Late and Long‐Term Effects of Breast Cancer Treatment and Surveillance Management for the General Practitioner

ObjectiveTo examine the most common long‐term and late effects of breast cancer treatment, the American Society of Clinical Oncology guidelines for surveillance, and recommendations for the primary care provider's role in delivering breast cancer survivorship care.Data SourcesA comprehensive literature review was conducted using CINAHL, PubMed, Google Scholar, and hand searches using the search terms breast cancer, survivor, and long‐term or late effects.Study SelectionArticles published in English from 2002 to 2012 that addressed the long‐term or late effects of adults with breast cancer were included.Data ExtractionFindings are discussed categorically, including the most common late and long‐term psychosocial effects from relevant studies.Data SynthesisTopics relevant to survivors included challenges to psychosocial, emotional, and cognitive well‐being; satisfaction with life; sexuality; body image; anxiety; fear of recurrence and post‐traumatic stress disorder; depression; cognitive dysfunction challenges to physical well‐being; adverse cardiovascular events; fatigue; lymphedema; musculoskeletal symptoms; accelerated bone loss and fractures; pain; skin changes due to radiation; disease recurrence; and new breast cancers.ConclusionsWith earlier detection methods and improvements in treatment options making breast cancer a highly survivable disease, there are more survivors of breast cancer than ever. The clinicians’ role in survivorship care is more important than ever to manage the potential long‐term and late effects of treatment, physical and emotional well‐being, and recurrent disease surveillance. However, the clinician's role in cancer follow‐up care is often poorly defined leading to a lack of awareness about the needs of survivors of breast cancer, suboptimal communication between providers and survivors, and an overall deficiency in quality care.     

Breast cancer during pregnancy

The terms gestational breast cancer (GBC) and pregnancy-associated breast cancer are given to breast cancer that occurs during pregnancy and up to one year post-partum. It is an uncommon event, and for even the most experienced clinician, whether oncologist, obstetrician or primary health worker, the complex issues that surround a diagnosis of breast cancer during pregnancy make management difficult. The prognosis overall for women diagnosed with GBC is poor, possibly due to delays in diagnosis. Primary physicians and obstetricians can play an important role in the early detection of GBC by promoting breast awareness in premenopausal women, including women who are pregnant or lactating; and by undertaking prompt and appropriate referral of pregnant and lactating women with breast abnormalities. Even in pregnant or lactating women, clinicians should always investigate a breast abnormality using triple assessment--clinical assessment, imaging and tissue biopsy. Breast cancer during pregnancy requires a multidisciplinary approach to ensure optimal care for both the mother and the baby. Breast cancer management can be adapted to protect the fetus, but this will be dependent on the gestation and disease status at diagnosis. Pregnancy after breast cancer does not appear to affect either cancer prognosis or pregnancy outcome. Obstetricians have a vital role to play in the care of these women by supporting them through their pregnancy, providing reassurance of fetal health and maintaining good communication with their other health providers.     

Gynecologic care for breast cancer survivors: assisting in the transition to wellness

Currently, there are >2 million survivors of breast cancer in the United States. Two years after cancer treatment, patients may transition to primary care providers and/or gynecologists. Many of these survivors may have difficulties with menopausal symptoms. If they do not know already, some of these women may want or need risk assessment for hereditary- or treatment-induced second cancers. At least 20% will also have significant psychologic, sexual, and/or relationship difficulties that require attention. All of the women will need assistance to learn and follow recommendations for surveillance, detecting recurrence, and promoting wellness. Thus, gynecologists play a critical role in helping these patients in their health care transitions. To assist the gynecologists, we have reviewed the evaluation and management of common sequelae of breast cancer diagnoses and treatments.     

Barriers to Cervical Cancer Screening and Follow‐up Care among Black Women in Massachusetts

ObjectiveTo explore factors that might lead to delays in appropriate cervical cancer screening and diagnosis among Black women in Massachusetts.DesignQualitative using focus groups.SettingHospitals, health centers, and community‐based organizations in Boston, Massachusetts.ParticipantsSixty‐four participants including Black, non‐Hispanic women from the general population and cervical cancer survivors, community leaders in women's health, and health care providers.MethodsSix focus groups. Data were analyzed using methods based on grounded theory.ResultsFindings from interviews revealed that inadequate information and education of providers and patients create barriers to appropriate screening and treatment practices for Black women. Fear, cultural beliefs, and compounding factors related to poverty, gender roles, and health system barriers create delays to screening and follow‐up care. Also, unconscious bias, therapeutic delays, and miscommunication are important factors affecting continuity of care.ConclusionThese results suggest a need for comprehensive, culturally specific cervical cancer prevention education initiatives and interventions for Black women and strategies to improve patient–provider relationships.     

Long‐Term Effects of Breast Cancer Surgery,Treatment, and Survivor Care

Women are increasingly surviving breast cancer, but up to 90% experience unexpected long‐term sequelae as a result of treatment. Symptoms may include physical, functional, emotional, and psychosocial changes that can dramatically alter the quality of life for breast cancer survivors. Primary care clinicians, including midwives, are likely to care for these women and should be familiar with common symptoms, treatment, and best practices to avoid permanent dysfunction. A holistic approach to assessment, treatment, and referral as needed is the most effective strategy. Although women experience significant changes after breast cancer treatment, many fail to receive thorough assessment of their symptoms, education about interventions, and treatment options to optimize health promoting strategies. Disparities exist in treatment availability, options, and survivorship. Long‐term physical changes include anatomic changes, chronic pain, phantom breast pain, axillary web syndrome, and lymphedema. In addition, women may have decreased strength, aerobic capacity, mobility, fatigue, and cognitive dysfunction. Emotional and psychosocial changes include depression, anxiety, fatigue, concerns about body image, and issues with sexuality. Treatment should be multifactorial based on thorough assessment of symptoms and can include medication, exercise, counseling, physical and occupational therapy, and alternative and complementary therapies. Primary care and gynecologic clinicians are well positioned to provide thorough evaluation, education, treatment, and referral for the most common sequelae of mastectomy and breast cancer treatments.     

Addressing Female Sexual Function after Cancer by Internists and Primary Care Providers

IntroductionThere are now almost 14 million cancer survivors in the United States, and for the majority of survivors, the bulk of post‐cancer medical care is provided by community primary care providers (PCPs). Sexual dysfunction is one of the most common and distressing quality of life issues facing female cancer survivors yet it has become increasingly evident that women's cancer‐related sexual dysfunction often goes unaddressed, including in primary care treatment setting.AimBuilding on a model that calls for an integrative approach to treatment, the aim is to concisely review barriers and challenges of managing cancer‐related female sexual dysfunction for PCPs and to offer specific and effective strategies that PCPs may use to treat common sexual problems in their female cancer survivors.MethodsLiterature was reviewed for relevant publications on the topic of treating cancer‐related sexual dysfunction and primary care, and interviews were conducted with experts on state‐of‐the‐art methods for treating cancer‐related sexual dysfunction.Main Outcome MeasureClinical evidence that demonstrates the effectiveness of simple strategies to manage cancer‐related female sexual dysfunction.ResultsCancer‐related female sexual dysfunction does not seem to be appropriately acknowledged and addressed in primary care treatment settings. There is evidence to show that simple and effective strategies exist to ameliorate many of these problems.ConclusionsPCPs provide the bulk of survivorship care and are therefore in a critical position to initiate assessment and treatment for female survivors with cancer‐related sexual dysfunction. Although PCPs are in need of increased support and preparation to manage this aspect of survivorship care, simple and effective strategies are available for PCPs to offer women as part of their clinical practice. Bober SL, Carter J, and Falk S. Addressing female sexual function after cancer by internists and primary care providers. J Sex Med 2013;10(suppl 1):112–119.     

Pregnancy-Associated Breast Cancer: Significance of Early Detection

Pregnancy‐associated breast cancer (PABC) is defined as cancer of the breast diagnosed during pregnancy and up to 1 year postpartum. Delays in diagnosis are frequently associated with increased morbidity and mortality. The aim of this article is to determine the significance of early detection of PABC and to alert health care providers to include PABC in the differential diagnosis when evaluating a breast mass in the perinatal period. This integrative literature review evaluated 15 research studies by using the hypothetical deductive model of clinical reasoning to determine factors related to diagnosis of PABC. As women delay childbearing, the incidence of PABC increases with age. In the reviewed studies, breast cancer was diagnosed with greater frequency in the postpartum period than during any trimester in pregnancy. Delay in diagnosis is complicated by axillary lymph node metastasis, high‐grade tumors at diagnosis, and poor outcomes. Early detection is a significant predictor of improved outcomes. Diagnostic modalities such as ultrasound, mammography, and biopsy can be safely used for diagnostic purposes in the evaluation of potential cases of PABC during pregnancy.     

Pregnancy‐Associated Stroke

Cerebrovascular accident, or stroke, is the fourth leading cause of death for all women and the eighth leading cause of pregnancy‐associated death. The physiologic changes of pregnancy increase the risk of cerebrovascular accident for women. With current incidence rates, a facility with 3300 births per year can anticipate caring for one woman with a pregnancy‐related stroke at least every 2 years. All maternity care providers must be able to assess women experiencing stroke‐like symptoms and initiate timely care to mitigate brain tissue damage, decrease long‐term morbidity, and prevent mortality. The 2 main types of stroke, ischemic and hemorrhagic, have similar presenting symptoms but very different pathophysiology and treatment. This article reviews assessment and initial treatment of pregnant and postpartum women experiencing stroke and provides guidance for subsequent maternity and primary care to assist front‐line perinatal care providers who may be the first to treat affected women or may resume primary care after diagnosis.     

Medication Safety During Pregnancy: Improving Evidence‐Based Practice

Nearly 90% of women in the United States have taken medications during pregnancy. Medication exposures during pregnancy can result in adverse pregnancy and neonatal outcomes including birth defects, fetal loss, intrauterine growth restriction, prematurity, and longer‐term neurodevelopmental outcomes. Advising pregnant women about the safety of medication use during pregnancy is complicated by a lack of data necessary to engage the woman in an informed discussion. Routinely, health care providers turn to the package insert, yet this information can be incomplete and can be based entirely on animal studies. Often, adequate safety data are not available. In a busy clinical setting, health care providers need to be able to quickly locate the most up‐to‐date information in order to counsel pregnant women concerned about medication exposure. Deciding where to locate the best available information is difficult, particularly when the needed information does not exist. Pregnancy registries are initiated to obtain more data about the safety of specific medication exposures during pregnancy; however, these studies are slow to produce meaningful information, and when they do, the information may not be readily available in a published form. Health care providers have valuable data in their everyday practice that can expand the knowledge base about medication safety during pregnancy. This review aims to discuss the limitations of the package insert regarding medication safety during pregnancy, highlight additional resources available to health care providers to inform practice, and communicate the importance of pregnancy registries for expanding knowledge about medication safety during pregnancy.     

Midwives as Primary Care Providers for Women

Midwives certified by the American Midwifery Certification Board (AMCB) are prepared to provide primary care to women from menarche across the lifespan and to well newborns to 28 days using consultation, collaboration, and referral to other providers as needed. The scope of midwifery in the United States did not always include primary care for women, although imprecise definitions of primary care make this difficult to study. The expansion of the scope of practice occurred in response to population needs and research on nurse‐midwifery practice patterns. The scope of practice of midwifery is tied to educational standards through the regulation and licensure at the state level. Although the current scope of practice includes primary care for women, many certified nurse‐midwives and certified midwives are unable to practice to the full extent of their education due to state‐level licensure restrictions. We discuss the addition of primary care to midwifery and the current state of AMCB‐certified midwives as primary care providers for women.     

The conundrum of breast density; guidance for healthcare providers

A finding of dense breasts on mammogram decreases the sensitivity of mammogram and increases a woman's risk of breast cancer. Supplemental screening can increase breast cancer detection in women with dense breasts, but caries a risk of increased false-positive test results. There are currently no clear guidelines for providers or patients on recommendations for supplemental screening after a mammogram finding of heterogeneously or extremely dense breasts on mammography. In addition, there is currently great variation in communication and management of breast density amongst physicians and other licensed providers. Women at higher risk for developing breast cancer would benefit most from supplemental screening. Standardizing recommendations and implementation of risk-based decision-making using a validated calculator would allow for earlier detection of breast cancer, clear guidance for providers, and ensure equitable care for patients.     

Group Prenatal Care for Women Receiving Medication‐Assisted Treatment for Opioid Use Disorder in Pregnancy: An Interprofessional Approach

Opioid use disorder among pregnant women is common and rapidly increasing nationwide. Group prenatal care is an innovative alternative to individual care for pregnant women and has been shown to improve women's and health care providers’ satisfaction and adherence to care. We describe a novel group prenatal care program colocated in an opioid treatment program that integrates prenatal care, substance use disorder counseling, and medication‐assisted treatment. Our interprofessional model draws on the unique contributions of physicians, midwives, nurses, and mental health professionals to address the complex needs of pregnant women with opioid use disorder. Participants reported increased trust and engagement with health care providers and peers, improved prenatal care and birth experience, and increased resilience for relapse prevention. Group prenatal care is an accepted and promising model for women with opioid use disorder in pregnancy and has the potential to improve outcomes for women and newborns.     

Women's Prenatal Concerns Regarding Breastfeeding: Are They Being Addressed?

Introduction: This study sought to identify women's concerns regarding breastfeeding during the prenatal period and determine whether women thought that health care providers addressed these concerns. Methods: A structured interview with both open‐ended and closed‐ended questions addressing the study objectives was administered to a cross‐sectional sample of 130 English‐speaking or Spanish‐speaking postpartum women at Yale‐New Haven Hospital. Results: When asked an open‐ended question regarding whether they had concerns about breastfeeding while making their decisions about feeding their infants, 81.5% of women identified at least 1 concern. Of these women, only 25.4% reported that this concern was addressed by the provider during prenatal care. When prompted with 8 common concerns regarding breastfeeding during the prenatal period, 95.4% of women identified at least 1 of these preidentified concerns. Only 17.4% of women who identified any of these 8 concerns reported that the concerns had been discussed with a provider. Discussion: Women's recall of prenatal health care discussions strongly suggests that providers are not adequately addressing women's concerns about breastfeeding.     

Prevention and treatment of breast cancer.

In the new millennium, practitioners who provide primary care for women of all ages must be well educated in the diagnosis and treatment modalities for breast carcinoma. This disease strikes one of eight women. That statistic alone should encourage diligent and persistent efforts to detect this disease early enough to prevent the large number of deaths annually Early detection will reduce the morbidity associated with breast cancer. Strong efforts are ongoing in the fields of genetics and breast cancer research to achieve earlier detection of breast cancer and a reduction in morbidity regardless of the stage of the breast carcinoma. As results of ongoing studies materialize and new studies are funded, it is hoped that more answers will emerge to combat the devastating effects of breast cancer.     

Evidence‐Based Guidance for Self‐Administration of Injectable Contraception

The requirement of in‐person visits every 3 months for a health care provider to administer intramuscular depot medroxyprogesterone acetate (DMPA‐IM) is a significant barrier to its use, particularly in the wake of the coronavirus pandemic. Time and travel costs as well as scheduling conflicts also negatively impact the receipt of subsequent contraceptive injections, which can result in unintended pregnancies. Subcutaneous depot medroxyprogesterone acetate (DMPA‐SC) can be self‐administered by individuals at home, expanding contraceptive access, convenience, and reproductive autonomy. With 30% less progestin, DMPA‐SC improves upon the DMPA‐IM formulation while retaining efficacy. As part of comprehensive contraceptive counseling, health care providers should consider offering DMPA‐SC to eligible individuals interested in self‐administration. Using a case study approach, evidence‐based recommendations are reviewed for the off‐label use of self‐administered DMPA‐SC in the United States.     

A study of the follow up patterns of women treated for CIN 2 and 3 before and after the introduction of the 1992 guidelines.

OBJECTIVE: To analyse the five year cytology follow up data after discharge on women treated for histologically proven cervical intraepithelial neoplasia (CIN) 2 and 3. To assess whether the introduction of the 1992 Guidelines for Clinical Practice and Programme Management affected follow up patterns. To identify who was lost to follow up and for what reasons. DESIGN: A retrospective cohort study of cervical cytological follow up data from 186 women treated for CIN 2 and 3. SETTING: Primary care services, West Midlands, United Kingdom. POPULATION: One hundred and eighty-six women with CIN 2 or 3 treated with large loop excision of the transformation zone at the City Hospital, Birmingham, in whom the first follow up smear at six months was normal. The women were divided into two groups: Group 1 consisted of women treated before the introduction of the Guidelines (1988-1990), and Group 2 consisted of women treated at the time of the introduction of the Guidelines in 1992. INTERVENTION: Introduction of the 1992 Guidelines for Clinical Practice and Programme Management. MAIN OUTCOME MEASURES: To determine the number of follow up smears each woman had over a five year period, to determine the number of women who had the recommended number of follow up smears, and to identify the number of women lost to follow up. RESULTS: The median (interquartile range) number of smears in Group 1 was five (four to six) and in Group 2 was four (four to five). A similar proportion of women in both groups subsequently had abnormal smears (15% and 13.6%). Only one woman required further treatment. 22% of women in Group 1 and 10.2% of women in Group 2 had the correct number of smears to fulfil the 1992 Guidelines. There were 21 women (11.3%) who only had one smear following discharge from the clinic in the five year follow up period. CONCLUSIONS: The data from both cohorts shows follow up to be poor, and the introduction of the 1992 Guidelines has yet to result in an improvement in follow up patterns. The absence of a national cervical cytology database means that surveys of cytology follow up data will continue to be difficult due to the problems of data collection from numerous health authorities and the mobility of women in this age group.     

Current Evidence Supporting Fertility and Pregnancy Among Young Survivors of Breast Cancer

Approximately 6% of invasive breast cancer is diagnosed in women younger than age 40 of age childbearing potential. Cancer‐directed therapies can cause hormonal and anatomical changes that negatively affect the reproductive potential of young survivors of breast cancer. Recent national guidelines on fertility preservation are widely available. However, gaps in care exist in the interdisciplinary evidence‐based management of young survivors of breast cancer with fertility and parenting concerns after cancer treatment.     

Frozen Hope: Fertility Preservation for Women With Cancer

Young women diagnosed with cancer have the option of preserving their fertility by using assisted reproductive technology (ART) techniques prior to undergoing cancer treatment. This article presents a composite case of a young woman with cancer who had many unanswered emotional and ethical questions about her future as a parent. Fertility preservation techniques, including preimplantation genetic diagnosis (PGD), and related patient education are described. Current literature regarding reproductive counseling for cancer survivors is reviewed. Resources for providing psychosocial support for decisions about fertility preservation are lagging behind the rapid pace of scientific advancements in cancer treatment and ART. As more young women are surviving cancer and taking steps to preserve fertility, there is great need for the provision of psychologic support services and the establishment of ethical guidelines to aid them on this path. Women's health care providers can provide support to cancer survivors facing fertility and parenting issues by becoming knowledgeable about the long‐term aspects of decision making and developing educational materials and guidelines for these patients.