Improving Cancer Survivorship: Embedding Tailored, Comprehensive Survivorship Care in the Breast Oncology Clinic

By Ann Partridge, MD, MPH, and Sandy Truong, Harvard Medical School student
 
Published Online: Wednesday, July 10, 2013
Dana-Farber Cancer Institute Dr. Ann Partridge
Ann Partridge, MD, MPH

Sandy Truong
Sandy Truong
 
Dana-Farber Cancer Institute
Boston, Massachusetts Strategic Partnerships
Optimal cancer survivorship care involves addressing a patient’s physical and psychosocial concerns during the period of time from diagnosis through the balance of life. Conventionally, for patients with early-stage breast cancer, the survivorship period is usually considered the time after initial active therapy (surgery, chemotherapy, radiation therapy). While many patients will remain on chronic endocrine therapy, it is during this time that patients are trying to recover from the acute toxicities of treatment, adjust to their “new normal,” and grapple with their futures.

Providers can help patients with breast cancer during this period of adjustment and beyond by attending to both individual patient concerns and problems as well as providing comprehensive survivorship-focused care, including: (1) surveillance, screening, and prevention of recurrent and new cancers, including screening for genetic risks, if appropriate; (2) counseling and referrals to improve modifiable health behaviors; (3) identification, counseling, and management of late and long-term effects of cancer and cancer treatment; and (4) coordination of care between providers to prevent gaps in noncancer care and avoid redundant or unnecessary care.

In the 2005 landmark report From Cancer Patient to Cancer Survivor: Lost in Transition, the Institute of Medicine recommended improving comprehensive survivorship care and that all survivors receive a care plan to map their survivorship care.1 However, our group and others have shown that there is substantial heterogeneity in survivorship care, and there has been only limited uptake and implementation of survivorship care plans.2,3

To improve the delivery of this comprehensive care approach to all breast cancer survivors, the Dana-Farber Cancer Institute’s Adult Survivorship Program has developed and launched a novel Embedded Survivorship Program in the Breast Oncology Clinic. All patients who are completing active treatment are scheduled for a survivorship visit with one of their providers in early follow-up.

At that visit, a treatment summary and survivorship care plan is generated for the patient in the electronic medical record. Working from a survivorship care plan template, patients are counseled based on evidence- and consensus-based guidelines we have created regarding their disease risks, future breast cancer screening and follow-up recommendations, primary care and gynecologic care recommendations, management of potential long-term and late effects, and optimal health behaviors after breast cancer. This process is providing a framework to our providers to deliver comprehensive survivorship counseling and care to all breast cancer patients early in the course of their survivorship.

Table. Issues to Address in Breast Cancer Survivorship

  • Providers needed and visit frequency
  • Screening of remaining breast tissue
  • Counseling regarding when to call and symptoms to watch for and lack of benefit for screening for metastatic disease for women with early breast cancer
  • Sexual functioning and menopausal symptoms
  • Genetic counseling
  • Bone health
  • Adherence with hormonal therapy
  • Health behaviors: weight, diet, exercise, smoking cessation, alcohol moderation
  • Fertility and contraception
  • Psychosocial health, fear of recurrence
  • Gynecologic care
  • Primary care physician follow-up care
  • Other specific issues tailored to patient (eg, cognitive concerns, lymphedema)
The Table on the left outlines the major issues that are addressed with patients during the survivorship visit. Of utmost concern, breast cancer survivors are at risk for locoregional or distant disease recurrence and new primary disease. To reduce rates of recurrence and breast cancer mortality, evidence- based guidelines recommend regular history and physical exam and surveillance mammography during follow-up care. Providers should promote continuation of chronic treatment (eg, adjuvant endocrine therapy) and lifestyle modifications to improve general health and reduce risk for cancer. Lifestyle factors, such as diet, alcohol consumption, weight and weight gain, physical activity, and smoking have all been found to be associated with risk of developing breast cancer and with prognosis after a diagnosis. Appropriate patient education and counseling, as well as facilitating referrals, may help patients to have improved quality of life with less fatigue, and possibly decrease risk of breast cancer recurrence and improve survival. Additionally, breast cancer survivors may be at increased risk of heart disease, diabetes, and osteoporosis, all of which benefit from improved health behaviors.

Online CME Activities
Free CME from PER
Community Practice Connections: 13th Annual International Congress on the Future of Breast Cancer®
Highlights From the 13th Annual International Congress on the Future of Breast Cancer®
Pancreatic Cancer: Novel and Emerging Approaches to Early Detection and Treatment
Oncology Best Practice: Challenges in Treating Chronic Lymphocytic Leukemia – The Older Patient and Comorbid Conditions
More Reading
$auto_registration$