Table 2.

Assessment and management of the long-term effects of breast cancer and its treatments

CATEGORY	RECOMMENDATIONS	LEVEL OF EVIDENCE*
Cardiovascular health	• Monitor lipid levels and provide cardiovascular monitoring as indicated	III15
	• Educate patient about healthy lifestyle modification (balanced diet, exercise, smoking cessation), potential cardiac risk factors, and when to report relevant symptoms (shortness of breath or fatigue) to health care providers	I15
Cognitive dysfunction	• Ask about cognitive difficulties	III15
	• Assess reversible contributing factors of cognitive impairment and optimally treat when possible	I15
	• Refer for neurocognitive assessment and rehabilitation if there are signs of cognitive impairment	I15
	• Suggest self-management and coping strategies for cognitive dysfunction (relaxation, stress management, routine exercise)	III18
Distress, depression, anxiety	• Assess for distress, depression, and anxiety	I15,23
	• Assess further if the patient is at higher risk of depression	II15
	• Offer counseling and pharmacotherapy or refer to mental health resources as indicated	I15
Fatigue	• Assess for fatigue, use severity rating scale, and treat causative factors	III15,18,23
	• Offer treatment or referral for factors affecting fatigue (mood disorders, sleep disturbance, pain, etc)	I15
	• Encourage regular physical activity, refer for CBT if indicated	I15,23
	• When fatigue is present, provide education and general strategies to manage fatigue, and evaluate	III18
	• Do not recommend methylphenidate or modafinil to manage fatigue, given insufficient evidence	III23
	• Preliminary evidence suggests that yoga is likely to improve fatigue	I23
Referral for genetic counseling	Consider referral for genetic counseling if breast cancer was diagnosed before age 50 y (especially < 35 y) ovarian cancer at any age (epithelial) bilateral breast cancer in the same woman both breast and ovarian cancers in the same woman or the same family multiple breast cancers on the same side of the family (paternal or maternal) male breast cancer Ashkenazi Jewish ethnicity	III24
Osteoporosis	• DEXA scan at baseline then every 2 y if the patient is taking aromatase inhibitors or GnRH agonists	III15
Pain and CIPN	• Assess for pain and contributing factors with pain scale and history	III15
	• Offer interventions such as acetaminophen, NSAIDs, physical activity, or acupuncture for pain	I15
	• Suggest physical activity for neuropathic pain	I15
	• Suggest duloxetine for neuropathic pain	I15
	• Refer to appropriate specialists once the cause of pain has been determined (eg, lymphedema specialist)	III15
	• Consider TENS for CIPN in survivors with contraindications to medication or for whom medication is ineffective	III18,25
	• Consider acupuncture as an adjunct option to treat patients with medication-resistant CIPN	III25
Sexual health	• Assess for signs and symptoms of sexual or intimacy problems	III15,18
	• Assess for reversible contributing factors to sexual problems and treat when appropriate	III15
	• Offer nonhormonal, water-based lubricants for vaginal dryness	I15
	• Refer for psychoeducational therapy and sexual or marital counseling when appropriate	I15
Premature menopause, menopausal symptoms	• Offer SNRIs, SSRIs, or gabapentin and lifestyle modifications to help vasomotor symptoms of premature menopause	I15
	• Consider CBT or routine exercise for treatment	II26
	• Consider tailored patient education interventions and consultations when appropriate to decrease menopausal symptoms	II27
Lymphedema	• Counsel weight loss for overweight or obese patients to prevent or reduce lymphedema risk	III15
	• Educate survivors about lymphedema signs and symptoms and assess for lymphedema	III18
	• Refer if symptoms are suggestive of lymphedema	III15
Infertility	• Refer survivors of childbearing age experiencing infertility to reproductive endocrinology and infertility specialists promptly	III15
Body image concerns	• Assess for body image concerns	III15
	• Refer to psychosocial resources as indicated	I15

CBT—cognitive behavioural therapy, CIPN—chemotherapy-induced peripheral neuropathy, DEXA—dual-energy x-ray absorptiometry, GnRH—gonadotropin-releasing hormone, NSAID—nonsteroidal anti-inflammatory drugs, SNRI—selective norepinephrine reuptake inhibitor, SSRI—selective serotonin reuptake inhibitor, TENS—transcutaneous electrical nerve stimulation.

^*Level I evidence includes at least 1 properly conducted randomized controlled trial, systematic review, or meta-analysis. Level II evidence includes other comparison trials; non-randomized, cohort, case-control, or epidemiologic studies; and preferably more than 1 study. Level III evidence includes expert opinion or consensus statements and influential reports or studies.