) and lymphoma (1.8%).
“We need to remember to always update family history and revisit genetic risk,” Partridge said. “This is an important time for our patients where we can prevent future disease.”
Long-term effects of therapy
Partridge also discussed long-term and late effects among cancer survivors.
The most common phenomenon is cancer-related fatigue, which affects between 50% and 80% of survivors.
Clinicians should first rule out and treat other potential causes of fatigue — such as pain, malnutrition, hypothyroidism, anemia, insomnia, depression and inactivity — before cancer-related fatigue can be treated with exercise, behavioral or psychotherapy, and complementary therapy, Partridge said.
Bodai and colleagues published a comprehensive review of long-term medical issues faced by breast cancer survivors after they complete treatment.
“Not only do they have the challenge of dealing with multiple long-term side effects of treatment protocols, but many are also forced to address the preexisting comorbidities of their therapies, which often include multiple other issues,” the researchers wrote.
Cardiovascular disease (CVD) is the No. 1 killer of women, according to Bodai and colleagues. Younger women are developing CVD at an increased rate, and women are being diagnosed with breast cancer at an earlier age.
“Many survivors of breast cancer are at significantly increased risk [for] death caused by CVD, far exceeding their risk [for] death resulting from the initial cancer itself or from a recurrent cancer,” the researchers wrote.
Chemotherapy, radiation therapy, hormonal blockade and targeted biologic therapies all have the potential to cause cardiovascular complications, Bodai and colleagues noted.
“Those addressing survivorship care must be aware of the need to incorporate a multidisciplinary approach to issues surrounding assessment and management of CVD,” they wrote.
Treatments prescribed for medication adverse events and other conditions accompanying breast cancer can lead to bone health issues, according to the review. These include drugs commonly prescribed for gastrointestinal symptoms, depression and inflammation. Cessation of hormonal blockade therapy can lead to estrogen deprivation, increasing the risk for osteoporosis.
Thyroid disease and diabetes are common comorbidities with breast cancer. Hypothyroidism and its treatment may increase the risk for osteoporosis, and both type 1 and type 2 diabetes may exacerbate it, according to the researchers.
Breast cancer-related lymphedema, which involves deformity, pain, reduction in limb use and extreme emotional distress, commonly occurs as a result of breast cancer treatment, Bodai and colleagues wrote.
“Many patients fear the development of lymphedema even more so than the diagnosis of the cancer itself or the loss of a breast,” as it is a lifelong, irreversible condition, the researchers wrote.
Thromboembolic events are uncommon consequences of all cancers, they added. A risk factor for these events unique to patients with breast cancer is the long-term use of indwelling catheters.
“Looking at improving long-term survival in breast cancer encompasses a total-health strategy that includes a focus on healthy eating, active living, healthy weight and emotional resilience,” Bodai and colleagues wrote.
Runowicz and colleagues, in the Breast Cancer Survivorship Care Guideline from the American Cancer Society and ASCO, recommended that primary care clinicians provide information to these patients on their condition, treatment, adverse events and support services. They should also discuss obesity, physical activity, nutrition and smoking cessation.
Coordination of care
No clear guidelines exist for comanagement of after care for breast cancer survivors, Runowicz and colleagues wrote, but the researchers recommended that primary care physicians obtain a survivorship care plan from the cancer treatment team and maintain communication.
Providers should also encourage patients to involve caregivers in their management.
“Awareness of and attention to the unique issues facing survivors and knowing how to counsel and follow these patients are critical,” Partridge said. “There are many resources, tools and support services available for cancer survivors and providers.” – by Nancy Hemphill, ELS, FAAO, and Jennifer Southall
- Bodai BI, et al. Perm J. 2015;doi:10.7812/TPP/14-241.
- Geurts YM, et al. Breast Cancer Res Treat. 2017;doi:10.1007/s10549-017-4340-3.
- Lehman CD, et al. N Engl J Med. 2007;doi:10.1056/NEJMoa065447.
- Li D, et al. Front Oncol. 2020;doi:10.3389/fonc.2019.01426.
- Partridge AH. The art and science of survivorship planning and management. Presented at: Miami Breast Cancer Conference; March 7-10, 2019; Miami.
- Runowicz CD, et al. CA Cancer J Clin. 2015;doi:10.3322/caac.21319.
Disclosure: Bodai and colleagues, Geurts and colleagues, Lehman and colleagues, and Li and colleagues report no relevant financial disclosures. Partridge reports serving as co-author of the breast cancer survivorship section for UpToDate. Runowicz reports no relevant financial disclosures. Please see that full study for all other authors’ relevant financial disclosures.