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ST. JOHN HEALTH
BREAST CARE PROGRAM
STANDARD4.3 PATIENT SURVEILLANCE
Standard of Care:
Followingcompletionof breastcancertherapy,all patientsshouldbe monitoredin the following
manner:
. History and physical examination should be completed every 3-6 months for the
first three years after primary therapy, every 6-12 months for years 4 and 5; then
annually thereafter.
. Patients should be counseled to perform monthly breast self-examination.
. First post-treatment mammogram should be completed withinl year of the initial
mammogram that led to diagnosis but no earlier than 6 months after the definitive
radiation therapy. Unless otherwise indicated, a yearly mammographic evaluation
should be performed. For patients who have had a lumpectomy, a mammogram
should be recommended every 6 months for the first 2-3 years.
. Regular gynecologic follow-up including a pelvic examination should be
completed on an annual basis for women with intact uteri. If patients are
receiving Tamoxifen, they should be advised to report any vaginal bleeding to
their physician(s).
. Continuity of care should continue indefInitely by a physician experienced in the
surveillance of cancer patients and in breast examination, including the
examination of irradiated breasts.
. Adjuvant endocrine therapy follow-up, to include patient adherence and
associated symptom management, should be managed by either a breast surgeon
or a medical oncologist.
Baseline levels of estradiol and gonadotropin followed by serial monitoring of
these hormones should be performed if an aromatase inhibitor is initiated in
women with amenorrhea following chemotherapy.
. Bone health should be monitored and supplemental calcium and Vitamin D given
to women who are at risk for osteopenia or osteoporosis (Le., premenopausal
women who experience early ovarian failure secondary to adjuvant chemotherapy
and postmenopausal women who are treated with an aromatase inhibitor).
Patients at high risk for familial breast cancer syndromes should be referred for
genetic counseling.
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The following evaluations are not recommended in asymptomatic patients with no
specific findings on clinical examination:
Routine blood tests (Le., CBC's and liver function tests);
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Imaging studies (i.e., chest x-ray, bone scans, liver ultrasound, computed
tomography scans);
Tumor markers (i.e., CAI5-3, CA27-29 and CEA);
FDG-PET scans ,for routine breast cancer surveillance;
Breast MRI for routine breast cancer surveillance, however, this would be
considered as an option for post-therapy surveillance and follow-up in women at
high risk of bilateral disease (e.g., carriers ofBRCA 1 or 2 mutations, strong
family history, dense breasts that might be difficult to interpret findings on a
mammogram).
These recommendations are not intended to supplant physician judgment with respect to
particular patients or special clinical situations and cannot be considered inclusive of all
proper methods of care or exclusive of other treatments reasonably directed at obtaining
the same result.
Standard of Practice:
. A follow-up care plan should be reviewed with each patient following the
completion of their adjuvant therapy.
. The patient will be given a copy of the "St. John Health Breast Care Program
Patient Guide for Follow-Up Care Following Breast Cancer Therapy" (see
attached).
. The nurse navigator should make contact with patients at their 6, 12,24 and 60month post-surgery to provide for follow-up and to evaluate patient status with
respect to fatigue, pain, lymphedema symptoms, hospitalization, satisfaction with
cosmesis, ongoing hormone therapy use, and disease recurrence.
Benefits of Procedure:
Possible early detection of disease recurrence;
Provide support for continuance of long-term therapy if applicable;
Monitor possible disease and treatment sequelae and provide for appropriate
intervention.
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References:
The evidence supports regular history, physical examination, and mammography as the
cornerstone of appropriate breast cancer follow-up. All patients should have a careful
history and physical examination performed by a physician experienced in the
surveillance of cancer patients and in breast examination. Examinations should be
performed every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and
5, and annually thereafter. For those who have undergone breast-conserving surgery, a
post-treatment mammogram should be obtained 1 year after the initial mammogram and
at least 6 months after completion of radiation therapy. Thereafter, unless otherwise
indicated, a yearly mammographic evaluation should be performed. Patients at high risk
for familial breast cancer syndromes should be referred for genetic counseling. The use
of CBCs, chemistry Ranels, bone scans, chest radiographs, liver ultrasounds, computed
tomography scans, [ 8F]fluorodeoxyglucose-positron emission tomography scanning,
magnetic resonance imaging, or tumor markers (carcinoembryonic antigen, CA 15-3, and
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CA 27-29) is not recommended for routine breast cancer follow-up in an otherwise
asymptomatic patient with no specific fmdings on clinical examination. Careful history
taking, physical examination, and regular mammography are recommended for
appropriate detection of breast cancer recurrence. (American Society of Clinical
Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in
the Adjuvant Setting)
Post-therapy follow-up is optimally performed by members of the treatment team and
includes the performance of regular physical examinations and mammography. In
patients undergoing breast-conserving therapy, the first follow-up mammogram should be
performed 6-12 months after the completion of breast-conserving radiation therapy. The
routine performance of alkaline phosphatase and liver function tests are not included in
the Guidelines. In addition, the Panel notes no evidence to support the use of "tumor
markers" for breast cancer, and routine bone scans, CT scans, MRI scans, PET scans, or
ultrasound examinations in the asymptomatic patient provide no advantage in survival or
ability to palliate recurrent disease and are, therefore, not recommended.
The use of dedicated breast MRI may be considered as an option for post-therapy
surveillance and follow-up in women at high risk of bilateral disease, such as carriers of
BRCA 1 or 2 mutations. Rates of contralateral breast cancer following either breastconserving therapy or mastectomy have been reported to be increased in women with
BRCA 1 or 2 mutations when compared with patients with sporadic breast cancer.
The Panel recommends that women with intact uteri who are taking tamoxifen should
have yearly gynecologic assessments and rapid evaluation of any vaginal spotting that
might occur because of the risk of tamoxifen-associated endometrial carcinoma in
postmenopausal women. The performance of routine endometrial biopsy or
ultrasonography in the asymptomatic woman is not recommended. Neither test has
demonstrated utility as a screening test in any population of women. The vast majority of
women with tamoxifen-associated uterine carcinoma have early vaginal spotting.
Symptom management for women on adjuvant endocrine therapies often requires
treatment of hot flashes and the treatment of concurrent depression. Venlafaxine has
specifically been studied and is an effective intervention in decreasing hot flashes.
Recent evidence has suggested that concomitant use of tamoxifen with certain selective
serotonin reuptake inhibitors (SSRIs) (e.g., paroxetine and fluoxetine) may decrease
plasma levels of endoxifen, an active metabolite of tamoxifen. These SSRIs may
interfere with the enzymatic conversion of tamoxifen to endoxifen by inhibiting a
particular isoform of cytochrome P-450 enzyme (CYP2D6) involved in the metabolism
oftamoxifen. However, the SSRIs citalopram and venlafaxine appear to have only
minimal effects on tamoxifen metabolism.
Premenopausal women who experience early ovarian failure secondary to adjuvant
chemotherapy and postmenopausal women who are treated with an aromatase inhibitor
are at increased risk for the development of osteopenia or osteoporosis with an associated
increased risk of bone fracture. The guideline thus recommends monitoring of bone
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health during surveillance in these high risk women, and supplemental calcium and
vitamin D. The use ofbisphosphonate is generally the preferred intervention to improve
or maintain bone mineral density of women with breast cancer and osteopenia or
osteoporosis. A dental c;xaminationwith preventive dentistry prior to initiation of
bisphophonate therapy is recommended.
A special situation arises in women who are premenopausal at diagnosis, who develop
amenorrhea during or following treatment, and for whom the use of an aromatase
inhibitor is considered. The continuation or return of ovarian function following
chemotherapy with or without amenorrhea has been documented. If an aromatase
inhibitor is considered in women with amenorrhea following treatment, baseline levels of
estradiol and gonadotropin followed by serial monitoring of these hormones should be
performed if endocrine therapy with an aromatase inhibitor is initiated. Bilateral
oophorectomy assures postmenopausal status in young women with therapy-induced
amenorrhea and may be considered prior to initiating therapy with an aromatase inhibitor
m a young woman.
Follow-up also includes assessment of patient adherence to ongoing medication regimens
such as endocrine therapies. Predictors of poor adherence to medication include the
presence of side effects associated with the medication, and incomplete understanding by
the patient of the benefits associated with regular administration of the medication. The
Panel recommends the implementation of simple strategies to enhance patient adherence
to endocrine therapy, such as direct questioning of the patient during office visits, as well
as brief, clear explanations on the value of taking the medication regularly and the
therapeutic importance oflonger durations of endocrine therapy. (National
Comprehensive Cancer Network: Breast Cancer Practice Guidelines, 2009)
Attested that this standard was reviewed a,d al?proved by the St. John Health
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Breast Care Advisory Board on:
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Dated:
'Cheryl A. ~esen, MD, FACS
Medical Director, St. John Health Breast Care Program
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ST. JOHN HEALTHBREAST CARE PROGRAM
PATIENTGUIDE FOR
FOLLOW-UPCARE FOLLOWINGBREASTCANCERTHERAPY
As part of your ongoing care within the St. John Health System, the following
recommendations are being provided to you as follow-up to the treatment you have
received for your breast cancer. The intent of these recommendations is to assure
for the close monitoring of your health care status, help you to cope with possible
treatment-related side effects, and to help sustain your general overall health.
Follow-up Care
*Physician visits
Post-treatment
mammogram
Breast self-examination
Pelvic examination
Bone Health
Colonoscopy
Recommendation
You should schedule an appointment with your surgeon, medical
oncologist or radiation oncologist (one of which will be your
designated follow-up physician) every 3-6 months for the first 3
years after your breast cancer surgery. In years 4 and 5, this
appointment should be scheduled every 6 months. Thereafter,
your follow-up physician appointment should occur once a year.
H you are taking endocrine therapy (i.e., tamoxifen or an
aromatase inhibitor drug), your medical oncologist or surgeon
wDl advise you on when to schedule physician appointments and
other possible evaluations. You should also continue to take the
hormone therapy as prescribed by your follow-uo ohvsician.
One of your follow-up physicians will advise you as to the timing
of your first mammogram which should be done within 6-12
months after your surgery. Thereafter, this evaluation should be
scheduled yearly or as recommended by your follow-up
physician. Hyou had a lumpectomy, your physician may
recommend that you have a mammogram every 6 months for the
first 2-3 years.
You should continue to perform a monthly breast selfexamination at the same time of the month.
You should schedule an annual gynecologic visit with your
OB/GYN physician at which time you wDl have a PAP test. H you
should experience any vaginal bleeding (especially if you are
taking tamoxifen), you should report this event to both your
OB/GYN and follow-up physician.
You may be at an increased risk of bone loss if you are a
premenopausal woman who experienced early menopause while
taking chemotherapy or if you are a postmenopausal woman who
has been treated with an aromatase inhibitor drug. Your followup physician may recommend that you take supplemental
calcium and vitamin D and have bone health assessments as
determined necessary.
Starting at the age of 50, it is recommended that you have a
colonoscopy every ten years unless you have a history of polyps or
family history of colon cancer. Your primary care physician may
then recommend that you have a colonoscopy at more frequent
intervals.
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Routine follow-up
You should continue to be followed by your primary care
physician if you have other medical conditions (e.g., high blood
pressure, diabetes, arthritis, etc.) for which you are receiving
treatment.
*Your follow-up visits and evaluations will be tailored to your specific needs. Blood tests
and x-rays (other than mammograms) are not routinely needed for most patients. Tests
that may be considered necessary for you will be ordered by your treating physician.
What to Look Out For
It is important to be aware of changes in your body in between physician visits.
Immediately call your follow-up physician if you experience the following symptoms:
. New lumps or nodules in your breast or the skin around your surgery site.
Bone pain
Chest pain
. Abdominal pain or swelling
Shortness of breath or difficulty breathing
. Persistent headaches
. Persistent cough
Nipple discharge
New rectal or vaginal bleeding
New fullness or redness in your breast or arm on the side of surgery
Back pain
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Lifestvle Recommendations
Other lifestylefactors are important in maintaining health and are highly recommended for
your well-being:
Ret!ular exercise: The American Cancer Society (ACS) recommends at least 30 minutes of
moderate to vigorous activity on 5 or more days a week. Moderate activity means anything
that makes you breathe as if you were walking briskly. Vigorous exercise causes the heart
rate to increase, deep breathing and sweating.
Weight lifting, yoga and tai chi are beneficial for improving flexibility, balance and
strength. Exercise is also valuable to help prevent treatment-related fatigue, improve mood
and sleep, and decrease stress.
The most important benefit of exercise is that you may reduce the risk of cancer recurrence
by boosting the body's immune system.
Maintain a healthv weieht: Increased tummy fat is a predictor for several diseases
including diabetes and cancer. Weight gain after menopause has been associated with a
higher risk of breast cancer. It is important that you try to achieve your ideal body weight,
which is based on your height and body frame.
Good nutrition: Good healthy eating habits are important for lowering the risks of many
diseases including cancer. Incorporating 5-10 servings of fruits and vegetables per day
should be the basis for your diet (a serving is % cup)- especially recommended are the
dark green leafy and orange vegetables. Blueberries are high in antioxidants which support
the healing processes and help to reduce the risk of cancer and infection. Studies suggest
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that a low-fat diet may be protective against cancer. It will certainly benefit your heart by
reducing the fats in your diet.
Women need to make su~ they are getting enough calcium in their diet by way of dairy
products or supplementation -'especially after menopause. The goal should be 1200 mg.
per day. Vitamin D plays a very important role on how calcium is absorbed, and some
studies show that Vitamin D levels may be low in patients with cancer. Please talk to your
physician about a blood test for Vitamin D if you haven't had one already.
Smokint! Cessation: Smoking and second-hand smoke will delay your healing time and
may have a negative impact on the effectiveness of both chemotherapy and radiation
therapy. It also increases your risk for developing cancer. Advise family and friends not to
smoke around you or when they are in your home or car for your continued recovery and
health.
Alcohol: Consuming 2 alcoholic drinks per day increases your risk of breast cancer by
one-third so try to limit your intake to 4 ounces per day or less. While wine may have
beneficial effects on the heart, you should also keep your intake to an occasional drink.
Stress Manat!ement: It is normal to have feelings of anxiety, depression, and stress. Your
emotions may trigger new physical problems of fatigue, poor sleep, headaches, body aches
and other symptoms. Be sure to secure help and support as needed to handle these feelings
and/or symptoms.
The mind-body connection should be part of your daily routine. Surrounding yourself with
a community of caring family, friends, church or synagogue is part of the healing team.
Joumaling, support groups, massage therapy, yoga, and music are good activities to relieve
these feelings and can also help to heal your spirit. Make time for fun! Laughter, pets and
children can reduce anxiety and improve mood. Laughter really is good medicine!
Please ask for a list of the many on-line resources available to aid you in your healing.
PLEASE DO NOT HESITATE TO MAKE CONTACT WITH
YOUR NURSE NA VIGATOR OR FOLLOW-UP PHYSICIAN IF YOU REQUIRE
ADDITIONAL SUPPORT OR HAVE ANY QUESTIONS AND/OR CONCERNS
REGARDING YOUR ONGOING CARE WITHIN THE
ST. JOHN HEALTH BREAST CARE PROGRAM
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