Wellbeing & psychosocial care

Ongoing assessment for toxicities/late effects

In patients with breast cancer ensure that follow-up care includes ongoing assessment and supportive care for possible long-term toxicities and late effects of adjuvant treatments (including secondary cancers, cardiovascular toxicity, lymphoedema, mental health (including distress, depression, anxiety, body image), sexual health, premature menopause, infertility, fatigue, weight gain, impaired cognitive function, musculoskeletal health, pain and neuropathy, and bone health).

Psychosocial assessment – General

Pay attention to the emotional needs of the person diagnosed with breast cancer and undertake psychosocial screening as soon as possible after breast cancer diagnosis and at the commencement of any new treatment. Use a validated and reliable measure that features reportable scores that are clinically meaningful, with established cut-offs.

Lymphoedema – Risk minimisation #2

When informing patients with breast cancer about the risk of developing lymphoedema or breast or chest wall oedema, advise them of the importance of using the treated arm in daily activities and of regular participation in physical activities and maintenance of a healthy weight to minimise the risk of lymphoedema/oedema. 

Treatment-related pain – Management

Where treatment-related pain is present, offer interventions such as paracetamol and non-steroidal anti-inflammatory drugs. Consider referral to a specialist practitioner (e.g. lymphoedema therapist, occupational therapist, or pain specialist) as appropriate, depending on the underlying cause of the pain. 

Psychosocial assessment – High risk

A detailed psychosocial assessment should be undertaken for patients at a higher risk of depression, e.g. patients with a history of mental health issues, patients with caring responsibilities, patients under financial stress, young patients, and those with multiple stressors.

Treatment-related arthralgia – Management

In patients with breast cancer who are experiencing arthralgia, encourage physical activity/exercise as exercise reduces musculoskeletal symptoms. If exercise or NSAIDs are unsuccessful, consider changing to a different aromatase inhibitor, use of duloxetine, or switching to tamoxifen. 

Psychosocial assessment – Referral

If signs of distress, depression, or anxiety are present, consider offering patients referral to counselling and/or appropriate psycho-oncology and mental health resources as clinically indicated.

Endocrine therapy and bone health – Advice to patients

Advise patients on the importance of weight-bearing exercise and on adequate calcium intake and vitamin D levels.

Cognitive impairment – Assessment and management

If cognitive impairment in association with breast cancer or its treatment is suspected, assess for and treat reversible contributing factors (e.g. thyroid dysfunction), discuss coping strategies, and offer referral to an appropriate health professional (geriatrician, neurologist, psychiatrist or psychologist) experienced in the assessment and management of cognitive impairment.

Return to work – Vocational rehabilitation

For patients contemplating returning to work, consider referral for vocational rehabilitation programs where available

Fatigue management and referral

Offer therapy or referral, as appropriate, for factors that may impact on or cause fatigue (e.g. depression, sleep disturbance, pain, anaemia, lymphoedema, thyroid or cardiac dysfunction). For those patients who do not have an otherwise identifiable cause of fatigue, offer referral to appropriate assessment and treatment services (such as a psychologist). 

Return to work – Caring duties support

Be aware that returning to work or caring duties after breast cancer treatment is often a challenge and that extra professional support may be needed (e.g. psychological services). 

Fear of recurrence

Ask patients if they are worried about the cancer recurring. Assess whether these worries are having a significant impact on their life and if so, offer referral to a psychologist.

Anxiety and depression

Diagnose and treat anxiety and depression in patients with breast cancer the same way as in the general population, noting that anxiety and depression reduce an individual’s ability to cope with disease and treatment burden. Be aware that menopausal symptoms and anxiety and depression are interconnected: treatment of menopausal symptoms may improve anxiety and depression (particularly via the resolution of sleep disturbance), while treatment of anxiety and depression may improve an individual’s ability to cope with menopausal symptoms.

Healthy lifestyle advice – Physical activity

Advise patients to undertake regular aerobic exercise and resistance exercise (strength training) before, during and after breast cancer treatment appropriate to their treatment and tailored to their general health, medical condition and fitness.

Treatment-related peripheral neuropathy – Assessment and management

Assess for peripheral neuropathy in relation to chemotherapy by asking patients about their symptoms, specifically symmetrical numbness and tingling in their hands and/or feet, and the characteristics of the symptoms. Physical activity and/or duloxetine may be helpful in the treatment of peripheral neuropathic pain, numbness, and tingling. Be aware that asymmetrical numbness of the hands may be due to carpal tunnel syndrome, which is more common in women with breast cancer on endocrine therapy and will require different management.

Healthy lifestyle advice – Sedentary behaviour

All patients with breast cancer should be advised to avoid inactivity and continue normal daily activities after diagnosis, and during and after breast cancer treatment, where possible.

Menopausal symptom management – Complementary or alternative therapies

Advise patients that there is negative or insufficient evidence of the effectiveness of other complementary or alternative therapies for the management of hot flushes, night sweats or vaginal dryness.

Healthy lifestyle advice – General

Advise all patients with breast cancer that a healthy lifestyle is associated with a lower risk of recurrence and improved survival. Discuss how a healthy lifestyle includes achieving and maintaining a healthy weight, limiting alcohol intake, cessation of smoking and undertaking regular physical activity.

Healthy lifestyle advice – Smoking cessation

Strongly encourage all patients with breast cancer to stop smoking. Advise patients that smoking increases the risk of complications of treatment (e.g. wound infection, deep vein thrombosis) and breast cancer recurrence, and worsens vasomotor symptoms.

Cardiac risk assessment

A baseline cardiac risk assessment, including an echocardiogram, should be undertaken for patients whose treatment will include chemotherapy (especially anthracyclines) or HER2 therapy (especially trastuzumab) or left-sided radiation therapy.

MDT treatment planning – Pregnant women

Include obstetricians and perinatologists in the multidisciplinary team (MDT) for the treatment of patients with breast cancer during pregnancy. Particular attention should be paid to each woman’s preferences and psychosocial needs due to the higher likelihood of distress.

MDT treatment planning – Cardiac care

Close and early collaboration between oncologists and cardiologists is recommended for those patients that require treatment with a potentially cardiotoxic treatment, particularly in the context of existing cardiovascular disease or multiple cardiovascular risk factors.

Treatment planning considerations – Older patients

Generally, age alone should not dictate treatment decisions, however all management decisions for an older patient should consider life expectancy; potential risks versus absolute benefits; treatment tolerance; patient preferences; potential barriers to treatment; polypharmacy; and assessment of functional status, comorbidities, falls, depression, cognition, nutritional status and social situation.

Fatigue and physical activity

In patients with breast cancer who are experiencing fatigue, encourage physical activity as exercise counteracts the adverse effects of cancer and its treatment.