Experts Issue New Guideline for Breast Cancer Survivor Care

“Carolyn

Carolyn D. Runowicz, MD, FASCO

Practitioners awaiting guidelines for the optimum support of breast cancer survivors now have a resource to turn to with the release of a new clinical oncology breast cancer survivorship care guideline, a collaborative effort of the American Society of Clinical Oncology (ASCO) and the American Cancer Society (ACS).

The guideline, which is intended for primary care and other clinicians who care for female breast cancer survivors, includes recommendations on surveillance for breast cancer recurrence, screening for second primary cancers, management of long-term and late effects, health promotion, and care coordination.

Although NCCN guidelines address symptom-specific survivorship care, the authors note, the aim of this new ASCO/ACS guideline is to provide “comprehensive, holistic recommendations specific to posttreatment breast cancer clinical care.”

Among the guideline’s key recommendations, which were published in both the Journal of Clinical Oncology and CA: A Cancer Journal for Clinicians, is that survivors have regular surveillance for breast cancer recurrence (including cancer-related history and physical examinations) and be screened for new primary breast cancer.

However, the new guideline does not recommend routine laboratory and imaging tests (except for mammography, if indicated) to check for possible breast cancer recurrence in patients who are asymptomatic, because the data do not support it, the authors noted.

Primary care clinicians’ pivotal role in survivorship care is highlighted in the guideline’s recommendation that these practitioners counsel patients about the importance of maintaining a healthy lifestyle and monitor survivors for posttreatment symptoms.

The guideline also calls on these practitioners to promote survivor adherence to prescribed adjuvant endocrine therapies.

"The new guideline addresses the issues facing women breast cancer survivors as they transition from treatment to survivorship," said Carolyn D. Runowicz, MD, FASCO, chair of the ASCO/ACS Expert Workgroup that developed the guideline. "The recommendations should result in high quality survivorship care, with a focus on improving their quality of life and health outcomes."

A multidisciplinary work group reflecting primary care, gynecology, surgical/medical/radiation oncology, and nursing reviewed 1073 peer-reviewed articles published through April 2015, of which 237 were included in the evidence base.

Physical and psychosocial long-term and late effects clinicians should be monitoring for in the breast cancer survivor population are:

• Body image concerns

• Lymphedema

• Cardiotoxicity

• Cognitive impairment

• Distress, depression, anxiety

• Premenopause/hot flashes

• Fatigue

• Bone and musculoskeletal health

• Sexual health and infertility

• Pain and neuropathy

In the area of risk evaluation and genetic counseling, the guideline recommends that, “primary care clinicians assess the patient’s cancer family history and offer genetic counseling if potential hereditary risk factors are suspected.”

The guideline recommends each patient have a treatment summary and survivorship care plan and ongoing communication between the patient/survivor’s primary care clinicians and oncology team beginning at diagnosis and through to survivorship, so that care is “evidence-based and well-coordinated.”

"I believe that this broad set of recommendations will provide for optimal health outcomes for the increasing number of breast cancer survivors," said Gary H. Lyman, MD, MPH, FASCO, FRCP, ASCO's representative on the ASCO/ACS Expert Panel that developed the guideline. "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."

Runowicz CD, Leach CR, Henry NL, et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline [published online ahead of print December 7, 2015] J Clin Oncol.