Chapter 83: Survivorship Issues in Breast Cancer

INTRODUCTION

Improvements in diagnosis and advances in targeted therapies have contributed to the increasing numbers of breast cancer survivors. The most recent estimate by the Surveillance Epidemiology and End Results (SEER) database estimates nearly 2.8 million breast cancer survivors alive as of 2013, an increase from previous estimates.¹ As the numbers of survivors have increased and as many of those survivors are living decades beyond their treatment, issues affecting survivorship and overall quality of life (QOL) have moved to the forefront of breast cancer research. Identification and classification of the persistent and late consequences of breast cancer treatment have become critical endpoints in many newly developed clinical trials. In fact, with the input of patient advocates contemporary clinical trial development frequently includes assessment of outcomes equally according to efficacy and anticipated impact on future QOL.

The NCCN considers an individual a cancer survivor from the time of diagnosis through the balance of her life which results in a heterogeneous spectrum of survivors from diagnosis to immediate posttreatment to permanent survivorship.² In contrast, the timing at which point a woman considers herself a survivor may differ by the stage and treatment factors of her disease. However, the process of psychosocial adaptation begins at the time of diagnosis as women are faced with a variety of treatment choices. A shared decision-making model around treatment and follow-up care has been associated with improved QOL.³ Further, researchers have investigated QOL both within 5 years of diagnosis and beyond 5 years demonstrating that while more than 50% of survivors reported specific treatment-related symptoms they still had excellent physical and emotional well-being and equivalent QOL when compared to healthy age-matched controls.^4-6 Clearly, while women vary widely in their response to diagnosis and treatment most return to rich and rewarding lives after treatment. The growing number of survivorship programs and the recent development of survivorship guidelines by the NCCN is a testament to survivors’ needs and aim to focus on both cancer surveillance and health and well-being issues. These health issues can be classified as persistent, posttreatment symptoms such as fatigue, premature menopause, sexual dysfunction and fertility concerns, or as long-term complications like lymphedema or cognitive dysfunction.

SURVEILLANCE

Monitoring for disease recurrence is an integral part of survivorship and can be associated with significant anxiety. Updated ASCO guidelines in 2013 reviewed 14 new publications including 3 meta-analyses and 5 randomized trials published since 2006.⁷ The consensus panel continues to recommend regular follow-up visits with clinical exams every 3 to 6 months for the first 3 years, every 6 to 12 months in years 4 and 5, and annually thereafter. Women should complete mammography 12 months after diagnosis and at least 6 months after the completion of radiation therapy in the setting of breast conservation. Then annual mammography is appropriate unless other clinical concerns exist. Annual breast MRI should be performed in ...