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December Ask the Expert: Post-Treatment and Survivorship Concerns

During the month of December, Living Beyond Breast Cancer expert P.K. Morrow, MD, answered your questions about post-treatment health and well-being,.

Question: After treatment, it's hard for me to distinguish health problems that could be symptoms of something potentially dangerous from non-threatening issues. How do I know when to be concerned? How do I know if it's just stress?

Dr. Morrow: This is a very important question. After treatment, we monitor patients through history, physical exam and breast imaging. In addition, certain symptoms lead us to further testing. For example, chronic bone pain that is persistent and lasts for two weeks or longer would lead oncologists to order a bone scan as well as either x-rays or an MRI. However, we understand that, from day to day, each person experiences fleeting aches, pains and discomfort in daily life that are unrelated to metastatic disease. Thus, after treatment, we ask that you inform your healthcare provider of any symptom that is bothering you chronically for two weeks or more. Of course, acute symptoms such as a sudden onset of chest pain should lead to an immediate clinic visit.

Question: If a postmenopausal woman has had surgery and radiation treatment for early-stage breast cancer, which specialist should be monitoring her care plan?

Dr. Morrow: The most important element in breast cancer follow-up care is undergoing regular physical examination and breast imaging and discussing your symptoms with your doctor. The follow-up care may be provided by your oncologist or your primary care doctor, as long as your primary care doctor has corresponded with your oncologist about the important elements of follow-up care for women diagnosed with breast cancer.

Question: What would you say is the no. 1 survivorship issue?

Dr. Morrow: I would like to pinpoint three top survivorship issues: fatigue/lack of energy, decreased concentration and poor sexual functioning. These were also the concerns that were noted in the Lance Armstrong Foundation LIVESTRONG poll.

Question: How much "wiggle room" is there with follow-up appointments? Specifically, we are retired snowbirds who travel between two places. I have kept all my follow-up at the original treatment location, but that stretches the times between follow ups ( i.e. 1 year becomes 15 months). I'm trying not to worry and to just enjoy life without treatments, but am I doing enough by following up later? I had triple-negative disease which seems to be more deadly if it recurs.

Dr. Morrow: While it is important to maintain routine follow-up, I agree that there can be some flexibility with follow-up appointments. What is most important is communication with your physician. If your interval between follow-up visits is lengthened by 1 to 2 months, but you keep your appointments and notify your physician if any concerning symptoms develop between visits, you are maintaining appropriate follow-up.

Question: I annually see my internist, gynecologist and medical oncologist. Ten years out, is seeing the medical oncologist still necessary?

Dr. Morrow: The most part of your oncology follow-up is that you are undergoing regular evaluation with patient history, physical examination and imaging. These components of care can be provided by either your oncologist or your internist, as long as your internist has communicated with your oncologist about appropriate care.

Question: Even after a year from chemo, I get heart palpitations when I walk to fast or jog lightly. As a former athlete, not being able to exercise full-on is demoralizing. Is this normal?

Dr. Morrow: A year after completing chemotherapy, your heart palpitations should have markedly improved. I would recommend discussing this with your physician and having further cardiac evaluation.

Question: If a breast cancer patient moves to a new locale following her breast cancer treatment, how would you suggest that she find a medical team for her post-treatment care plan?

Dr. Morrow: I would recommend that she first discuss her move with her current oncologist. Her current oncologist may be able to suggest colleagues who would be effective in her post-treatment care in the new location.

The oncologist could also facilitate the move by providing her medical records by fax/mail, as well as corresponding with the future oncologist ahead of time so that her transition to her new location is seamless.

If her current oncologist does not know any colleagues in the new location,, the woman may consider asking the primary care physician in her new location to recommend a trusted oncologist.

Question: I did genetic testing for BRCA1 and BRCA2 10 years ago. I was negative but told my family history was very strong. Are there new genetic tests available? Is it worth having them done?

Dr. Morrow: In 2006, Myriad Genetics, the company that performs the BRCA1 and BRCA2 testing in the United States, introduced BART (BRACAnalysis Rearrangement Test), a new molecular diagnostic test that detects additional large genomic rearrangements in both BRCA1 and BRCA2 that were not seen in the comprehensive BRACAnalysis. Women who have an especially strong personal and/or family history of breast and ovarian cancer should discuss this test with their healthcare provider.

Question: What questions should I ask my oncologist during post treatment office visits?

Dr. Morrow: Take the opportunity to ask your oncologist:

1) What is the recommended interval between follow-up visits?

2) What is my risk of recurrence, and during what period of time is that risk the greatest?

3) What symptoms should you be watching out for?

4) What are expected side effects of treatment, and when/do they improve?

Question: Regarding fear of recurrence, what is some of the best advice you have heard given? What advice do you give?

Dr. Morrow: Fear of recurrence is such a difficult barrier to making a full recovery from cancer. I advise patients to participate in mindfulness, in terms of keeping their attention and concentration focused upon the present, to prevent fears from taking control of their everyday lives. I also advise them that once they have finished treatment, while they want to be aware of symptoms, they also want to be able to take back control of their life from the cancer. They can do this by living in the present and focusing on enjoying their lives.