Introduction

Breast cancer is the most common malignancy in the female population, with a cure rate that exceeds 80%. The gradual increase in incidence, associated with an aging population and the implementation of screening programs, together with lower mortality rates, account for an increased number of patients who are breast cancer survivors (BCSs) [1].

BCSs often have a life that is conditioned by the sequelae or morbidities related to treatment of the disease and, despite the high cure rates, many of the patients are no longer able to enjoy the quality of life achieved by women in our society. The treatments administered can leave physical, psychological, and psychosocial sequelae that may manifest or persist even years after having completed treatment and can interfere with their well-being and reincorporation into ordinary social and occupational activities [2].

Breast cancer is not a single disease, and treatment options depend on each tumor’s biology and behavior, as well as on each patient’s characteristics. Among patient characteristics, we must mention age, overall health status, and menopause status as being highly important factors when defining individualized treatment and preventing certain treatment-derived complications [3].

There are three essential aims that BCS follow-up pursues: (1) early diagnosis of relapses, (2) minimizing the impact of sequelae and complications derived from breast cancer diagnosis and treatment, and (3) encouraging healthcare and preventive measures to promote well-being and decrease risks to their health. Thus, a better quality of life might be achieved by helping BCSs to reintegrate as fully as possible into the various areas of their lives, i.e., family, work, and social activities [4, 5].

The need for specialized hospital-based care (SC) and primary care (PC) to share BCS patient follow-up activities has become evident in recent years and requires effective coordination. This shared, coordinated follow-up must ensure that the three previously named goals are met. The primary care physician plays a prominent role in detecting relapses and second neoplasms, dealing with late-onset effects of cancer treatment, managing comorbidity, psychological care, promoting healthy lifestyles, and recommending health prevention strategies, as well as normalizing the healthcare of patients who have been cured of breast cancer. Furthermore, BCSs continue to benefit from receiving care by the hospital-based specialist, especially during the first 5 years of follow-up [6,7,8,9].

In this document, we present a guideline that has been drafted and agreed among different scientific societies whose members care for BCSs. The purpose of this guideline is to archive that the follow-up of these patients will be shared, collaborative, and coordinated among SC and PC professionals.

Treatment-derived health problems

As previously noted, the therapies administered may entail different sequelae that can translate into impaired quality of life for women who have overcome breast cancer. Some sequelae are late onset. Identifying these issues and correcting them can improve adaptation to daily life [9]. On the other hand, certain adverse effects may condition adherence to prolonged hormone therapy. It is also important to know whether the patients are receiving other medications or alternative therapies that might interfere with the activity of endocrine therapy. The PC physician is best suited to detect and control these side effects.

The side effects that call for special attention according to their frequency are as follows: lymphedema, effects derived from ovarian failure and menopause-related symptoms, overweight, cardiotoxicity, other vascular toxicities, neurotoxicity, ocular toxicity, cognitive impairment, skin alterations, and the risk of second neoplasms. The characteristics of these side effects and management recommendations are summarized in Table 1.

Table 1 Side effects and recommendations for their management
Full size table

In addition, there are general recommendations that must be followed [8, 9]:

  • Overweight avoidance Weight gain has been associated with a worse treatment response and greater risk of relapse.

  • Healthy diet and exercise Epidemiological studies have proven a benefit for patients following a low-fat diet together with at least 150 min of vigorous physical activity per week [10]. The recommended diet is high in fresh fruits, vegetables, and legumes (at least two pieces of fruit per day); patients are also recommended to lower their intake of red meat (to 1–2 times per week) and processed meats and increase consumption of blue fish, olive oil use and consume dairy products, as well as take advantage of all the elements comprising a Mediterranean diet.

  • Smoking avoidance

  • Moderate alcohol intake It is recommended that women abstain from drinking more than 20 g of alcohol per day. The following beverages equal 20 g of alcohol: 250 ml of beer, one glass of red wine (150 ml), or a quarter of a glass (25 ml) of a higher grade liquor (e.g., gin, whisky, anise, and tequila).

  • Use of complementary therapies Some of these therapies could interfere with patient treatment. Acupuncture must be properly performed and with necessary aseptic measures to minimize the risk of infection. Complementary or integrative therapies cannot substitute for a specific antitumor treatment.

  • Awareness of symptoms that indicate possible relapse or second tumors The following symptoms should be monitored: persistent bone pain that increases with movement and fails to remit with rest, persistent cough, dyspnea, asthenia, anorexia, or unexplained weight loss, vaginal bleeding in postmenopausal women, change in intestinal rhythm, rectal bleeding, or persistent headache or other neurological deficit. Thus, an early diagnosis can be made.

  • Confirmation of compliance with antiestrogenic hormone therapy Control and positive reinforcement to maintain the prescribed treatment even over prolonged periods (5–10 years).

  • Return to work Support and guidance appropriate to the patient’s stage of evolution. In the case of complementary treatment, it is recommended that patients wait for a reasonable time so that they can recover from the side effects of treatment.

  • Active alertness of the appearance of symptoms suggestive of heart disease.

Proposal of joint primary care and specialized care follow-up (Table 2)

Studies conducted thus far have revealed that radiological testing is not useful, except for yearly mammograms and that a PC physician or nurse can conduct follow-up if they are motivated and trained to care for the complications or morbidities that BCS present. Patient satisfaction will depend more on how they are treated than on where follow-up is undertaken. Studies have also concluded that relapses are detected similarly in PC or SC and that there are no differences in overall survival with any of the different follow-up schemes (with imaging studies and tumor markers compared with history, breast examination, and yearly mammogram), if the patient is guaranteed access to healthcare services in the presence of a symptom or sign of alarm [11].

Table 2 Proposed follow-up together with primary care
Full size table

However, long-term survivors who have overcome breast cancer require outstanding coordination and communication between PC and SC. It is proposed that patients already treated in the hospital be classified into three groups: (1) low risk; (2) intermediate risk, and (3) high risk. Table 2 summarizes the management recommendations coordinated between PC and SC.

Follow-up visits of female BCSs should include the following:

  • History aimed at ruling out warning signs of relapse or the presence of sequelae, comorbidities, or second neoplasms.

  • Adherence to adjuvant endocrine therapy when indicated.

  • A physical examination that includes examination of the breasts and adjacent node regions.

  • Bilateral, yearly mammograms in two projections, after conservative surgery of the breast or if the breast has been reconstructed. Annual follow-up visits will be maintained throughout their lifetime because these patients, unlike the healthy population who undergo biannual mammograms in screening campaigns, have a 5–10% probability of developing local relapse or a second neoplasm within 10 years post-treatment; this higher risk remains throughout their entire lives. Mammograms can be performed within the scope of PC or with the aid of the specialist in Obstetrics and Gynecology.

  • Recommendations for prevention and health promotion.

Role of the primary care physician

More and more women who have had breast cancer are being cared for in primary care. Optimal care by the PC physician includes the prevention, detection of relapses and possible second neoplasms, care for comorbidities, and the approach to late-onset effects of cancer treatment. It is also up to the PC physician to refer all women who have had breast cancer and present an accumulation of cases of cancer in the family to the reference Genetic Counseling Centers. The criteria for reference to a Genetic Counseling Center are as follows: having one or more first- or second-degree relatives with a breast or ovarian tumor under the age of 50; having a relative with bilateral breast tumors, having a male relative with breast cancer; having a relative with breast cancer with a triple-negative phenotype and less than 60 years of age [10]. Patients should also be referred to these centers when colon cancer is detected in different members of the family under the age of 50 at presentation.

Follow-up of BCS calls for a multidisciplinary approach and excellent coordination and communication between PC and SC. The oncologist should facilitate a case report when initiating and completing treatment; this report should include the type and clinical status of the tumor, treatment intent, treatments received, and toxicities that may have arisen during treatment. This information is fundamental to elaborating an individualized care plan that makes appropriate follow-up possible.

Below is the proposed minimum content that would be advisable to include in the report issued by SC to share patient information with PC:

Initial oncological report

  1. 1.

    Disease debut (symptom duration, origin [population screening programs, fast track diagnostics, PC physician, others]).

  2. 2.

    Diagnostic testing (imaging studies performed to determine the diagnosis, pathology results of biopsy with immunohistochemical report, clinical TNM).

  3. 3.

    Surgical procedure (if performed, and postoperative TNM).

  4. 4.

    Extension study, prognostic and predictive factors, results of the genomic study of the risk of relapse (if performed).

  5. 5.

    General treatment approach and anticipated date of initiation Medical Oncology’s treatment prescription:

    1. (a)

      Drugs

    2. (b)

      Sequence of administration. Courses

    3. (c)

      Anticipated duration.

  6. 6.

    Radiation treatment approach (when applicable):

    1. (a)

      Volumes to be treated, total dose, and fractioning.

    2. (b)

      Radiotherapy technique: 3D, IMRT, partial radiation, intraoperative radiation, source, and energy.

    3. 7.

      Prevention guidelines considering possible side effects of treatment.

    4. 8.

      Report if patient is participating in a Clinical Trial.

    5. 9.

      Estimation of time off work Consideration must be paid as to whether the time off work has to do with the characteristics of the workplace, associated risks, and compatibility with the degree of functioning following treatment.

    6. 10.

      Date of the next visit to SC. In some Autonomous Communities, the PC physician can consult them, but not in all of them.

Report upon completion of the initial phase of treatment

Once the initial stage of treatment is completed (surgery, treatment with chemotherapy, and/or targeted drugs and radiotherapy), after the first 6–15 months, a new stage opens. This period is no less important than the diagnostic stage, given the uncertainty surrounding the quality and continuity of life, during which information about the patient’s status must be shared again with PC physicians.

  1. 1.

    Regarding clinical situation during the initial stage of treatment.

    1. (a)

      Full report that includes the previously listed items (points 1, 2, 3, and 4);

    2. (b)

      All treatments received: radiotherapy, hormone therapy, or biological therapy, and if the patient has been included in a clinical trial. Treatment duration and related side effects and their treatment prevention (points 5 and 6);

    3. (c)

      Information about the risk of cardiotoxicity and type of cardiovascular monitoring undertaken;

    4. (d)

      Overall evolution;

    5. (e)

      Information regarding schedules for follow-up: tests and timing, outline of visits with SC.

  2. 2.

    Regarding clinical recommendations

    1. (a)

      Warning signs that a new appointment should be set up with SC;

    2. (b)

      Specific approach to lymphedema: when, how, and who to refer to;

    3. (c)

      Motor rehabilitation if necessary and recommendations regarding physical exercise;

    4. (d)

      Specific approach toward side effects of hormone medication. Recommendations for the prevention/treatment of osteoporosis and related side effects;

    5. (e)

      Control of mammary implants/expander/prosthetic replacement, and related events;

    6. (f)

      Dietary recommendations;

    7. (g)

      Special considerations regarding patients’ health issues and comorbidities, and

    8. (h)

      Complementary therapies and their repercussions.

  3. 3.

    Psychosocial and occupational recommendations

    1. (a)

      Specific aspects to be considered depending on the patient’s psychological situation, family and social impact. Need for specific social support;

    2. (b)

      Psychological approach. Fear of relapse;

    3. (c)

      Recommendations about sexuality and contraception;

    4. (d)

      Recommendations about returning to work or resuming previous activities. Pursuing a life path/professional plan, and

    5. (e)

      In certain women who want to be mothers, recommendations will be made about the best time to conceive. Young women who have preserved oocytes or ovarian cortex should be referred to Fertility Services at the Obstetrics and Gynecology Department.