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Communication between PCP, oncologist crucial in treating breast cancer survivors

Agustin C. Garcia

NEW ORLEANS — In breast cancer follow-up, primary care physicians must consult with and maintain good communication with the oncology team, according to a presentation at the ACP Internal Medicine Meeting.

Breast cancer is very common, with more than 330,000 new cases of breast cancer every year in the United States, Agustin C. Garcia, MD, professor of medicine and section chief of hematology oncology at Louisiana State University, said during his presentation.

Since 1989, there has been a 40% decrease in death rates from breast cancer regardless of ethnicity, he noted.

Currently, there are more than 3 million breast cancer survivors, he said.

“PCPs will see breast cancer survivors on a regular basis because there are many who continue their care after getting their standard breast cancer therapy,” Garcia said.

Therefore, delineation of care remains a lingering question for many PCPs who care for breast cancer survivors, he said.

Breast cancer surveillance is an important factor in follow-up treatment, according to Garcia.

“Surveillance for breast cancer should include limited testing for cancer recurrence and focus on overall health and PCP concerns,” he said.

Physicians should conduct a history and physical exam one to four times per year for 5 years after diagnosis, then annually, he said. Physicians should also periodically screen for changes in family history and perform mammography annually, he said.

Additionally, women on tamoxifen require an annual pelvic exam, he said. It is also important to monitor the bone health of women on aromatase inhibitors or those with premature ovarian failure, he said.

Garcia noted that routine imaging of a reconstructed breast is not necessary nor is laboratory or imaging studies for metastases screening for asymptomatic patients.

“PCPs should assess and encourage adherence to adjuvant endocrine therapy, an active lifestyle and healthy diet,” he said.

The goal of post treatment cancer surveillance is to improve survival related to either systemic or local cancer, according to Garcia.

“We can only increase survival if two things happen,” he said. “First, most recurrences are detected at an early stage during the surveillance visits. Second, early treatment of recurrent disease leads to better survival.”

Physicians should look for signs and symptoms suggestive of breast cancer relapse, including masses in ipsilateral breast, masses in chest wall, rash and lymph nodes in ipsilateral axillary, supraclavicular or infraclavicular lymphadenopathy, according to Garcia. Physicians should also be aware of bone, pulmonary and liver relapse, he said.

A history and physical exam should be performed every 3 to 6 months during the first 3 years after primary therapy, every 6 to 12 months for the next 2 years and then annually, he said.

Data from several studies show that there is no benefit of doing intense surveillance of patients, he noted. Additionally, routine laboratory and imaging tests used for surveillance are not recommended because they have significant false-positive and false-negative rates and higher costs, Garcia said.

“Breast cancer survivors are at higher risk of second primary cancers,” he said.

Identifying which patients have genetic predisposition for breast cancer is important, he said. Physicians should also reassess periodically, screen for other cancers as appropriate, according to Garcia.

Physicians should assess, identify and manage physical and psychosocial long-term and late effects of breast cancer and treatment which may include body image concerns, lymphedema, cardiotoxicity, cognitive impairment, hot flashes, depression, distress, anxiety, fatigue, pain and infertility, according to Garcia. Referral to the appropriate sources may be necessary, he said.

To promote the health of breast cancer survivors, PCPs should encourage their patients to maintain a healthy weight, avoid inactivity, limit alcohol, avoid smoking and consume a diet high in fruits and vegetables, whole grains and legumes and low in saturated fats, Garcia said.

He stressed the importance of care coordination with the oncologist.

“More and more cancer practices are developing cancer survivorship plans,” he said.

PCPs should obtain the survivorship care plan and closely consult and communicate with the cancer treatment team throughout the patient’s diagnosis, treatment and posttreatment care, according to Garcia.

Studies have shown that there are no differences in recurrence, death or complications in breast cancer survivors cared for by the PCP compared with the oncologist, he noted. – by Alaina Tedesco

Reference:

Garcia AC. Breast cancer follow-up: Who, what, when. Presented at: ACP Internal Medicine Annual Meeting; April 19-21, 2018; New Orleans.

Disclosure: Garcia reports receiving research support from Boston Biomedical, Celldex Therapeutics, Cascadian Therapeutics, Seattle Genetics and Iovance Biotherapeutics.