Editor’s key points
Advances in adjuvant breast cancer therapies have led to an improved 5-year survival rate of 87%.
As a result, cancer centre resources have become overwhelmed with the management of survivors as well as patients receiving active treatment, and there has been a progressive shift in the care of stable breast cancer survivors to primary care.
This article aims to outline an evidence-based survivorship care plan to facilitate care of breast cancer survivors in primary care.
The Breast Cancer Survivorship Tool enables patients to advocate for their own care with an easily accessible, peer-reviewed guideline that is user friendly. Use of the tool will allow primary care providers to be confident that they are providing high-quality, evidence-based standardized care for their patients who have had breast cancer.
Breast Cancer Survivorship Tool
Facilitating breast cancer survivorship care for family physicians and patients
Anna N. Wilkinson MSc MD CCFP FCFP Catherine E. Boutet RN MD
Abstract
Objective To create an evidence-based national Breast Cancer Survivorship (BCS) Tool that facilitates appropriate care of breast cancer patients by primary care providers after patients have completed adjuvant therapy.
Sources of information MEDLINE and PubMed were searched from 2002 to 2018 with the key words breast cancer, survivorship, survivorship care plan, guideline, review, meta-analysis, chemotherapy, radiotherapy, treatment complications, adverse effects, late effects, screening, health promotion, and follow up care.
National or provincial cancer care organization guidelines were also reviewed.
Evidence was graded as level I, II, or III.
Main message The BCS Tool provides an evidence-based template to ensure seamless transitions of care from cancer centres to primary care. Four steps of survivorship care are outlined in this article: care knowledge and coordination, cancer surveillance, management of long-term side effects of treatment, and health promotion.
Conclusion The BCS Tool will support primary care providers in ensuring breast cancer survivors receive high-quality, evidence-based care.
N
early 1 in 8 women will develop breast cancer during the course of their lives, with an astounding 26 300 new cases in Canada in 2017.1 Fortunately, important recent advances have been made in therapies for breast cancer, including surgery, chemotherapy, and biologic, endocrine, and radiation therapies, with an improvement in the 5-year survival rate to 87%.1 As a result, scarce cancer centre resources have become overwhelmed managing the care of survivors as well as patients receiving active treatment.Consequently, there has been a progressive shift in the care of stable breast cancer survivors to the domain of primary care; however, there has been lit- tle education for primary care providers to enable and support the provision of this care in an evidence-based fashion.2 Indeed, survivorship care plans currently vary from centre to centre, and from province to province.3-6
The Cancer Care Member Interest Group is a College of Family Physicians of Canada (CFPC) committee of family physicians who have a special interest in oncology, with representation from across Canada. As part of its mandate to support family physicians in oncology, this committee developed an evidence- based Breast Cancer Survivorship (BCS) Tool, for use by both patients and pro- viders to ensure uniform, appropriate care for these patients. The tool and its development are presented in this article. An easy-to-print version of the BCS Tool can be downloaded from CFPlus* and it is available on the CFPC website and can be found through a Google search.7
*An easy-to-print version of the Breast Cancer Survivorship Tool is available from CFPlus.
Go to the full text of the article online and click on the CFPlus tab.
Case description
Mrs X. is a 59-year-old woman who has recent- ly completed treatment for cancer in her left breast (T2N1M0—2 primary tumours, 1 regional lymph node involved, and no distant metastases; estrogen receptor–
progesterone receptor positive; human epidermal growth factor receptor 2 positive). Her treatment has included lumpectomy with sentinel node biopsy; adju- vant chemotherapy with doxorubicin, cyclophospha- mide, and paclitaxel; trastuzumab; bisphosphonate;
and radiation therapy. She is taking an aromatase inhibitor, which she is expected to continue taking for at least 5 years. She is discharged from the cancer centre and returned to your care for ongoing follow-up.
What do you need to do to ensure her care is adequate?
Sources of Information
The BCS Tool was created based on the results of a sys- tematic literature review. MEDLINE and PubMed were searched from 2002 to 2018 with the following MESH terms: breast cancer, survivorship, survivorship care plan, guideline, review, meta-analysis, chemotherapy, radiother- apy, treatment complications, adverse effects, late effects, screening, health promotion, and follow up care. National (American and Canadian) or provincial cancer organi- zation guidelines with an evidence-based approach to breast cancer screening and surveillance, posttreatment side effects, posttreatment surveillance, and health pro- motion in survivorship care in the primary care setting were also reviewed where available.
Evidence was categorized as level I, II, or III depend- ing on whether recommendations were based on ran- domized controlled trials, systematic reviews, or meta-analyses (level I); non-randomized, cohort, case- control, or epidemiologic studies (level II); or expert opinion or consensus statements (level III).
Key recommendations and themes were amalgam- ated into a tool, and levels of evidence were noted wherever possible. The BCS Tool was reviewed by medi- cal oncologists and members of the CFPC Cancer Care Program Committee to ensure the appropriateness of content and national applicability.
Main message
The BCS Tool (page 1 appears in Figure 1) presents evidence-based standard-of-care recommendations for breast cancer patients following adjuvant therapy. The tool is designed to be used by both patients and primary care providers. The tool is broken down into 4 steps:
• know your patient,
• cancer surveillance,
• management of long-term side effects of treatment, and
• health promotion.
patient to patient, depending on the pathology of their tumours (Table 1).8,9 The first step of providing appropri- ate breast cancer survivor care is understanding exactly which therapies the patient has received. Treatment side effects and monitoring requirements will vary widely based on the specific therapies.
The adjuvant therapy that a breast cancer patient receives depends on the risk of recurrence. Treatment might include chemotherapy, radiation therapy, and, if a patient’s tumour expresses the HER2 receptor (human epidermal growth factor receptor 2), she might also be offered the targeted therapy trastuzumab.
Endocrine therapy is offered to patients with tumours that are estrogen receptor–progesterone recep- tor positive. Estrogen blockade has been shown to decrease breast cancer mortality by about one-third throughout the first 15 years after definitive therapy.10 Postmenopausal women are offered endocrine ther- apy with aromatase inhibitors, which block peripheral conversion of androgens to estrogen. Although more effective than tamoxifen, aromatase inhibitors are con- traindicated in premenopausal women, as lower periph- eral levels of estrogen will induce the hypothalamus and pituitary gland to increase ovarian estrogen produc- tion.11 Premenopausal or perimenopausal women can therefore take tamoxifen or, if they wish to obtain the added benefits conferred by therapy with an aromatase inhibitor, they must first achieve ovarian suppression via surgery or treatment with a gonadotropin-releasing hor- mone (GnRH) agonist. Tamoxifen, aromatase inhibitors, and GnRH agonists all have unique side effect profiles that require specific follow-up care.
Bisphosphonates have been found to be associated with a reduction in breast cancer recurrence in bone (rate ratio of 0.76) and in mortality (rate ratio of 0.82) in postmenopausal women.12 Current guidelines sug- gest that postmenopausal women with intermediate- or high-risk cancers should receive zoledronic acid every 6 months for 3 years.13 Family physicians should inter- pret bone mineral density (BMD) measurements with the knowledge that their patients might have received, or are still receiving, bisphosphonates.
Step 2: cancer surveillance. All breast cancer survi- vors should have follow-up visits with primary care pro- viders every 6 months for the first 5 years after treatment completion. These appointments should include a thor- ough history, screening for signs and symptoms of local or distant recurrence, and treatment of side effects.8,14 The BCS Tool highlights common sites of disease recur- rence and associated symptoms, as well as common complications of therapy, which will help family physi- cians in their directed review of systems.
Br ea st C an ce r S ur vi vo rs hi p To ol
Kn o w Y our P atie n t H ealth Ca re T eam
Tr ea tme nt H is to ry
Age at diagnosis: Date of diagnosis: Breast cancer site: L R BL Type: Grade: Margins: Lymph nodes involved: ER+/ ER- PR+/PR- HER2+/ HER2- TNM: Stage: Genetic testing: Menopausal status: Date of last mammogram:
Surgery Lumpectomy Mastectomy Sentinel node biopsyAxillary dissection ReconstructionImplant Other Chemotherapy Drug Regimen: Anthracycline (doxorubicin/epirubicin) given: Yes No Radiation therapy Total dose: Location: HerceptinYesNo BisphosphonateYesNo Ovarian suppressionMedical Surgical Endocrine therapyDrug:Start date: Intended treatment duration: Drug:Start date: Intended treatment duration: Date treatment completed:
© 2019 The College of Family Physicians of Canada All rights reserved. This material may be reproduced in full for educational, personal, and non-commercial use only, with attribution provided accord- ing to the citation information below. For all other uses permission must be acquired from the College of Family Physicians of Canada. How to cite this document: College of Family Physicians of Canada. Breast Cancer Survivorship Tool. Mississauga, ON: College of Family Physicians of Canada; 2019.
survivorship care is understanding what breast cancer treatments an individual has received. Print this form and complete it by hand or Potential for cardiotoxicity
Family physician: Medical oncologist: Radiation oncologist: General surgeon: Plastic surgeon:
STEP 1
Fi gu re 1
This is page 1 of the Breast Cancer Survivorship Tool. The full tool is available from CFPlus. Go to the full text of the article online and click on the CFPlus tab.symptoms, and fears around recurrence create consider- able distress and anxiety.15 Clinical breast examinations should be done every 6 months, with specific attention paid to the regional lymph nodes, chest wall, lungs, and abdomen. Patients should be advised to perform monthly breast self-examinations.14 A diagnostic mammogram should be done annually.8 The cumulative effects of cancer therapy—chemotherapy, glucocorticoids (as antiemetics), and endocrine therapy—cause a degree of bone loss that is considerably greater than expected age-related bone loss.16 Baseline BMD measurement should therefore be performed for all postmenopausal women completing breast can- cer therapy, as well as those patients with chemotherapy- induced premature menopause or those taking endocrine therapy with aromatase inhibitors or GnRH agonists.6 Patients who continue taking aromatase inhibitors are at increased risk of osteoporosis and should be screened on an ongoing basis with BMD measurement every 2 years,17 although clinical judgment should be employed to adjust the interval of BMD measurement depending on fracture risk. Lipid levels should also be monitored while patients are taking aromatase inhibitors, as these agents can cause hyperlipidemia.14,18
Family physicians are in the unique circumstance of caring for patients as well as their extended families, and this position might allow for detection of familial can- cer syndromes. Consider referring patients for genetic screening if criteria outlined in Box 1 are met.19-22
might present immediately after therapy or might become apparent many years after completion of therapy.
Regardless of the therapy received, breast cancer survi- vors are at a higher risk of cognitive dysfunction, fatigue, and psychological distress.21-24 Breast cancer therapy can affect all spheres of life and might contribute to rela- tionship issues, financial hardship, and ongoing anxiety around disease recurrence. Providers should be sensitive to psychological distress and should screen regularly and refer patients for counseling where appropriate.15 If phar- macotherapy is required, caution should be used if pre- scribing paroxetine or fluoxetine, as these agents might Table 1. Potential adjuvant therapies for breast cancer
TYPE OF
TREATMENT INDICATION DURATION OF THERAPY
Chemotherapy • Individual decision based on risk stratification including ER-PR and HER2 status, tumour
size, grade, lymphovascular invasion, lymph node status, and recurrence score 4-6 cycles of chemotherapy
Trastuzumab • HER2 positive Every 3 wk for 1 y
Bisphosphonates • Intermediate- or high-risk cancers in the postmenopausal setting Every 6 mo for 3 y Radiation
therapy • Post lumpectomy
-Whole or partial breast XRT
• Post mastectomy
- Consideration of XRT if tumour > 5 cm or there are other unfavourable pathologic factors
• Node-positive disease -Nodal XRT to be discussed
40.05 Gy in 15 fractions or 50 Gy in 25 fractions
Endocrine
therapy • ER or PR positive
• Premenopausal -Tamoxifen
- Aromatase inhibitor if surgical (oophorectomy) or medical (GnRH agonist) ovarian suppression
• Postmenopausal
-Aromatase inhibitors (letrozole, anastrozole, exemestane)
5-10 y
ER—estrogen receptor, GnRH—gonadotropin-releasing hormone, HER2—human epidermal growth factor receptor 2, PR—progesterone receptor, XRT—external radiation therapy.
Data from Khatcheressian et al8 and Crew et al.9
Box 1. Criteria for referral for familial breast cancer syndrome
Consider referring patients for genetic testing if any of the following criteria are met:
• Breast cancer diagnosis at age < 50 y (especially < 35 y)
• Triple-negative breast cancer at age < 60 y
• Ovarian cancer at any age
• Bilateral breast cancer
• Breast and ovarian cancer in the same woman or family
• Multiple breast cancers on the same side of family (maternal or paternal)
• Male breast cancer
• Ashkenazi Jewish ethnicity
Data from Falleti et al21 and Reuter-Lorenz and Cimprich.22
node dissection compared with 40% with axillary dis- section. Optimal management of lymphedema includes weight loss, compression sleeves, and massage therapy, with referral to a lymphedema specialist where available.25
Patients taking tamoxifen have a relative increase in venous thromboembolic disease by a factor of 2 to 3, and have an increase in the relative risk of endometrial cancer of 2.7.17 Any vaginal bleeding in postmenopausal women taking tamoxifen must be investigated to rule out endometrial cancer. Aromatase inhibitors can cause considerable and often dose-limiting arthralgias and myalgias and increase the relative risk of osteoporotic fractures by 47%.9,26
Cardiovascular health can be affected by all breast cancer therapies. The anthracycline chemotherapeu- tic agents epirubicin and doxorubicin might cause a decrease in ejection fraction, which can manifest as heart failure many years after completion of treatment.27 Trastuzumab can also cause a decrease in heart function while taking the therapy, although this might be revers- ible if trastuzumab is discontinued.28 Left-sided radiation can compound cardiotoxicity by causing fibrosis of any component of the heart, including valves, blood vessels, myocardium, and the conduction system.29,30 Finally, aromatase inhibitors can contribute to the development of hypertension and hyperlipidemia.18 Ongoing surveil- lance of cardiac function in asymptomatic breast cancer survivors is currently not recommended16; however, pri- mary care providers should view any symptoms of heart failure that might develop at any time after breast can- cer treatment in the context of this therapy.
Step 4: health promotion. Breast cancer survivors who are physically active, maintain a healthy weight, and avoid smoking and excessive alcohol use have a decreased risk of breast cancer recurrence.31-33 Family doctors should actively engage with their patients who are breast cancer survivors to promote a healthy lifestyle.
With the myriad recommendations for breast cancer survivorship care, routine preventive health maneuvers can be overlooked. One Canadian study found that dur- ing a 4-year period, 65% of breast cancer survivors were never screened for colorectal cancer, and 40% were not screened for cervical cancer.34 Primary care providers must ensure that survivorship care also includes appro- priate preventive care.
Case resolution
Mrs X. should have an appointment with her family physician every 6 months, during which a review of systems should be done to look for signs of recur- rence, side effects of therapy, and symptoms of fatigue, anxiety, or depression. These visits should include a clinical examination, including the breasts, regional lymph nodes, chest, and abdomen. Mrs X.
should be encouraged to do breast self-examination
every month. She should have a mammogram ordered, which should be performed 1 year after her original diagnostic mammogram and repeated annually. Given that Mrs X. is taking an aroma- tase inhibitor, she should have her BMD measured every 2 years and annual lipid level monitoring. She should continue with her regular preventive health care. With the combination of anthracycline, left- sided radiation, and trastuzumab, any signs sug- gestive of cardiac dysfunction (eg, dyspnea, pedal edema) should be investigated immediately, with a low threshold for referral to cardiology. The BCS Tool can be shared with Mrs X. to encourage her involve- ment in her survivorship care.
Conclusion
Family physicians are increasingly responsible for sur- vivorship care as cancer centres continue to be over- burdened. Survivorship care clearly belongs within the primary care domain. Family physicians are better posi- tioned than cancer centres to provide optimal breast cancer survivor care, as they have the benefit of long- term relationships with their patients, in-depth knowl- edge of patients’ social supports and families, a strong interest in preventive care, and an awareness and com- prehension of a patient’s medical issues beyond cancer.
The BCS Tool presented in this article is a means to build bridges between oncology, primary care, and patients. The BCS Tool enables patients to advocate for their own care with an easily accessible, peer-reviewed guideline that is user friendly. The use of the BCS Tool will allow primary care providers to be confident that they are providing high-quality, evidence-based, standardized care for their breast cancer patients.
Dr Wilkinson is Assistant Professor in the Department of Family Medicine and Program Director of the PGY3 Family Practice Oncology program at the University of Ottawa in Ontario and is Chair of the Cancer Care Member Interest Group of the College of Family Physicians of Canada. Dr Boutet is an internal medicine resident at McGill University in Montreal, Que.
Acknowledgment
Dr Boutet received a Patient Education Grant for Family Medicine Residents and a Support Program Grant from the College of Family Physicians of Canada.
Contributors
Both authors contributed to the literature review, its interpretation, and preparing the manuscript for submission.
Competing interests None declared Correspondence
Dr Anna N. Wilkinson; e-mail anwilkinson@toh.ca References
1. Canadian Cancer Statistics Advisory Committee. Canadian cancer statistics. A 2018 special report on cancer incidence by stage. Toronto, ON: Canadian Cancer Society; 2018. Available from:
cancer.ca/Canadian-Cancer-Statistics-2018-EN. Accessed 2019 Jan 30.
2. Luctkar-Flude M, Aiken A, McColl MA, Tranmer J, Langley H. Are primary care providers imple- menting evidence-based care for breast cancer survivors? Can Fam Physician 2015;61:978-84.
3. Olson R, editor. Your cancer survivorship care plan. Vanc ouver, BC: BC Cancer Agency, Northern Health; 2012. Available from: www.bccancer.bc.ca/survivorship-site/Documents/
Generic%20CP%20Electronic%20-%20revised%20June%202013.pdf. Accessed 2020 Mar 31.
4. Hamilton Health Sciences, Juravinski Cancer Center. Breast cancer survivorship care plan.
Hamilton, ON: Hamilton Health Sciences.
5. The Ottawa Hospital. Wellness Beyond Cancer Program. Survivorship. Ottawa, ON: The Ottawa Hospital. Available from https://www.ottawahospital.on.ca/en/clinical-services/
deptpgrmcs/programs/cancer-program/what-we-offer-our-programs-and-services/
wellness-beyond-cancer-program/. Accessed 2017 Dec 1.
6. Cancer Care Ontario. Ontario breast cancer follow-up care clinical guidance summary.
Toronto, ON: Cancer Care Ontario; 2019. Available from: https://www.cancercareontario.ca/
sites/ccocancercare/files/guidelines/summary/SurvivorshipClinicalGuidanceBreast.pdf.
Accessed 2020 Mar 31.
7. College of Family Physicians of Canada. Breast Cancer Survivorship Tool. Mississauga, ON: College of Family Physicians of Canada; 2019. Available from: https://portal.cfpc.ca/
resourcesdocs/uploadedFiles/Directories/Committees_List/BCS_Tool_Eng_Sep30_2019.
pdf. Accessed 2020 Apr 9.
8. Khatcheressian JL, Hurley P, Bantug E, Esserman LJ, Grunfeld E, Halberg F, et al. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013;31(7):961-65. Epub 2012 Nov 5.
9. Crew KD, Greenlee H, Capodice J, Raptis G, Brafman L, Fuentes D, et al. Prevalence of joint symptoms in postmenopausal women taking aromatase inhibitors for early-stage breast cancer. J Clin Oncol 2007;25(25):3877-83.
10. Early Breast Cancer Trialists’ Collaborative Group. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;365(9472):1687-717.
11. Pistelli M, Della Mora A, Ballatore Z, Berardi R. Aromatase inhibitors in premeno- pausal women with breast cancer: the state of the art and future prospects. Curr Oncol 2018;25(2):e168-75. Epub 2018 Apr 30.
12. Early Breast Cancer Trialists’ Collaborative Group. Adjuvant bisphosphonate treatment in early breast cancer: meta-analyses of individual patient data from randomized trials.
Lancet 2015;386(10001):1353-61. Epub 2015 Jul 23. Errata in: Lancet 2016;387(10013):30, Lancet 2017;389(10088):2472.
13. Dhesy-Thind S, Fletcher GG, Blanchette PS, Clemons MJ, Gandhi S, Gupta R, et al. Use of adjuvant bisphosphonates and other bone-modifying agents in breast cancer. Guideline 1-22-A. Toronto, ON: Cancer Care Ontario; 2016.
14. Sisler J, Chaput G, Sussman J, Ozokwelu E. Follow-up after treatment for breast cancer.
Practical guide to survivorship care for family physicians. Can Fam Physician 2016;62:805-11 (Eng), e578-85 (Fr).
15. Howell D, Keshavarz H, Esplen MJ, Hack T, Hamel M, Howes J, et al. Pan-Canadian practice guideline: screening, assessment and management of psychosocial distress, depression and anxiety in adults with cancer. Version 2. Canadian Partnership Against Cancer, Canadian Association of Psychosocial Oncology; 2015.
16. Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, Cowens-Alvarado RL, et al. American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. J Clin Oncol 2016;34(6):611-35. Epub 2015 Dec 7.
17. Awan A, Esfahani K. Endocrine therapy for breast cancer in the primary care setting. Curr Oncol 2018;25(4):285-91. Epub 2018 Aug 14.
18. Foglietta J, Inno A, de Iuliis F, Sini V, Duranti S, Turazza M, et al. Cardiotoxicity of aromatase inhibitors in breast cancer patients. Clin Breast Cancer 2017;17(1):11-7. Epub 2016 Jul 25.
19. Moyer VA; U.S. Preventive Services Task Force. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160(4):271-81.
20. Heisey R, Carroll JC. Identification and management of women with a family history of breast cancer. Practical guide for clinicians. Can Fam Physician 2016;62:799-803.
21. Falleti MG, Sanfilippo A, Maruff P, Weih L, Phillips KA. The nature and severity of cognitive impairment associated with adjuvant chemotherapy in women with breast cancer: a meta- analysis of the current literature. Brain Cogn 2005;59(1):60-70. Epub 2005 Jun 21.
22. Reuter-Lorenz PA, Cimprich B. Cognitive function and breast cancer: promise and potential insights from functional brain imaging. Breast Cancer Res Treat 2013;137(1):33-43. Epub 2012 Oct 9.
23. Ahles TA, Saykin AJ. Breast cancer chemotherapy-related cognitive dysfunction. Clin Breast Cancer 2002;3(Suppl 3):S84-90.
24. Correa DD, Ahles TA. Cognitive adverse effects of chemotherapy in breast cancer patients.
Curr Opin Support Palliat Care 2007;1(1):57-62.
25. Gradishar WJ, Anderson BO, Balassanian R, Blair SL, Burstein HJ, Cyr A, et al. Breast cancer, version 4.2017, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2018;16(3):310-20.
26. Amir E, Seruga B, Niraula S, Carlsson L, Ocaña A. Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: a systematic review and meta-analysis. J Natl Canc Inst 2011;103(17):1299-309. Epub 2011 Jul 9.
27. Raj S, Franco VI, Lipshultz SE. Anthracycline-induced cardiotoxicity: a review of pathophysi- ology, diagnosis, and treatment. Curr Treat Options Cardiovasc Med 2014;16(6):315.
28. Lenihan DJ, Oliva S, Chow EJ, Cardinale D. Cardiac toxicity in cancer survivors. Cancer 2013;119(Suppl 11):2131-42.
29. Straub JM, New J, Hamilton CD, Lominska C, Shnayder Y, Thomas SM. Radiation-induced fibrosis: mechanisms and implications for therapy. J Cancer Res Clin Oncol 2015;141(11):1985- 94. Epub 2015 Apr 25.
30. Roychoudhuri R, Robinson D, Putcha V, Cuzick J, Darby S, Møller H. Increased cardiovascular mortality more than fifteen years after radiotherapy for breast cancer: a population based study. BMC Cancer 2007;7(9).
31. Kushi LH, Doyle C, McCullough M, Rock CL, Demark-Wahnefried W, Bandera EV, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention: reduc- ing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin 2012;62(1):30-67.
32. Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin 2012;62(4):243-74. Epub 2012 Apr 26. Erratum in: CA Cancer J Clin 2013;63(3):215.
33. Kwan ML, Kushi LH, Weltzien E, Tam EK, Castillo A, Sweeney C, et al. Alcohol consumption and breast cancer recurrence and survival among women with early-stage breast cancer:
the Life After Cancer Epidemiology study. J Clin Oncol 2010;28(29):4410-6. Epub 2010 Aug 30.
34. Grunfeld E, Moineddin R, Gunraj N, Del Giudice ME, Hodgson DC, Kwon JS, et al.
Cancer screening practices of cancer survivors. Population-based, longitudinal study.
Can Fam Physician 2012;58:980-6.
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.
This article has been peer reviewed. Can Fam Physician 2020;66:321-6 La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mai 2020 à la page e142.
