With improved breast cancer survival rates, GPs are likely to see such patients in remission, and are in prime position to care for their unique needs. The SingHealth Duke-NUS Breast Centre shares more about the GP's key roles.
With improved breast cancer survival rates, general practitioners (GPs) are likely to see such patients in remission, and are in prime position to care for their unique needs. The SingHealth Duke-NUS Breast Centre shares how GPs can help manage not just these patients’ physical health, but also lifestyle considerations, sexual issues and fertility issues.
INTRODUCTION
Breast cancer is the commonest cancer among women in Singapore.
With improvements in treatment, breast cancer patients now have better survival rates and can live longer. As such, GPs may encounter these patients in the primary care setting, and it is paramount for them to know how to manage this group.
In this article, we highlight some of the pertinent issues that breast cancer survivors could potentially face five years and beyond following their diagnosis and treatment, and how to manage them.
How GPs Can Care for Breast Cancer Patients in Remission for the Past Five Years or Longer
The care of this group of patients can be categorised using the acronym ‘PALS’:
Physical health
Attention to mental health
Lifestyle changes
Sexual/fertility issues
1. Physical health
Surveillance for recurrence
The 10-year recurrence rate was reported as 20.5%, with the majority of recurrences being systemic metastasis.1 It can occur anytime and even years after treatment.
As a result, breast cancer patients undergo lifelong follow-up and are advised to perform monthly breast self-examination. At five years of remission and beyond, these patients are followed up with an annual clinical exam and mammogram.
Recurrence can be systemic and/or locoregional, thus GPs should look out for symptoms suggestive of systemic metastasis and any recent abnormal changes of the ipsilateral breast or chest wall (if a mastectomy without reconstruction was performed), axillary, neck lumps, etc.
In such cases and in cases with abnormal mammogram, patients should be referred to their breast specialist for further evaluation.
Second cancer in contralateral breast
This risk is increased now that breast cancer patients are surviving longer. Should this happen, patients should be referred to their breast specialist for further evaluation.
Side effects
From surgery
This could include ipsilateral arm lymphoedema, chronic breast pain, and so on. The risk of arm lymphoedema is increased after axillary lymph node dissection and/or axillary radiotherapy.
Hence, in this group of patients and in patients with a previous or current history of arm lymphoedema, avoid procedures on the affected arm if possible.
For arm lymphoedema of recent onset, they should be referred to their breast specialist for further evaluation.
From radiotherapy
Most side effects are rare. These may include:
Skin changes with permanent pigmentation and telangiectasia
Fibrosis of the breast causing contraction and firmness
Rib fractures
Nerve damage around the treatment area, resulting in numbness, pain and weakness
Radiation pneumonitis, which can manifest as cough and/or breathlessness, is uncommon. It is diagnosed on CT and requires treatment with steroids.
Other rare but serious side effects include cardiac toxicity manifesting as cardiac failure, if the radiotherapy was given to the left breast and secondary cancers in the treated area.
From chemotherapy
The majority of these side effects tend to be short-term, with most patients likely to recover shortly upon completion of treatment.
However, there are some side effects that can be long-lasting. These may include peripheral neuropathy in the fingers and/or toes from the use of taxane chemotherapy, causing chronic numbness.
Unfortunately, there are not many effective pharmacological treatments available, though medications such as gabapentin may help in those with neuropathic pain.
Vitamin B supplementation is commonly used by many doctors for chemotherapy-induced peripheral neuropathy, but evidence supporting its efficacy is limited.
From endocrine therapy
These drugs include tamoxifen or aromatase inhibitors (such as letrozole, anastrozole or exemestane) and are typically given for five to 10 years.
Tamoxifen
Its side effects may include menopausal symptoms such as hot flushes, weight gain as well as small risks of thromboembolism and endometrial cancer.
Therefore, patients on tamoxifen with abnormal vaginal bleeding should be referred to a gynaecologist for assessment. Avoid selective serotonin reuptake inhibitors (SSRIs) for treatment of depression or hot flushes as they can have drug interactions with tamoxifen.
Aromatase inhibitors
These are commonly associated with arthralgia, especially in the small finger joints, as well as an increased risk of bone loss and osteoporosis.
When on aromatase inhibitors, patients should be on calcium and vitamin D supplementation and regular bone health monitoring with a bone mineral density (BMD) test at one-to-two-year intervals, depending on the patient’s previous BMD result.
If there is decreasing bone mass, the patient can be started on bisphosphonates and given osteoporosis prevention advice. If bisphosphonates are started for the first time, they should be referred for dental clearance first, to minimise the risk of osteonecrosis of the jaw as a side effect.
2. Attention to mental health
Long-term survivors may still face psychological challenges such as anxiety, depression as well as body image issues.2 Hence, do check on the mental well-being of the patient.
Breast cancer support groups and counsellors can help with psychological support. Refer to a psychiatrist if there is concern about the patient’s mental health.
3. Lifestyle changes
Leading a heathy lifestyle
To reduce the risk of recurrence or second breast cancer, and also for the patient’s own health and well-being, patients are advised to lead a healthy lifestyle which includes:
No smoking
Regular exercise of moderate intensity of at least 150 minutes per week
Keeping their body mass index (BMI) in the healthy range of 18.5 to 22.9 kg/m2
No alcohol, or limiting alcohol intake to a glass or less per day
Having a healthy balanced diet
Managing and screening for chronic conditions
Breast cancer survivors are at risk of diseases like hyperlipidaemia, hypertension, diabetes, ischaemic heart disease and stroke.3 This could be due to multiple factors, including baseline factors like obesity as well as factors related to therapy, such as deconditioning and weight gain.
Patients with known medical conditions should be managed accordingly. For patients with no known medical conditions and who are above 40 years old, they should be screened for these chronic medical conditions in line with the national screening guidelines.
For a holistic approach, colorectal cancer screening is recommended in patients aged 50 years and above, whereas cervical cancer screening is recommended for women aged 25 to 69 years who have had sexual intercourse.
4. Sexual/fertility issues
Breast cancer survivors with prior chemotherapy may experience early menopause with decreased sexual desire, and symptoms of vaginal atrophy such as vaginal dryness.
Vaginal atrophy
In patients with troubling vaginal atrophy symptoms, vaginal moisturisers and vaginal lubricants could be used during sexual intercourse. Such non-oestrogen-based topicals should be explored first, though vaginal oestrogen-based cream is generally considered safe but should be used sparingly.
Systemic hormone replacement therapy is strictly contraindicated. Patients with no improvement of symptoms can be referred to a gynaecologist for further management.
Fertility issues
Fertility could be affected by chemotherapy. This issue would usually have been addressed prior to the start of chemotherapy, particularly in patients of child-bearing potential.
Having a prior diagnosis of breast cancer is not a contraindication to pregnancy, provided the patient is no longer on endocrine therapy. However, it is crucial that any decision on cessation of endocrine therapy and timing of pregnancy be discussed with the oncologist.
CONCLUSION
In conclusion, while breast cancer patients could now live longer with advances in treatment, it is paramount that they also retain their quality of life. This group of patients has unique needs, and a holistic approach using the acronym ‘PALS’ could be used in their management.
REFERENCES
van Maaren MC, de Munck L, Strobbe LJA et al. Ten-year recurrence rates for breast cancer subtypes in the Netherlands: A large population-based study. Int J Cancer. 2019;144:263-272.
Carreira H, Williams R, Müller M et al. Associations Between Breast Cancer Survivorship and Adverse Mental Health Outcomes: A Systematic Review. J Natl Cancer Inst. 2018;110:1311-1327.
Bradshaw PT, Stevens J, Khankari N et al. Cardiovascular Disease Mortality Among Breast Cancer Survivors. Epidemiology. 2016;27:6-13.
Clin Assoc Prof Lim Geok Hoon
Service Chief & Senior Consultant, SingHealth Duke-NUS Breast Centre;
Head & Senior Consultant, KK Breast Department, KK Women’s and Children’s Hospital
Clinical Associate Professor Lim Geok Hoon is the Head of the KK Breast Department at KK Women’s and Children’s Hospital. She pioneered the minimal scar mastectomy technique suited for Asian women and developed the first virtual simulator for teaching oncoplastic surgery. She firmly believes in providing holistic care for breast cancer survivors.
Asst Prof Ng Chee Hui Raymond
Senior Consultant, Division of Medical Oncology, National Cancer Centre Singapore;
Visiting Consultant, KK Breast Department, KK Women’s and Children’s Hospital
Assistant Professor Ng Chee Hui Raymond is a Senior Consultant with the breast oncology team at the National Cancer Centre Singapore. He completed a Master’s in Public Health from the National University of Singapore in 2010. Prof Ng is passionate about medical education and spends part of his time every week lecturing and mentoring medical students at the university.
Clin Assoc Prof Rukshini Puvanendran
Head & Senior Consultant, Family Medicine Service;
Co-Lead, KK Menopause Centre, KK Women’s and Children’s Hospital
Clinical Associate Professor Rukshini Puvanendran is the Head and Senior Consultant in the Family Medicine Service at KK Women’s and Children’s Hospital. Her interests are in mid-life women’s health and women’s cancer survivorship.
Clin Asst Prof Lim Wei Tching Faye Lynnette
Senior Consultant, Division of Radiation Oncology, National Cancer Centre Singapore
Clinical Assistant Professor Lim Wei Tching Faye Lynnette is a senior radiation oncologist practicing at the National Cancer Centre Singapore. She has a special interest in the treatment of young women with breast cancer, as well as proton therapy and its utility in advanced breast cancer. She has extensive experience in the treatment of complex breast cancers.
GPs can call the SingHealth Duke-NUS Breast Centre for appointments at the following hotlines or click here to visit the website:
Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000
KK Women’s and Children’s Hospital: 6692 2984
National Cancer Centre Singapore: 6436 8288
