Preparing for the Breast Cancer Paradigm Shift

Though it’s good news that there are more survivors, it’s bad news that we are still without a way to prevent the disease as the incidence continues to rise. Meanwhile, according to a number of studies, new oncologists aren’t increasing at the same rate as new patients. This fact has led many thought leaders to acknowledge that it will no longer be possible or practical for a breast cancer patient, after adjuvant treatment, to be followed by her cancer team for the long term. Usually cancer specialists follow their patients for at least five years and, in some cases, indefinitely. Considering the fact that cancer survivors in this country now number 10.5 million, this practice will have to end; there won’t be enough hours in the day for cancer specialists to see newly diagnosed patients as well as those of us who have completed our treatment and are officially considered survivors. Cancer specialists can’t put 10 pounds of salt (the newly diagnosed as well as the long-term follow-up patients) into the 5-pound bag.

So where will we go? Who will assume the daunting responsibility of ensuring we are being properly monitored for recurrence, development of other related cancers (such as ovarian), menopausal management needs, long-term side effects from chemo and radiation, and in general be our “breast cancer survivor doctor?”

Studies have been conducted and more are under way to look at the clinical outcomes of having primary care physicians (PCPs) rather than cancer specialists follow survivors long term. And the news is not good. A recent study (see page 47) shows screening goes down for cancer survivors who are followed by PCPs instead of cancer specialists. Another study indicated no change in survival for breast cancer patients who had completed initial treatment whether they were followed by a cancer specialist or PCP — data that may make it harder for survivors to have insurance coverage if they continue care under their oncologist.

To add to this challenge, currently 77 percent of women diagnosed with breast cancer are 50 or older and it is projected that approximately 66 percent of the new cases will occur in women younger than 65. This means survivors are not only being diagnosed younger than ever before, but will also be living longer, resulting in the need for oncology monitoring lasting for decades to come.

So where will we go? Who will assume the daunting responsibility of ensuring we are being properly monitored for recurrence … and in general be our “breast cancer survivor doctor?”

Is your PCP, internal medicine doctor, family physician and/or gynecologist ready to care for you once you are one to two years out from treatment? How can we expect these professionals to care for us without the proper training in the needs of breast cancer survivors, clinically and psychologically?

It’s going to be critically important that these doctors and primary care nurses receive the education they need to confidently take care of you, and you need to feel confident in their care and medical advice, too.

Here are a few of the things that healthcare professionals will need to know:

> The signals that the patient may have symptoms of local or distant recurrence

> Menopausal management recognizing that HRT is not an option in most cases

> Recognition and management of long-term side effects caused by chemotherapy, targeted therapy, radiation and hormonal therapy, such as cardiac and pulmonary problems, bone loss and osteoporosis

> The psychological needs of breast cancer survivors, such as depression and cognitive dysfunction, from soon after completing treatment to decades later

> How to assess family risk of breast cancer for the next generation as well as the siblings of the patient

> What drugs can and can’t be given to breast cancer patients who are currently taking or were on specific chemotherapy or hormonal therapy regimens

> Physical changes that will impact the future, such as what vessels were used during breast reconstruction when DIEP flap or S-GAP was performed that may impact how cardiac surgery needs to be performed in the event the survivor develops heart issues

> What blood tests are needed for survivor management

> What diagnostic tools are best to use and when.

More than ever before this issue puts pressure on the survivor to also know the answers to each of these questions, and this starts with every breast cancer survivor creating a survivor plan that details what treatment she or he underwent, which drugs were used, how much

radiation was given, and what happened physically during reconstruction.

So start talking to your PCP and gynecologist. Get to know them better so they can get to know you beyond the scope of care they are accustomed to providing. Soon they will be instrumental in the long-term management of care for breast cancer survivors.

It's certainly no surprise that there are more breast cancer survivors today than ever before. The incidence of breast cancer for 2007 (invasive and ductal carcinoma in situ) surpassed a quarter of a million women (and a few thousand men). But the good news is that more women than ever before are surviving.