Physician Discharge Letter

Dear Doctor:

Your patient ________________ is being discharged from the Cancer Center back to your care for continued follow-up. We ask that you schedule regular follow-up visits and recommend the following schedule, consistent with Canadian Medical Association guidelines:

For all patients after breast cancer treatment:

Clinical examination every 6 months for 2 years, and then annually.
Clinical examination should consist of examination of the breast(s), chest wall, supraclavicular and axillary lymph nodes, auscultation of the chest and palpation of the liver.

Annual diagnostic mammography (which may be performed at the Cross Cancer Institute or any other accredited mammography facility).
For any patient with a history of breast cancer, the use of estrogen, raloxifene or any hormone replacement therapy is contraindicated.
Routine investigations (e.g. bone scans, ultrasound of the abdomen, chest X-ray, laboratory tests) are not recommended for asymptomatic patients.

For patients receiving tamoxifen:

Patients receiving tamoxifen are at a slightly increased risk of deep vein thrombosis and endometrial cancer.
Patients experiencing abnormal vaginal bleeding should be referred to a gynecologist.

For patients receiving aromatase inhibitors (e.g.: anastrozole/Arimidex, exemestane/Aromasin, letrozole/Femara):

Patients receiving aromatase inhibitors are at risk for developing osteopenia and/or osteoporosis.
Baseline and annual bone density (DEXA scans) should be performed and treated according to clinical practice guidelines.
Standard recommendations in terms of optimizing bone health: Calcium 1,000 to 1,500 mg per day, Vitamin D 800 - 1000 IU per day, regular physical activity, and risk factor modification should apply.
Raloxifene (Evista) is not recommended for treatment of osteoporosis in patients with a previous breast cancer diagnosis.

You may write the prescription for your patient, and the Cancer Centre Pharmacy will dispense the medication. Your office may also fax the prescription the Cancer Center for it to be mailed you your patient.

Signs and Symptoms of Local Recurrence or Metastatic Disease:

If your patient is having any of the following symptoms we recommend that you schedule the appropriate investigations and copy the results to the Cancer Centre:

Signs & Symptoms of Local Recurrence or Metastatic Disease
Symptom	Investigation
new mass in breast	mammography (possibly with biopsy)
rash or nodule on chest wall	biopsy if only site of possible recurrence
palpable lymphadenopathy	biopsy if only site of possible recurrence
new persistent bone pain	bone scan and plain films of affected site(s)
new persistent cough or dyspnea	chest xray
hepatomegaly or pain in the right upper quadrant	ultrasound and/or CT scan of abdomen plus liver enzymes
other symptom(s) / finding(s)	dependent on specific problem(s)

URGENT referral to the cancer Centre is recommended for ANY of the following symptoms:
back pain with limb weakness, change in sensation, change in reflexes, or loss of bowel/bladder control	urgent referral to Radiation Oncologist for possible spinal cord compression
new persistent headache (especially with visual changes, nausea or seizures)	urgent referral to Radiation Oncologist for possible brain metastases
altered level of consciousness, nausea, vomiting, and/or pain associated with hypercalcemia	urgent referral to Medical Oncologist for management of hypercalcemia

If at any time you have concerns regarding possible local or metastatic recurrence and require an urgent referral, please contact our Appointment Booking office and we will arrange to see the patient. Should you have any specific questions, one of the oncologists in Radiation Oncology or Medical Oncology will speak with you.

We appreciate your partnership in caring for this patient,

Alberta Breast Cancer Program Team (www.albertabreast.com)

References:

Aromatase Inhibitors

American Society of Clinical Oncology Technology Assessment on the Use of Aromatase Inhibitors As Adjuvant Therapy for Postmenopausal Women With Hormone Receptor-Positive Breast Cancer: Status Report 2004. JCO. January 20, 2005;23(3) (http://www.jco.org/cgi/reprint/JCO.2005.09.121v2)
Cancer Care Ontario: Clinical Breast Cancer Evidence-based Series and Practice Guidelines. The Role of Aromatase Inhibitors in Adjuvant Therapy for Postmenopausal Women with Hormone Receptor-positive Breast Cancer. 1-18EBS. October 2005. (http://www.cancercare.on.ca/pdf/pebc1-18s.pdf).

Breast Cancer Surveillance

American Society of Clinical Oncology: 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology Vol 24(31) November 1, 2006, pp 5091 - 5097 and Flow Sheet.
Clinical practice guidelines for care and treatment of breast cancer: follow-up after treatment for breast cancer *summary of the 2005 update). CMAJ. May 10, 2005;172(10) (http://www.cmaj.ca/cgi/content/full/172/10/1319/DCI1/1).

Osteoporosis

Osteoporosis Society of Canada Web Site (http://www.osteoporosis.ca)
2002 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canda CMAJ, November 12, 2002. (http://www.cmaj.ca/cgi/content/full/167/10_suppl/s1)
Recommendations for Bone Mineral Density Reporting in Canada. Can Assoc Radiol J 2005;56(3):178-188.
Canadian Consensus Conference on Osteoporosis, 2006 update. J Obstet Gynaecol Can. 2006 Feb 28(2 Suppl 1) S95 - S112.
WHO Fracture Risk Assessment tool

Lipids

Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update. CMAJ 2003;169:921-924.

This report is disclosed to the providers copied per HIA s.35(1)(b) for continuing care, and is privileged and confidential. If you receive it in error, please phone the Alberta Cancer Board immediately at (780) 432-8292.