Implementation of breast cancer survivorship guideline recommendations by primary care providers: N = 82.
| ISSUE OR TOPIC | KEY GUIDELINE RECOMMENDATION | IMPLEMENTS ROUTINELY, N (%) | AWARE OF BUT DOES NOT IMPLEMENT ROUTINELY, N (%) | NOT AWARE, N (%) |
|---|---|---|---|---|
| Mammogram | Recommend annual bilateral mammogram or, in case of unilateral mastectomy, annual mammogram of the contralateral breast | 72 (87.8) | 5 (6.1) | 5 (6.1) |
| Contraception | Hormonal contraceptives are not recommended for women with breast cancer; barrier methods are preferred (condoms, diaphragms, IUD, tubal ligation, or partner vasectomy) | 71 (86.6) | 6 (7.3) | 5 (6.1) |
| Osteoporosis | Postmenopausal or premenopausal survivors with risk factors for osteoporosis, or those taking aromatase inhibitors, should undergo a BMD test (by DEXA scan) at baseline and then every 1–2 y | 55 (67.1) | 13 (15.9) | 14 (17.1) |
| Weight management | Encourage breast cancer survivors to achieve and maintain a healthy weight (BMI 20–25 kg/m2) | 55 (67.1) | 16 (19.5) | 11 (13.4) |
| Nutrition | Encourage breast cancer survivors to obtain needed nutrients through dietary sources; consider supplements only if nutrient deficiency is demonstrated | 53 (64.6) | 14 (17.1) | 15 (18.3) |
| Alcohol consumption | Encourage cancer survivors to limit alcohol consumption to no more than 1 drink/d for women or 2 drink/d for men | 49 (59.8) | 18 (22.0) | 15 (18.3) |
| BSE | Counsel breast cancer survivors to perform monthly BSE and inform them that BSE does not replace mammography as a breast cancer surveillance tool | 42 (51.2) | 15 (18.3) | 25 (30.5) |
| Nonroutine tests | In the absence of clinical findings, the following tests are not recommended for routine follow-up: CBC; liver or kidney function tests; chest x-ray scan; bone scan; liver or abdominal ultrasound; CT scan; FDG-PET scan; breast MRI; testing for breast cancer tumour markers (eg, CA 15-3, CA 27.29, CEA) | 42 (51.2) | 8 (9.8) | 32 (39.0) |
| Vaccines | Encourage the following vaccines, following usual doses and schedules: TIV, pneumococcal (PPSV-23, PCV-13); tetanus, diphtheria, pertussis; and HPV | 40 (48.8) | 12 (14.6) | 30 (36.6) |
| Pain | Consider nonpharmacologic interventions for pain in conjunction with pharmacologic ones: bed, bath, and walking supports; TENS; positioning; energy conservation; acupuncture or acupressure; physical therapy; exercise; psychosocial, behavioural, or interventional procedures | 39 (47.6) | 28 (34.1) | 15 (18.3) |
| Hot flushes | Consider SSRIs or SNRIs to reduce severity of hot flushes; caution must be used when using these agents in conjunction with tamoxifen; gabapentin and clonidine are other options for management of hot flushes | 35 (42.7) | 27 (32.9) | 20 (24.4) |
| Exercise | Recommend weekly exercise: at least 150 min of moderate-intensity activity, strength training, and stretching of major muscle groups and tendons | 34 (41.5) | 20 (24.4) | 28 (34.1) |
| Follow-up | All survivors should have a careful history and physical examination every 3–6 mo for the first 3 y after primary treatment, every 6–12 mo for the next 2 y, then annually | 34 (41.5) | 29 (35.4) | 19 (23.2) |
| Fatigue activity | Recommend engaging in 30 min of moderate-intensity physical activity most days unless contraindicated (eg, fast walking, cycling, swimming, and resistance training) | 31 (37.8) | 25 (30.5) | 26 (31.7) |
| Lymphedema | Strength training has been shown to be safe for survivors with lymphedema and might improve lymphedema symptoms | 27 (32.9) | 19 (23.2) | 36 (43.9) |
| Cognitive dysfunction | Consider instruction in self-management and coping strategies, relaxation, stress management, and routine exercise | 27 (32.9) | 33 (40.2) | 22 (26.8) |
| Gynecologic examination | Women taking tamoxifen should have a gynecologic assessment every 12 mo if uterus present | 26 (31.7) | 22 (26.8) | 34 (41.5) |
| Screening | Screen all survivors periodically to determine needs and interventions for symptoms experienced in the past 4 mo: anxiety and depression; cognitive function; exercise; fatigue; immunizations or infections; pain; sexual function; and sleep disorders | 23 (28.0) | 33 (40.2) | 26 (31.7) |
| Sexual functioning | Ask survivors about their sexual function at regular intervals, including their sexual functioning before cancer treatment, their current activity, and how cancer treatment has affected their sexual functioning and intimacy | 23 (28.0) | 34 (41.5) | 25 (30.5) |
| Distress screening | Screen all survivors for anxiety and depression at transition to survivorship and regular intervals using a 0–10 severity rating scale (0 = no anxiety or depression; 10 = worst you can imagine) or NCCN brief distress screening tool | 12 (14.6) | 27 (32.9) | 43 (52.4) |
| Fatigue screening | Screen all survivors for fatigue at regular intervals using a 0–10 severity rating scale such as ESAS (0 = no fatigue; 10 = worst you can imagine) or have survivors rate their fatigue as none, mild, moderate, or severe | 9 (11.0) | 29 (35.4) | 44 (53.7) |
BMD—bone mineral density, BMI—body mass index, BSE—breast self-examination, CA—cancer antigen, CBC—complete blood count, CEA—carcinoembryonic antigen, CT—computed tomography, DEXA—dual-energy x-ray absorptiometry, ESAS—Edmonton Symptom Assessment System, FDG-PET—fluorodeoxyglucose positron emission tomography, HPV—human papillomavirus, IUD—intrauterine device, MRI—magnetic resonance imaging, NCCN—National Comprehensive Cancer Network, PCV—pneumococcal conjugate vaccine, PPSV—pneumococcal polysaccharide vaccine, SNRI—serotonin-norepinephrine reuptake inhibitor, SSRI—selective serotonin reuptake inhibitor, TENS—transcutaneous electrical nerve stimulation, TIV—trivalent influenza vaccine.