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Summary Guidelines
These guidelines aim to streamline follow up care. They are not a mandatory protocol. These guidelines may be varied in accordance with patient or clinician preferences, clinical indications, geography and convenience. If the patient is on a clinical trial the trial protocol will supersede these guidelines. Follow Up Frequency
very low risk breast cancer patients can be given the option of follow up low-moderate risk breast cancer patients can be given the option of follow Patients in remission may be discharged to the GP for further ongoing follow-up. Beyond Yr 5
Assessment at Follow Up Visits
At each visit ask about new lumps, bone pain, chest pain, dyspnoea, Medical History abdominal pain and persistent headaches. If post-menopausal and
taking Tamoxifen, ask about vaginal bleeding.
Including breasts, regional lymph nodes and chest wall, as well as lungs Physical
and abdomen if indicated. The arms should be examined for Examination
3-6 months after radiotherapy or 1 year after initial mammogram that led to diagnosis, then annually.
Mammogram
Ultrasound
Other Imaging Only if clinically indicated
Blood Tests
Only if clinically indicated
Genetic Testing
Criteria for a referral to a Familial Cancer Centre for genetic counseling and possible testing include: • age <40 years at time of diagnosis • history of ovarian cancer at any age in the patient or any first- or second-degree relatives • any first degree relative with a history of breast cancer diagnosed before age 50 years • two or more first- or second-degree relatives diagnosed with breast cancer at any age • patient or relative with a diagnosis of bilateral breast cancer • history of breast cancer in a male relative • member of a family in which the presence of a high risk breast cancer gene mutation has been • one first or second degree relative diagnosed with breast cancer at age 45 or younger plus another relative on the same side of the family with sarcoma at age 45 or younger • breast cancer pathology suggestive of a high risk breast cancer gene mutation Other Points
The guidelines will be reviewed every 12 months at the Breast Tumour Group meetings, to alter the Please visit the WCMICS website to see a copy of the comprehensive guideline with more specific advice Note: This is not the final format of the guidelines. Lead Clinicians at each hospital will be consulted as to the best format and method of disseminating these guidelines within their institutions. _____________________________________________________________________________________________________ WCMICS – Development of guidelines for consistent breast cancer follow-up, including timelines for discharge back the General GP WCMICS BREAST CANCER FOLLOW-UP GUIDELINES
(COMPREHENSIVE VERSION)
Frequency: Every 3-6 months for the first 2 years after primary therapy; every 6-
12 months for years 3 to 5; annually thereafter. There is no compelling evidence to support any particular frequency of visits. No benefit has been demonstrated from more frequent visits compared to a schedule of one visit every 1-2 years. In fact, a majority of patients express a preference for reducing rather than increasing the • History & physical examination: All visits should include a medical history.
Symptoms of recurrence including new lumps, bone pain, chest pain, dyspnoea, abdominal pain, or persistent headaches should be sought.2 For post-menopausal women taking Tamoxifen, it is important to ask about vaginal bleeding. Physical examination should include breasts, regional lymph nodes, and chest wall, as well as lungs and abdomen if indicated. The arms should be examined for lymphoedema.3 Mammography: First post-treatment mammogram should be performed at 3-6
months after completion of radiotherapy in breast conserving therapy, or 1 year after the initial mammogram that lead to the diagnosis in patients treated with mastectomy. Subsequent mammograms should be performed annually. Ultrasonography should be used as an adjunct to mammography as indicated.4,5 In women in whom the initial breast cancer was not visible on mammography or ultrasound, annual breast MRI may be considered in addition to the conventional imaging, although data are currently lacking to support this view. • Routine imaging studies and blood tests: These should not be performed for the
purpose of detecting distant metastases, as there is no evidence that early treatment of metastatic disease improves survival.6,7,8,9,10 Routine blood tests such as FBE and LFTs are not recommended. Tumour markers including CA 15-3, CA 27.29 and CEA are also not recommended.11 Imaging studies including CXR, bone scans, liver ultrasound, CT scans, PET scans and breast MRI should also not be performed routinely. Routine transvaginal ultrasonography in asymptomatic women taking tamoxifen is not recommended as the false positive rate may be as high as 20%. Unnecessary staging studies result in patient anxiety, the need for additional tests including potential invasive procedures, and increased costs.12 • Patient education regarding symptoms or recurrence: More than half of breast
cancer recurrences are symptomatic and found between scheduled follow-up visits.13 Physicians should counsel patients about the symptoms of recurrence including new lumps, bone pain, chest pain, abdominal pain, dyspnoea, persistent headaches or mastectomy scar changes. Patients should be encouraged to report new, persistent symptoms promptly, without waiting for the next scheduled appointment. Breast awareness and Breast self-examination (BSE): In keeping with the
current recommendations from The Cancer Council Victoria and the National Breast and Ovarian Cancer Centre (NBOCC), all women should be encouraged to be ‘breast aware’. Women should be provided with education and support to become familiar with the normal appearance and feeling of their breasts at different times; the aim is to be able to notice any unusual changes that could be a sign of a new breast cancer. Women should be instructed to see their doctor if they notice any of the following changes that are new or different: a lump or lumpy area, thickening of the breast tissue, discharge from the nipple, skin dimpling/discoloration, an inverted nipple, a painful area, change in shape of the breast, or anything that is not ‘usual’. For women treated for breast cancer, there are no randomized data examining the effect of BSE in conjunction with regular surveillance mammography. It has no survival benefit as a screening manoeuvre in the absence of mammography for women without breast cancer. Women who choose to practice BSE should be informed that its efficacy is unproven and that it may increase their chances of having a benign breast biopsy.14 _____________________________________________________________________________________________________ WCMICS – Development of guidelines for consistent breast cancer follow-up, including timelines for discharge back the General GP
Referral for genetic counselling: Criteria for referral for genetic counselling are
outlined in the NBOCC publication “Advice About Familial Aspects of Breast Cancer and Epithelial Ovarian Cancer” and include: (i) age <40 years at time of diagnosis, (ii) Ashkenazi Jewish heritage, (iii) history of ovarian cancer at any age in the patient or any first- or second-degree relatives, (iv) any first degree relative with a history of breast cancer diagnosed before age 50 years, (v) two or more first- or second-degree relatives diagnosed with breast cancer at any age, (vi) patient or relative with a diagnosis of bilateral breast cancer, (vii) history of breast cancer in a male relative.15 Clinical trials: Participation in clinical trials should be encouraged and facilitated.
Physicians treating patients with breast cancer should be aware of currently available trials, and patients should be given the opportunity to participate in them. Co-ordination of care: With the involvement of various specialists as well as the
General Practitioner (GP) and Breast Care Nurse (BCN) in the treatment of an individual patient, it is important that follow-up be co-ordinated to ensure patients are not subjected to an excessive number of visits. Ideally, at the completion of each patient’s primary treatment (including surgery, chemotherapy and radiotherapy, but not endocrine therapy), there should be an “end of treatment review” in a multidisciplinary setting and an individualized follow-up schedule tailored. This would enable individual patient’s follow-up needs to be taken into consideration including recurrence risk based on pathology, whether radiotherapy was performed, type of endocrine therapy, and co-morbidities. The discipline to see the patient at each visit (surgery, medical oncology, radiation oncology) will be determined and documented and this should avoid duplication of visits.16 The BCN should be available to provide • Transfer of Care to General Practitioner: Follow-up by GPs is acceptable to many
patients and GPs.17 Follow-up by a GP leads to the same outcomes (time to diagnosis of recurrence and health-related quality of life) as follow-up with a specialist.18,19 One study has revealed a greater level of satisfaction amongst patients having GP follow-up compared to specialist follow-up.20 If agreeable, after 5-years of specialist follow-up women with breast cancer in remission should be discharged to the patient’s GP for further ongoing follow-up. When care is transferred to the GP, both the GP and the patient should be informed of the appropriate follow-up and management strategy. If a patient with low-risk early-stage breast cancer desires follow-up exclusively with a GP, care may be transferred to the GP approximately 1 year after diagnosis.2 A shared-care model that integrates specialist and GP follow- up is also possible. This would be taken into consideration at the “end of treatment review” with the GP being included in the follow-up schedule. The level of shared follow-up provided by the specialist and GP would depend on patient and provider preferences. A written treatment summary information and plan of follow-up would be provided to both the patient and GP. Communication: Communication between all members of the team must be ensured
to avoid duplication of visits and tests. All involved clinicians should be informed of each others’ activities. It is essential that the patient’s current GP is kept informed of the outcome of visits and of any investigations undertaken, preferably with a letter after each follow-up visit. When GPs take primary responsibility for follow-up care, knowledge of new treatments (e.g. the benefits of extended hormonal therapy with an aromatase inhibitor after tamoxifen) is needed. Methods for disseminating new knowledge are essential. When GPs assume responsibility for follow-up, contact should be maintained with the treating specialists. Mechanisms should exist for a speedy re-referral appointment. When discussing follow-up with breast cancer patients, they should be provided with complete and accurate information about the goals, expectations, and limitations of the follow-up program. _____________________________________________________________________________________________________ WCMICS – Development of guidelines for consistent breast cancer follow-up, including timelines for discharge back the General GP Special Issues
The following special topics of concern to breast cancer survivors should be addressed during follow-up. • Hot flushes: Oestrogen therapy, although highly effective, is generally
contraindicated, especially if the woman had an oestrogen-receptor-positive tumour. Certain selective serotonin-reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), citaloprim (Cipramil) and paroxetine (Aropax), the selective serotonin- and norepinephrine-reuptake inhibitor (SNRI) venlafaxine (Efexor), as well as the anticonvulsant gabapentin (Neurontin), reduce the frequency and severity of hot flushes by approximately 50%. Paroxetine should not be used with tamoxifen as it • Sexual dysfunction: Offer sexual counselling if due to altered body image. If due
to treatment induced menopause try nonhormonal vaginal moisturizing or lubricating preparations. Intravaginal oestrogen preparations should be used with caution and after careful discussion of risks and benefits with the patient, especially in women with oestrogen-receptor-positive breast cancer who are taking aromatase inhibitors. • Cognitive dysfuntion: Transient decline in cognitive function is associated with
adjuvant therapy, particularly chemotherapy22,23 and possibly endocrine therapy, although this is less well documented. No therapy is proven effective. Women should be reassured that therapy-associated cognitive symptoms are rarely progressive. Assess and treat patients with emotional distress as this may be the underlying cause of subjective complaints of impaired cognitive functioning. • Depression/Anxiety: Usually a response to the diagnosis and its associated
treatment. Patients should be actively monitored during follow-up for signs and symptoms of depression and anxiety. Management with counselling, antidepressants and anxiolytics as required. • Fatigue: May affect approximately one-quarter to one-third of breast cancer
survivors but its mechanisms remain unclear.24 Patients should be specifically asked about symptoms of fatigue. Physiologic causes (anaemia, hypothyroidism) should be investigated and ruled out. Depression and pain are potentially treatable underlying • Weight management: Weight gain is a common problem for breast cancer
survivors. Weight gain has been associated with receipt of adjuvant chemotherapy and onset of menopause26, but not with tamoxifen or aromatase inhibitors. In addition to the negative impact on health-related quality of life and weight-related illnesses, obesity and weight gain after diagnosis is associated with higher rates of breast cancer recurrence and mortality.3,27 Weight management should be discussed with all breast cancer survivors, and overweight patients should be encouraged to participate in evidence-based weight-management programs. • Bone Health: Women with a history of breast cancer may be at increased risk of
osteoporosis and fractures because of loss of bone mineral density owing to premature ovarian failure from chemotherapy or to aromatase inhibitors used as adjuvant therapy.28,29,30,31 Patients who are postmenopausal or premenopausal with risk factors for osteoporosis (lean body habitus, smoking, family history of osteoporotic fracture) should undergo a screening bone mineral density test. Women taking aromatase inhibitors should have a baseline bone mineral density test and then be monitored closely for the development of osteoporosis. There is no clear evidence regarding the frequency of bone mineral density monitoring in these patients, however, an annual bone mineral density test is recommended.32 Women who are osteoporotic should have underlying causes excluded by checking calcium and vitamin D levels. These women at increased risk should be counselled regarding weight-bearing exercise, avoidance of smoking, adequate calcium (1200-1500mg daily) and vitamin D (400-800 IU daily) intake. Bisphosphonate therapy should be considered if osteoporosis is present. Raloxifene is not recommended for use in women with a history of breast cancer. _____________________________________________________________________________________________________ WCMICS – Development of guidelines for consistent breast cancer follow-up, including timelines for discharge back the General GP • Arthralgias and myalgias: Related most commonly to treatment with aromatase
inhibitors, but occasionally seen with tamoxifen therapy. Exclude features suggestive of metastatic bone disease (such as persistent and progressively more severe long bone or back pain) which would warrant imaging. Treat conservatively with reassurance, paracetamol and NSAIDs. • Pregnancy: Women considering pregnancy following a diagnosis of breast cancer
should be informed of the limited data on the effect of pregnancy on outcomes such as breast cancer recurrence and survival. Most of the studies have been retrospective case series or case-control studies with small numbers of patients.33,34,35 Nevertheless, there is currently no evidence that subsequent pregnancy adversely affects survival.
References

1. Gulliford T, Opomu M, Wilson E, Hanham I, Epstein R. Popularity of less frequent follow up for breast cancer in randomised study: initial findings from the hotline study. BMJ 1997; 314: 174-177. 2. Khatcheressian JL, Wolff AC, Smith TJ, Grunfeld E, Muss HB, Vogel VG, Halberg F, Somerfield MR, Davidson NE. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 2006; 24: 5091-5097. 3. Grunfeld E, Dhesy-Thind S, Levine M. Clinical practice guidelines for the care and treatment of breast cancer: follow-up after treatment for breast cancer (summary of the 2005 update). CMAJ 2005; 172: 1319-1320. 4. NHMRC, National Breast Cancer Centre. Clinical practice guidelines for the management of early breast cancer. 2001. 5. Grunfeld E, Noorani H, McGahan L, Paszat L, Coyle D, van Walraven C, Joyce J, Sawka C. Surveillance mammography after treatment of primary breast cancer: a systematic review. The Breast 2002; 11: 228-235. 6. Roselli del Turco M, Palli D, Cariddi A, Ciatto S, Pacini P, Distante V. Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer Follow-Up. JAMA 1994; 271: 7. Palli D, Russo A, Saieva C, Ciatto S, Rosselli del Turco M, Distante V, Pacini P. Intensive versus clinical follow-up after treatment of primary breast cancer: 10-year update of a randomized trial. National Research Council Project on Breast Cancer Follow-Up [letter]. JAMA 1999; 281: 1586. 8. The GIVIO Investigators. Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. A multicenter randomized controlled trial. 9. Schapira DV, Urban N. A minimalist policy for breast cancer surveillance. JAMA 10. Rojas MP, Telaro E, Russo A, Moschetti I, Coe L, Fossati R, Palli D, Roselli del Turco M, Liberati A. Follow-up strategies for women treated for early breast cancer. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD001768. DOI: 10.1002/14651858.CD001768.pub2. 11. Harris L, Fritsche H, Mennel R, Norton L, Ravdin P, Taube S, Somerfield MR, Hayes DF, Bast Jr RC. American Society of Clinical Oncology 2007 update of recommendations for the use of tumor markers in breast cancer. J Clin Oncol 2007; 25: 5287-5312. 12. Tolaney SM, Winer EP. Follow-up care of patients with breast cancer. The Breast 13. De Bock GH, Bonnema J, van Der Hage J, Kievit J, van de Velde CLH. Effectiveness of routine visits and routine tests in detecting isolated locoregional recurrences after treatment for early-stage invasive breast cancer: a meta-analysis and systematic review. J Clin Oncol 2004; 19: 4010-4018. 14. Thomas DB, Gao DL, Ray RM, Wang WW, Allison CJ, Chen FL, Porter P, Hu YW, Zhao GL, Pan LD, Li W, Wu C, Coriaty Z, Evans I, Lin MG, Stalsberg H, Self SG. _____________________________________________________________________________________________________ WCMICS – Development of guidelines for consistent breast cancer follow-up, including timelines for discharge back the General GP Randomized trial of breast self-examination in Shanghai: Final results. J Natl Cancer Inst 2002; 94: 1445-1457. 15. National Comprehensive Cancer Network. Genetic/Familial High-Risk assessment: Breast and Ovarian. Clinical practice guidelines in oncology, V.1.2007. (Available at 16. Breast Service, Peter MacCallum Cancer Centre. Follow-up after treatment for early- stage breast cancer. Breast Service Management Protocols. 2007. 17. Grunfeld E, Mant D, Vessey MP, Yudkin P. Evaluating primary care follow-up of breast cancer: methods and preliminary results of three studies. Ann Oncol 1995; 6 Suppl 18. Grunfeld E, Mant D, Yudkin P, Adewuyi-Dalton R, Cole D, Stewart J, Fitzpatrick R, Vessey M. Routine follow-up of breast cancer in primary care: randomised trial. BMJ 19. Grunfeld E, Levine MN, Julian JA, Coyle D, Szechtman B, Mirsky D, Verma S, Dent S, Sawka C, Pritchard KI, Ginsburg D, Wood M, Whelan T. Randomized trial of long-term follow-up for early-stage breast cancer: A comparison of family physician versus specialist care. J Clin Oncol 2006; 24: 848-855. 20. Grunfeld E, Fitzpatrick R, Mant D, Yudkin P, Adewuyi-Dalton R, Stewart J, Cole D, Vessey M. Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist care: results from a randomized controlled trial. Br J Gen Pract 1999; 49: 705-710. 21. Hayes DF. Follow-up of patients with early breast cancer. NEJM 2007; 356: 2505- 22. Brezden CB, Phillips KA, Abdolell M, Bunston T, Tannock IF. Cognitive function in breast cancer patients receiving adjuvant chemotherapy. J Clin Oncol 2000; 18: 23. Ahles TA, Saykin AJ, Furstenberg CT, Cole B, Mott LA, Skalla K, Whedon MB, Bivens S, Mitchell T, Greenberg ER, Siberfarb PM. Neuropsychologic impact of standard-dose systemic chemotherapy in long-term survivors of breast cancer and lymphoma. J Clin Oncol 2002; 20: 485-493. 24. Tchen N, Juffs HG, Downie FP, Yi Q-L, Hu H, Chemerynsky I, Clemons M, Crump M, Goss PE, Warr D, Tweedale ME, Tannock IF. Cognitive function, fatigue, and menopausal symptoms in women receiving adjuvant chemotherapy for breast cancer. J Clin Oncol 2003; 21: 4175-4183. 25. Bower JE, Ganz PA, Desmond KA, Rowland JH, Meyerowitz BE, Belin TR. Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin 26. Goodwin PJ, Ennis M, Pritchard KI, McCready D, Koo J, Sidlofsky S, Trudeau M, Hood N, Redwood S. Adjuvant treatment and onset of menopause predict weight gain after breast cancer diagnosis. J Clin Oncol 1999; 17: 120-129. 27. Kroenke CH, Chen WY, Rosner B, Holmes MD. Weight, weight gain, and survival after breast cancer diagnosis. J Clin Oncol 2005; 23: 1370-1378. 28. Goss PE, Ingle JN, Martino S, Robert NJ, Muss HB, Piccart MJ, Castiglione M, Tu D, Shepherd LE, Pritchard KI, Livingston RB, Davidson NE, Norton L, Perez EA, Abrams JS, Therasse P, Palmer MJ, Pater JL. A randomized trial of letrozole on postmenopausal women after five years of tamoxifen therapy for early-stage breast cancer. NEJM 2003; 349: 1793-1802. 29. The ATAC (Arimidex, Tamoxifen, Alone or in Combination) Trialists’ Group. Anastrazole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: first results of the ATAC randomised trail. Lancet 2002; 359: 2131-2139. 30. The ATAC Trialists’ Group. Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years’ adjuvant treatment for breast cancer. Lancet 2005; 365: 60-62. 31. Coombes RC, Hall E, Gibson LJ, Paridaens R, et al. A randomized trial of exemestane after two to three years of tamoxifen therapy in postmenopausal women with primary breast cancer. NEJM 2004; 350: 1081-1092. _____________________________________________________________________________________________________ WCMICS – Development of guidelines for consistent breast cancer follow-up, including timelines for discharge back the General GP 32. Hillner BE, Ingle JN, Chlebowski RT, Gralow J, Yee GC, Janjan NA, Cauley JA, Blumenstein BA, Albain KS, Lipton A, Brown S. American Society of Clinical Oncology 2003 update on the role of bisphosphonates and bone health issues in women with breast cancer. J Clin Oncol 2003; 21: 4042-4057. 33. Velentgas P, Daling JR, Malone KE, Weiss NS, Williams MA, Self SG, Mueller BA. Pregnancy after breast cancer – outcomes and influence on mortality. Cancer 1999; 85: 2424-2432. 34. Gelber S, Coates AS, Goldhirsch A, Castiglione-Gertsch M, Marini G, Lindtner J, Edelmann DZ, Gudgeon A, Harvey V, Gelber RD for the International Breast Cancer Study Group. Effect of pregnancy on overall survival after the diagnosis of early-stage breast cancer. J Clin Oncol 2001; 19: 1671-1675. 35. Mueller BA, Simon MS, Deapen D, Kamineni A, Malone KE, Daling JR. Childbearing and survival after breast carcinoma in young women. Cancer 2003; 98: 1131-1140. _____________________________________________________________________________________________________ WCMICS – Development of guidelines for consistent breast cancer follow-up, including timelines for discharge back the General GP

Source: http://www.wcmics.org/docs/BreastCancerFollowUpGuidelines.pdf

Doi:10.1016/j.jalz.2009.05.027

Alzheimer’s Imaging Consortium IC-P: Poster PresentationsBackground: Rosiglitazone, a peroxisome proliferator-activated receptorcopy. Because of their high iron content, plaques typically appear as hypo-[gamma] (PPAR[gamma]) agonist, has an anti-inflammatory effect in theintense spots on T2-weighted scans. One of the challenges in imagingbrain, decreasing interleukin-1[beta] concentration

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