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Common Issues in Breast Cancer Survivors


More breast cancer patients than ever before are being declared NED (no evidence of disease), after the completion of active breast cancer treatment and deemed “cured” or “in full remission” after they’ve remained cancer-free for at least five years.

Because of the great number of survivors, those who specialize in taking care of women with breast cancer find themselves under administrative pressure to ‘discharge’ survivors from their practice — suspend follow-up appointments — in order to accommodate new patients and to care for women with metastatic breast cancer.

This has shifted the burden of care in survivorship away from the cancer clinic entirely.

“Care of women who complete active therapy for breast cancer is shifting from the breast cancer specialist to other providers, including primary care providers and other specialists who are not as familiar with the evaluation and management of unique issues faced by many breast cancer survivors,” says Duke Cancer Institute breast medical oncologist and professor of Medicine Gretchen Kimmick, MD, MS.

Kimmick is the co-editor, with DCI clinical psychologist Rebecca Shelby, PhD, and Duke Cancer Network medical director Linda Sutton, MD, of a new first-of-its-kind textbook designed for all providers who “have the desire to improve the lives of those who have been treated for breast cancer.” 

Sutton, a professor of Medicine and medical oncologist who sees patients at Gibson Cancer Center and Scotland Cancer Treatment Center (Duke Cancer Network affiliates) and Kimmick, who sees patients at the Duke Cancer Center Breast Clinic in Durham, have treated and cared for thousands of women with breast cancer for almost three decades.

Shelby, an associate professor of Psychiatry and Behavioral Sciences and Population Health Sciences, is highly skilled in caring for breast cancer survivors and is specifically trained in both psycho-oncology and sex therapy. The combined expertise of these three editors brings great depth of knowledge and unique insights to each chapter.

Most of the 21 chapters in the 337-page book — titled "Common Issues in Breast Cancer Survivors: A Practical Guide to Evaluation and Management" — are co-authored by breast cancer specialist(s) and specialists outside the oncology field with expertise in the area of concern, including:

  • hot flashes
  • genito-urinary symptoms
  • of menopause
  • sexual concerns
  • arthralgias
  • breast pain
  • neuropathy
  • chemotherapy-related cognitive impairment
  • fatigue
  • sleep issues and insomnia
  • depression and anxiety
  • weight change
  • lymphedema
  • bone loss
  • heart and cardiovascular
  • disease
  • diabetes
  • skin and nail issues
  • hair loss

The book also brings attention to the role of genetics in breast cancer, available national and international guidelines for the care of breast cancer survivors, and special considerations in breast imaging in survivorship to screen for new breast cancers and cancer recurrence. And while the focus of this book is on caring for female breast cancer survivors, there’s also a chapter on special concerns related to male breast cancer survivors.

The international list of authors includes 40 plus specialists from Duke Cancer Institute and Duke Health, as well as specialists from the Mayo Clinic, Johns Hopkins Medical Institute, University of Melbourne (Australia), University of Rochester School of Medicine and Dentistry, Harvard Medical School, Dana Farber Cancer Institute, Ohio State University, UNC Health and UNC Lineberger Comprehensive Cancer Center, University of Texas MD Anderson Cancer Center, and Augusta Health.

While the volume was written with providers in mind, Kimmick suggests it may also be a useful resource for patients.

“The practice of medicine has become very complex, such that the subtleties of one sub-specialty can rarely be mastered by someone in general practice or another sub-specialty,” she says. “This can put more burden on patients, in terms of diagnosis and finding treatment management options. Our hope is that this book will serve as a resource to medical providers and patients alike.”

Leonor Corsino, MD, MHS
Leonor Corsino, MD, MHS

Ask a Duke Health Expert (a few chapter snapshots)


Leonor Corsino, MD, MHS (Diabetes chapter co-author, with Jasmine McNeill, MD, formerly at Duke)

Diabetes and Metabolism Specialist, Endocrinologist
Duke Endocrinology Clinic 1A (Durham, NC)
Duke Regional Hospital (Durham, NC)
Duke University Hospital (Durham, NC)

Assoc. Professor, Dept. of Medicine (Tenure),
Division of Endocrinology, Metabolism and Nutrition
Assoc. Professor, Dept. of Population Health Sciences
Assoc. Dean of Students Affairs, Duke School of Medicine
Assoc. Director, Master of Biomedical Sciences
Co-Director, Duke CTSI Community Engaged Research Initiative (CERI)

The Takeaway

Diabetes is such a common disease in the world and in this country that is hard not to see a patient without it. It is estimated that over 400 million people have diabetes in the world and in the U.S. a total of 34.2 million people have diabetes (10.5% of the US population)

Providers need to be aware of the association between diabetes and breast cancer and that diabetes cannot be ignored. Women with diabetes and breast cancer might have a higher risk of death.

I don't like to generalize, but in some cases the cancer treatment takes precedence and diabetes is completely off the radar. I think that is changing as providers become more aware of the impact of glycemic control (the typical levels of blood sugar (glucose) in a person with diabetes) in patients with cancer.

Treating diabetes in a patient with breast cancer should be a multidisciplinary approach; a collaborative team together aiming to help the patient navigate such a challenging process and time.

The information in this chapter applies to the treatment of all patients with breast cancer and diabetes, including survivors and those who are undergoing active treatment.

Patient Resources

I am not sure this chapter is written in a way that any patient might be able to benefit from it. Resources on this topic written with the patient in mind might be more digestible, such as the American Diabetes Association page on diabetes and cancer

Beyond Breast Cancer

There are some different regimens used for different cancers with different side effects so the experience for a breast cancer patient — in terms of diabetes-related side effects — might be different than for someone with another type of cancer.

The importance of glycemic control, however, is critically important for all providers and cancer patients to understand.

Elise A. Olsen, MD
Elise A. Olsen, MD

Hair Loss

Elise A. Olsen, MD (Hair Loss chapter, sole author)

Duke Dermatology Clinic - Clinic 3K (Durham, NC)

Professor, Dept. of Medicine
Professor, Dept. of Dermatology
Founder and Director, Cutaneous Lymphoma Research and Treatment Center
Founder and Director, Hair Disorders Research and Treatment Center
Duke University Medical Center

The Takeaway

This chapter is not about covering up hair loss, but rather it’s about finding out the cause and reviewing the hair loss treatments currently available and safe for breast cancer survivors to use.

Correct diagnosis by a dermatologist is the most important component of finding an appropriate treatment. Dermatologists are trained in the diagnosis and treatment of hair disorders. There are treatments for hair loss that can help, depending on the diagnosis and severity, and new treatments being developed all the time.

Hair loss in breast cancer patients may be caused by many things. Patients who have breast cancer may experience worsening of a prior hair loss condition, hair loss related to their chemotherapy or endocrine therapy, or a new condition unrelated or aggravated by prior cancer treatment.

The type, dose and time course of chemotherapy that women receive will determine the amount of hair loss they have during treatment as well as whether full recovery of hair growth occurs after treatment.

Other treatments besides chemotherapy, such as medications that reduce estrogen (aromatase inhibitors for example) may either cause or unveil an underlying female pattern hair loss.  This type of hair loss occurs primarily on the top of the scalp as opposed to chemotherapy related hair loss that occurs all over the scalp.

Patient Resources

I think this would be an excellent book for breast cancer patients, either going through treatment or afterwards.  

Beyond Breast Cancer

Providers who treat female cancer patients who have another cancer (not breast cancer) can also benefit from this chapter.

Issues of hair loss occur in all cancer patients — women or men — who receive chemotherapy, the difference being the type, dose and time course of the chemotherapeutic agents utilized. Only patients with certain types of cancer include treatment with estrogen inhibitors. Where used, the same issues apply. 

Patrick Cacchio, PA-C, MHS
Patrick Cacchio, PA-C, MHS

Bone Loss

Patrick Cacchio, PA-C, MHS (Bone Loss chapter co-author with Jennie Petruney, MSN, ANP-BC, and Kenneth Lyles, MD)

Physician Assistant specializing in metabolic bone disorders, including osteoporosis
Duke Endocrinology Clinic - Clinic 1A (Durham, NC)
Duke Endocrinology at Brier Creek  (Raleigh, NC)

The Takeaway

Our chapter provides a guide to the diagnostic evaluation and management of bone loss in women who have a history of breast cancer.  

Bone loss is common as women age and is frequently under-diagnosed and under-treated.

Postmenopausal breast cancer survivors are at an even increased risk of bone loss, particularly those with hormone receptor positive breast cancer who may be taking an aromatase inhibitor as adjuvant therapy. Fractures in this population of patients are associated with increased morbidity and mortality, which could often be prevented with early diagnosis and treatment.

We hope this chapter will serve as a valuable resource to all who provide care to patients who have been diagnosed and treated for breast cancer, regardless of their specialty or background.

Patient Resources

For patients and families, there are excellent programs and information available from the National Bone Health & Osteoporosis Foundation.

Heather N. Moore, PharmD, BCOP, CPP
Heather N. Moore, PharmD, BCOP, CPP


Heather N. Moore, PharmD, BCOP, CPP
(Neuropathy chapter co-author, with Mallika Weant, PHARMD, Kimberly Slawson, MSN, FNP-CCarey Anders, MD, and Anne Marie Fras, MD)

Clinical Oncology Pharmacist, Breast Oncology
Duke Cancer Center Breast Clinic (Durham, NC)

The Takeaway

Neuropathy is a common side effect of breast cancer treatment that is not always adequately addressed by providers. There are multiple mechanisms for neuropathies that can impact the best treatment option. Our chapter provides a great review of these mechanisms and provides treatment recommendations, based upon current literature/data support, that can be most helpful for our patients.

Many therapies have been studied, but not all have support in the literature to recommend their use.

While treatment of neuropathies in breast cancer patients is predominantly managed by oncologists, as patients continue into survivorship for many years this responsibility is shared by primary care, the survivorship clinic, and neurology for more complicated patients.

Beyond Breast Cancer

Chemotherapy- induced neuropathies are common across many malignancies. Taxanes, a class of chemotherapy drugs, are utilized in many cancer types. Thus, other providers utilizing these therapies can also benefit from this section of the book.

Gretchen Kimmick, MD, MS
Gretchen Kimmick, MD, MS


Gretchen Kimmick, MD, MS (Arthralgias chapter co-author, with Rachel Pienknagura, PA-C, MMS, and Sophia Weinmann, MD)

Breast Medical Oncologist
Duke Cancer Center Breast Clinic (Durham, NC)

Professor, Dept. of Medicine, Division of Medical Oncology

The Takeaway

Arthralgia is common as we age and is a side effect in some women taking an aromatase inhibitor. A provider may down-play the significance of the side effect on a woman’s life, in light of the great number of lives saved with the medicine. However, acknowledging, managing and alleviating this symptom may help women stay on treatment, a potentially life-saving medicine. 

Treatment of arthralgia falls on all of these disciplines — oncology, rheumatology and primary care — most importantly, it should be recognized as important and manageable. 

Beyond Breast Cancer

Though this chapter was written with patients on adjuvant endocrine therapy for breast cancer in mind, the evaluation and management recommendations in this chapter apply to most postmenopausal women and patients with arthralgias in general. 

DCI Adult Cancer Survivorship Clinic

Our Survivorship Clinic providers specialize in oncology and family medicine. We focus on the late and long-term effects caused by cancer treatments. This includes monitoring for cancer return. We work with you, your oncologists, and primary care teams to form the best plan to help you live a fuller life after treatment.

Learn more about our Survivorship Clinic
This page was reviewed on 02/19/2024