The Challenges and Strategies of Breast Cancer Survivorship Care

The Challenges and Strategies of Breast Cancer Survivorship Care

Dr. Beverly Moy
Breast cancer is the second most common malignancy in women and has an approximately 90% 5-year survival rate in the United States following treatment of early-stage disease.1 There are approximately 3.1 million breast cancer survivors in the United States, and caring for this population can be fraught with challenges, including managing long-term treatment side effects, reducing the risk of recurrence, and screening for new cancers.2 Experts will discuss these considerations, and efforts to improve breast cancer survivorship care at the individual and community level, during the June 6 Education Session “Breast Cancer Survivorship: Strategies for Optimal Care.”*

Dr. Michelle E. Melisko
“There has certainly been a call from a national standpoint for highlighting the importance of overall survivorship care,” said session Chair Beverly Moy, MD, MPH, of Massachusetts General Hospital. In January, ASCO held its first Cancer Survivorship Symposium, which covered issues facing patients with various cancers following treatment.

There has been a particular emphasis on optimizing breast cancer survivorship care, Dr. Moy said. “One of the reasons is that breast cancer survival has been improving over the last decade, which creates wonderful challenges in how best to care for these many patients,” she explained. In addition, more endocrine and HER2-based therapies have become available over the years, and their side effects have to be managed.

Dr. Debra L. Barton Photo courtesy of Michigan Photography
ASCO and the National Comprehensive Cancer Network (NCCN) have both issued guidelines for treating specific symptoms in breast cancer survivors, including cardiac toxicity and neuropathy. Last year, ASCO and the American Cancer Society published a joint guideline to advise oncologists and primary care doctors in caring for breast cancer survivors.3

During this session, Dr. Moy hopes that attendees will gain a better understanding of the importance of prioritizing care for breast cancer survivors. This care includes medications and complementary therapies to manage treatment side effects and lifestyle interventions to reduce the risk of recurrence.

Models of Survivorship Care Delivery

Dr. William J. Gradishar
Many medical societies recommend that every patient with breast cancer receives a survivorship care plan at the end of treatment, which includes a summary of their personalized treatment and its possible long-term and late side effects, information about recurrence, and guidelines for follow-up care to address these issues. However, cancer centers face a number of barriers to implementing survivorship care plans, primarily, insufficient staff, resources, funding, and training.

During the first presentation of the session, Dr. Moy will discuss the three main models for delivering breast cancer survivorship care in the United States and some of their challenges. She will also provide examples of cancer centers that have implemented each type. In the first model, patients receive a one-time consultation with a survivorship specialist and then have regular follow-up care with their oncologist or primary care physician. The second model places more emphasis on transitioning patients back to their primary care physician but still involves periodic appointments with nurse practitioners or other experts at cancer clinics. Finally, the third model involves a multidisciplinary team of oncologists, nurse practitioners, and other specialists, such as nutritionists and psychologists, depending on the needs of the patient.

There is currently not enough evidence for these models in terms of their implementation, effect on patient outcomes and quality-of-life measures, and providers’ perceptions of their impact and challenges. “We need more research in this area, which will be one of the points of my talk,” Dr. Moy said.

Lifestyle Modifications for Risk Reduction

Many breast cancer survivors are eager to incorporate lifestyle modifications, such as losing weight or cutting sugar, into their survivorship care plan, even if they may be more resistant to taking medications to manage comorbidities such as hypertension and high cholesterol, said Michelle E. Melisko, MD, of the University of California, San Francisco.

During her presentation, Dr. Melisko will discuss the evidence for the benefits of various lifestyle modifications in breast cancer survivorship care. “Exercise is probably the most strongly associated with improved outcomes,” Dr. Melisko said. These benefits include reduced rate of all-cause mortality, and they appear to occur independent of weight loss.4 However, studies to date have failed to show that dietary changes, such as reducing fat or increasing fruits and vegetables, reduce the risk of breast cancer recurrence or improve overall survival.

In general, there is confusion among patients between the factors that increase the risk of developing breast cancer and those that increase the risk of recurrence after being diagnosed.

For example, “there is sort of a blanket feeling among the breast cancer community that you have to quit drinking entirely,” Dr. Melisko said. Although heavy alcohol consumption increases the risk of developing breast cancer, it only significantly increases risk of recurrence among the subset of breast cancer survivors, including those who are postmenopausal, obese, and have HR-positive breast cancer.

Improving Adherence to Endocrine Therapy

Out of the 3.1 million breast cancer survivors in the United States, the majority of those with HR-positive disease will receive endocrine therapy, such as tamoxifen or aromatase inhibitors. These agents, which block the effects or production of estrogen in certain tissues, can carry numerous side effects and are associated with high rates of nonadherence.5

During the third presentation of this session, Debra L. Barton, PhD, AOCN, FAAN, RN, of the University of Michigan School of Nursing, will discuss the prevalence of endocrine therapy nonadherence, the side effects that are most bothersome to women—such as hot flashes, vaginal dryness, joint pain, and fatigue—and how to manage those side effects.

“The last thing women want is to take four additional pills just to manage the side effects of one pill,” Dr. Barton said. She will discuss the evidence around some behavioral interventions and complementary therapies, such as stress reduction techniques, hypnosis, yoga, and acupuncture, that may help women manage the side effects of endocrine therapy.

Bone Agents as Adjuvant Therapy?

It is well established that breast cancer treatments, including aromatase inhibitors and chemotherapy, decrease bone mineral density and increase the risk of fractures. Several trials have demonstrated that bone agents, such as bisphosphonates and denosumab, can prevent bone loss associated with treatment for early breast cancer.

“Where it gets a little murkier is in using these agents as a treatment for breast cancer,” said William J. Gradishar, MD, FASCO, of Northwestern University Feinberg School of Medicine, who will discuss this issue during the final presentation of the session.

Although several trials suggest that bisphosphonates and denosumab could improve disease-free and overall survival for certain groups of women, the findings are equivocal, and questions remain about the agents and duration of treatment that could offer these adjuvant benefits.  

– Carina Storrs, PhD


*Program information as of March 18, 2016; for session times and locations, please refer to the ASCO iPlanner.