Life after breast, prostate, and colon cancer: Primary care’s role

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When patients survive cancer, they eventually come back to their primary care physicians. This group has special needs, including surveillance for recurrent and new cancer, health promotion, and interventions to mitigate the lingering effects of the cancer and the adverse effects of its treatment.


  • The American Society of Clinical Oncology has developed evidence-based recommendations for follow-up care and surveillance for new and recurrent cancer in cancer survivors. In general, this surveillance should be more frequent in the first months and years after cancer treatment but can become less so as time goes on.
  • Health promotion in cancer survivors involves the same advice regarding smoking cessation, diet, exercise, and mental health that all patients require.
  • Depending on the type of cancer and treatment, long-term adverse effects include fatigue, sexual dysfunction, osteo­porosis, neuropathy, bladder and bowel dysfunction, and cardiovascular disease.
  • A survivorship care plan can be drawn up with input from the patient, oncologist, primary care physician, and other caregivers so that everyone can be clear as to what is going on.



In 2015, about 1.6 million Americans received a diagnosis of cancer.1 In 2012, when 13.7 million people were living with cancer in the United States, the estimated 5-year survival rate of all cancers was 66.5%.1 Today, breast, prostate, and colon cancers have 5-year survival rates of 89.4%, 98.9%, and 64.9%, respectively.

With this rising trend in survival, primary care physicians have been steadily assuming the long-term care of these patients. The phrase “cancer survivorship” was coined by the National Comprehensive Cancer Network to describe the experience of living with, through, and beyond a cancer diagnosis.2

As cancer becomes a chronic medical condition, the primary care physician assumes a vital role in the treatment of the unique and evolving needs of this patient population.

This article discusses the specific needs of patients surviving breast, prostate, and colon cancer with special focus on surveillance guidelines for recurrence, development of concomitant malignancies, assessment of psychosocial and physical effects, and disease conditions related to the treatment of cancer itself.


Follow-up care in patients being treated for cancer is vital to survivorship. It includes promoting healthy living, managing treatment side effects, and monitoring for long-term side effects and possible recurrence.

Patients previously treated for malignancy are more susceptible to second primary cancers, for an array of reasons including the effects of prior treatment, shared environmental exposures such as smoking, and genetic susceptibility.2 Therefore, it is important for the primary care physician to recognize signs and symptoms and to screen cancer survivors appropriately. The American Society of Clinical Oncology (ASCO) has developed evidence-based recommendations for follow-up care,3 which we review here.

Breast cancer

For breast cancer patients, history and physical examinations are recommended every 3 to 6 months for the first 3 years, every 6 to 12 months in years 4 and 5, and annually thereafter.3

A repeat mammogram should be performed 1 year after the initial mammogram that led to the diagnosis. If the patient underwent radiation therapy, a repeat mammogram of the affected breast should be done 6 months after completion of radiation. Finally, a mammogram should be done every 6 to 12 months thereafter.3 It is also recommended that patients perform a monthly breast self-examination, but this does not replace the annual mammogram.3

Women who are treated with tamoxifen should have an annual gynecologic assessment if they have a uterus and should be encouraged to discuss any abnormal vaginal bleeding with their physician, given the increased risk of uterine cancer.2

ASCO does not recommend routine use of complete blood cell counts, complete metabolic panels, bone scans, chest radiography, computed tomography, ultrasonography, positron-emission tomography, or tumor markers in patients who are asymptomatic.3

Prostate cancer

ASCO’s recommendations for patients recovering from prostate cancer include regular histories and physical examinations and general health promotion. Prostate-specific antigen (PSA) testing is recommended every 6 to 12 months for the first 5 years after treatment and annually thereafter. More frequent PSA testing may be required in men at higher risk of recurrence or in patients who may undergo additional treatment, including radiation and surgery.4 Higher risk of disease recurrence is thought to depend on disease-specific factors at the time of original diagnosis including pretreatment PSA, Gleason score, and tumor stage.4 This should be discussed between the oncologist and primary care physician.

In regard to digital rectal examinations, the oncologist and primary care physician should jointly determine the frequency of examination. The frequency of digital rectal examinations remains an area of controversy due to their low sensitivity for detecting recurrences. Digital rectal examinations may be omitted in patients with undetectable levels of PSA.4

In regard to second primary malignancies, prostate cancer survivors who have undergone pelvic radiation therapy have a slightly higher risk of bladder and colorectal cancer. The lifetime incidence of bladder cancer after pelvic radiation is 5% to 6%, compared with 2.4% in the general population.1,5 A prostate cancer survivor presenting with hematuria should be referred to a urologist for cystoscopy and evaluation of the upper urinary tract to rule out cancer.4

Similarly, patients presenting with rectal bleeding should be referred to a gastroenterologist and the treating radiation oncologist for complete evaluation. The risk of rectal cancer after pelvic radiation therapy increases to about the same level as in someone who has a first-degree relative with colorectal cancer.5 Therefore, it is recommended that patients undergo screening for colorectal cancer in conjunction with existing evidence-based guidelines. There is no evidence to suggest that increased intensity of screening improves overall or disease-specific survival.4

Colon cancer

In patients with resected colorectal cancer, continued surveillance is important to evaluate for recurrent cancer as well as for metachronous neoplasms. Consensus statements indicate that surveillance colonoscopy should be continued for those who have undergone surgical resection for stage I, II, or III colon or rectal cancers, and for those patients with stage IV who have undergone surgical resection with curative intent.6

Patients who undergo curative resection of rectal or colon cancer should have a colonoscopy 1 year after resection or 1 year after the colonoscopy was performed, to clear the colon of synchronous disease. Subsequently, if the colonoscopy done at 1 year is normal, the interval before the next colonoscopy is 3 years. If that colonoscopy is normal, the next colonoscopy is in 5 years. Time intervals may be shorter if there is evidence of hereditary nonpolyposis colorectal cancer or adenoma.

Patients who underwent low anterior resection of rectal cancer should undergo periodic examination of the rectum to evaluate for local recurrence. Although effectiveness is not proven, endoscopic ultrasonography or flexible sigmoidoscopy is suggested at 3- to 6-month intervals for the first 2 to 3 years after resection. This is independent of colonoscopy.6,7

Additionally, ASCO recommends a history and physical examination and carcinoembryonic antigen testing every 3 to 6 months for the first 5 years. Computed tomography of the chest, abdomen, and pelvis should be done annually for the first 3 years after the end of treatment.7

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