Certainly, the information and resources to accomplish this transition are readily available; however, they are scattered throughout the literature and therefore are not easily accessible or available to the primary care physician. It is imperative that the information available regarding survivorship issues be accessible in an organized and useful format. This article is a modest attempt to provide a comprehensive review of the long-term medical issues relevant to survivorship after the diagnosis and treatment of breast cancer. A predicted shortage of oncologists by 2020 is well-recognized. Therefore, the bulk of long-term care will become dependent on the primary care physician. This shift of care means that these physicians will need to be well educated in the long-term medical issues related to breast cancer treatment.Long-term survival rates after a diagnosis of breast cancer are steadily rising. This is good news, but clinicians must also recognize that this brings new challenges to the medical community. As breast cancer becomes a chronic condition rather than a life-threatening illness owing to advances in early diagnosis and more effective treatments, health care practitioners must recognize and manage the long-term sequelae of the constellation of therapeutic modalities. Survivors of breast cancer represent a unique and extremely complex group of patients; 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. Therapies have additional and/or additive side effects that may interfere with treatments directed toward the new primary diagnosis of breast cancer. Our mandate is to establish a smooth transition from patient with breast cancer to survivor of breast cancer while providing ongoing and future guidance.
It is estimated that there are approximately 2.5 million survivors of breast cancer in the US.1 This figure will expand to 3.4 million in 2015, representing an increase of 31%.2 The millions more worldwide are probably grossly underestimated because of the poor or inefficient reporting systems and the lack of reliable cancer registries in third-world countries.3 In 2006, the Institute of Medicine (IOM) issued a milestone comprehensive report, From Cancer Patient to Cancer Survivor: Lost in Transition.4 Of the 10 recommendations regarding cancer survivorship by the IOM, the issues receiving the utmost attention to date have been the provision of a summary of diagnosis, treatment received (treatment summary), future follow-up care plans, and healthy lifestyle recommendations.5 A recent Special Series Overview6 eloquently described a number of major topics that have been addressed by world-renowned experts since the IOM recommendations were published.6 These include long-term cardiovascular issues secondary to treatment protocols,7 bone health,8 the increased risk of second primary malignancies (SPMs),9 the development of lymphedema,10 and other issues that, although extremely important, may not be life-threatening. Multiple other concerns have been inadequately addressed, including the increased risk of venous thromboembolism in the setting of malignancy,11-13 the failure of adherence and compliance to prescribed adjuvant hormonal therapies,14-16 and lifestyle changes with recommendations for effective modifications.
Although of major importance, issues regarding sexuality and fertility preservation are not addressed in this review. The reader is directed to excellent reviews of breast cancer and sexuality,17,18 as well as extensive guidelines regarding fertility preservation.19In addition, nonspecific symptoms secondary to treatment protocols (eg, fatigue, insomnia, pain, cognition) are omitted because recent and thorough reviews of these issues are readily available.20 Furthermore, these are excluded because many are nonspecific symptoms and are not unique to a diagnosis of breast cancer.
Survivorship care programs provide an important component of the patient treatment pathway but fail in the elaboration and communication to the patient regarding many issues relevant to long-term survival. Most long-term care plans inadequately address the most important medical issues involving the long-term consequences of survivorship. Although the primary recommendations of the 2006 IOM report are sound,4 we would add the importance of patient education regarding some of the long-term sequelae of this disease and its treatment. These include the symptoms of the issues addressed in this article: cardiovascular diseases (CVDs) secondary to treatment modalities, bone health, SPMs, lymphedema, thromboembolic risks, long-term compliance with oral medications, and finally, lifestyle interventions.
Although most people with breast cancer will not die of breast cancer, their comorbidities (eg, obesity, hypertension, hyperlipidemia, and diabetes mellitus [DM]) will most certainly affect disease-free survival (DFS) and, ultimately, overall survival (OS). In this review we address lifestyle changes, which are largely dependent on body mass index (BMI) and include diet and exercise, and review recommendations regarding these issues. Survivors of breast cancer represent a unique group who must be cognizant of the long-term side effects of their treatment protocols and be given information to encourage a proactive approach to their overall health. Finally, a robust reference resource list is included in this article for those who wish to delve into specific issues in greater depth.