BREAST CANCER REVIEW 

Breast Cancer in the U.S.

Anatomy and Pathology

Risk Factors

Detection and Screening

Diagnosis and Staging

Treatment Options

Breast Reconstruction

Follow-Up Care and Support

Follow-Up Care and Support

Introduction

The goals of follow-up care and support are to detect potentially treatable, recurrent breast cancer; screen for new primary breast cancer; screen for other cancers (as recommended by surveillance guidelines); monitor and manage late and long-term treatment effects; and address psychosocial and practical issues that may arise as the result of breast cancer and its treatments.

Follow-Up Medical Visits

A primary concern of follow-up care is the early detection of potentially treatable, recurrent breast cancer. Besides recurrence, patients should be routinely screened for a new cancer that may develop in the preserved or contralateral breast (i.e., a second breast primary). In addition, women who have had breast cancer are at increased risk for developing other secondary cancers.¹ Studies have shown a 20-30 percent increased risk for a second cancer in various sites, including the endometrium, ovary, thyroid, lung, soft tissue, blood, skin, stomach and colon, with higher risks among younger patients.² Follow-up surveillance should address these risks, and also the known long-term side effects of treatment, such as tamoxifen with its increased risk of endometrial cancer and to a lesser extent, uterine sarcoma.³ Ongoing participation from the primary care provider (PCP) helps to ensure patient compliance with recommended guidelines and facilitates a coordinated system of care.

The medical provider should be experienced in surveillance recommendations and breast exam, including examination of irradiated breasts. A recent randomized study showed family physicians did an equally good job as oncologists in following women with early breast cancer for recurrences and quality of life issues.⁴ If follow-up is transferred to a PCP, the PCP and the patient need to be informed of the long-term options regarding adjuvant hormonal therapy for the particular patient. This may necessitate re-referral for oncology assessment at intervals consistent with guidelines for adjuvant hormonal therapy.^5, 6

In October 2006, the American Society of Clinical Oncology (ASCO) revised their guidelines for the continuing care of women who have been treated for breast cancer.⁷ Follow-up care should be individualized according to patient circumstances (type of treatment received, overall health, etc.) as determined by the judgment of the physician. For additional information, please see American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-up and Management Guideline in the Adjuvant Setting.⁸  A comparison table of the 2006 revision guidelines to those developed in 1998 is also available (see 2006 Update Revisions Table - toolbox sidebar). Lastly, a patient version of the ASCO Guidelines can be found on the People Living with Cancer web site (Patient Guide: Follow-Up Care for Breast Cancer).

ACSO recommendations for follow-up care:

• Medical History/Eliciting of Symptoms every 3-6 months for the first 3 years after primary therapy, then every 6-12 months for 2 years, then annually. (Patients should be educated about symptoms of recurrence. )
• Physical Examination every 3-6 months for the first 3 years after primary therapy, then every 6-12 months for 2 years, then annually.
• Breast Self-Examination should be instructed and performed monthly. 
• Mammogram annually. (First post-treatment mammogram 1 year after the initial mammogram that leads to diagnosis, but patients who have had breast conserving surgery should have their first post-treatment mammogram 6 months after completion of radiation, then annually or as indicated. Patients who have had a mastectomy still require regular mammograms.)
• Pelvic Examination annually. (Patients who take or have taken tamoxifen should be asked specifically about vaginal discharge or bleeding. Routine endometrial biopsies are not recommended. Longer intervals may be appropriate for women who have had a total abdominal hysterectomy and oophorectomy per CDC guidelines.)

For asymptomatic women in good physical condition, ASCO does not recommend:

• Chest x-ray
• Bone scan
• Ultrasound of liver
• Computed tomography scan (also referred to as computerized axial tomography)
• FDG-Pet scanning
• Breast MRI
• Breast cancer tumor markers CA 15-3, CA 27.29, and CEA
• Complete blood count*
• Chemistry studies (i.e., tests for liver and kidney function, protein, albumin, and calcium levels)* ⁹

*Some tests, such as complete blood count (CBC) and chemistry studies, will be routinely performed during regular annual physical examinations.

Screening for other cancers should be done in accordance with recommended guidelines for the general population. Women at high risk for inherited forms of breast or ovary cancer syndromes may benefit from additional surveillance for cancer of the ovary, including pelvic ultrasound and measurement of blood CA-125 levels, although the benefits of such surveillance are not known.¹⁰ 

Controversy Over Follow-up Schedule and Screening Tests

Some oncologists have noted that the "measure of the utility of surveillance tests is that the tests detect disease before the onset of symptoms, and that treatment when the disease is asymptomatic leads to better survival or improved quality of life."¹¹ In the case of metastatic breast cancer, there is no scientific evidence that treatment of asymptomatic women improves survival or survival quality compared with treatment at the onset of symptoms. As reported by the National Cancer Institute (NCI), even when bone scans, liver sonography, chest x-rays, and blood tests of liver function "permit earlier detection of recurrent disease, patient survival is unaffected."¹² This lack of treatment advantage, coupled with the issue of  false-positive tests and their inherent risks and uncertainties, is considered by some medical experts to "contravene the use of intensive screening in breast cancer follow-up."^13, 14 Nevertheless, it should be noted that both the frequency of follow-up and the appropriateness of screening tests after the completion of primary treatment remain controversial.

Top

Recurrent Breast Cancer

Breast cancer can recur at any time throughout the patient’s lifetime. A recently published overview by the Early Breast Cancer Trialists' Collaborative Group looked at 15-year breast cancer recurrence and survival rates, and although the hazard ratios for recurrence are highest during the first few years after diagnosis, there seems to be a steady relapse rate through 15 years and beyond. They found in women with estrogen receptor–positive breast cancer treated with tamoxifen for 5 years, the 15-year probability of death from breast cancer is more than 3 times as great as the 5-year probability. This suggests that the majority of breast cancer recurrences occur more than 5 years after diagnosis when patients are observed for more than 15 years. These findings have implications for long-term breast cancer surveillance and for choice of adjuvant endocrine therapy.¹⁵

Risk of recurrence increases with lymph node involvement at diagnosis and with increases in primary tumor size and number of positive lymph nodes. Other prognostic factors include tumor grade, hormone receptor status, and the oncogene expression of the primary tumor. In general, women with more aggressive forms of breast cancer are at greater risk for recurrence than other women. To reduce this risk, patients are often treated with adjuvant therapies.

Breast cancer can return locally, regionally, or it can metastasize to distant locations in the body. The most common sites of breast cancer recurrence are the local area of the breast or chest wall and distant sites. Regional breast cancer recurrences are least common, occurring in approximately 2% of all breast cancer cases.¹⁶ If breast cancer metastasizes, it most commonly spreads to the bone, lungs or liver. It may also spread to other sites, such as the brain, adrenal glands, ovaries, or elsewhere.

• Local recurrence is cancer that recurs in the same location, or close to the same location, as the original cancer. (Local recurrence is possible even after mastectomy, since some breast skin and fat remain.)
• Regional recurrence describes breast cancer that has spread beyond the location of the original cancer and nearby lymph nodes, but remains within the chest region.
• Distant recurrence is cancer that has metastasized through the lymph system or bloodstream to another region of the body, such as the bone, lungs, liver, or other areas.

Long-Term and Late Treatment Effects

Another concern of follow-up care are long-term and late treatment effects, also called aftereffects. Below are some of the potential aftereffects associated with treatments for breast cancer. Patients should be informed of potential aftereffects related to their individual treatments. They should be told what symptoms to look for, how to reduce risks, and how best to manage any that may occur. (For symptom management, providers are referred to ASCO's information summaries, adapted from ASCO's Optimizing Cancer Care: The Importance of Symptom Management.)  

Surgery: Surgical procedures in the treatment of breast cancer can affect the nerves, muscles, and lymph glands in the chest region and upper body. Two of the most common aftereffects are limited arm movement and lymphedema. Lymphedema occurs in as many as 15% of women who undergo axillary lymph node dissection (ALND) and may develop soon after surgery or years later. Risk is higher when ALND is followed by radiation therapy and much lower for women who undergo sentinel lymph node biopsy (SLNB).²² Other common complications of breast surgery are bleeding, seromas, and infections. Breast surgery may also be associated with long-term residual numbness or pain.

Radiation Therapy:  Radiation to the chest area may cause skin changes, including skin reddening, darkening or thickening, itching or peeling (as if sunburned), enlarged pores, broken blood vessels near the skin's surface (telangiectasia), and increased or decreased skin sensitivity, among other changes. Post-treatment side effects may also include breast soreness and possible stiffness in the shoulders. As with surgery, radiation therapy to the lymph nodes can lead to lymphedema. Another possible complication may occur with radiation to the chest area, which can cause scarring of the lungs (pulmonary fibrosis).²³ Chest area radiation also increases risk for certain secondary cancers, including chest wall sarcoma and ipsilateral lung cancer, although such late effects are rare.²⁴ Also rare are rib fractures, brachial plexopathy, pneumonitis, and myocardial infarction.²⁵ Patients treated with internal radiation (brachytherapy) may experience many of the same side effects as those described, in addition to breast tenderness or tightness.

Chemotherapy: Late and long-term side effects of chemotherapy vary greatly from patient to patient and from drug to drug. Fatigue, often associated with anemia, is most common. Women treated with multiple therapies (e.g., radiation, chemotherapy, biological therapy); patients with advanced disease; and the elderly are at greater risk. Weight gain is another possible aftereffect with certain chemotherapeutic drugs, especially for premenopausal women and patients who have had prolonged treatment.²⁶ For perimenopausal women (within 10 years of menopause), chemotherapy can trigger the end of menstruation and fertility. Symptoms associated with natural menopause may follow, such as hot flashes, mood changes, vaginal dryness, and loss of libido. (Premature menopause is uncommon in women younger than 30 years.)²⁷ Chemotherapy can also impact cognitive functioning for up to 10 years after treatment, resulting in concentration deficit and memory loss.^28, 29 Congestive heart failure, which may develop months or years later, occurs in a small proportion of women (0.5% - 1.0%) treated with standard-dose, anthracycline-based chemotherapy regimens.³⁰ Myelodysplastic syndrome and acute myeloid leukemia are also rare complications of some chemotherapy regimens.³¹ In general, patients treated with chemotherapy have lowered resistance to infections due to weakened immune systems, and should be monitored for symptoms (e.g., fever, chills or sweating; redness, swelling, or pain, particularly around a cut or wound, etc.).

Hormone Therapy: For women with breast cancer, hormone therapy is used to lower the risk of recurrence. The recommended hormone therapy includes tamoxifen, aromatase inhibitors, the combination of these, or SERDs. All are used to treat metastatic breast cancer.³² During treatment, the most common side effects with tamoxifen are hot flashes, nausea, irregular menstrual cycles, and vaginal irritations. A small number of women who take tamoxifen may experience mood swings and/or depression.³³ Risk of endometrial cancer is a potential serious complication with tamoxifen. About 1.5% of postmenopausal women taking tamoxifen develop endometrial cancer over 10 years, a rate 3 times that of women not taking tamoxifen.³⁴ Additionally, recent research indicates that women who have used tamoxifen have an increased risk, although very small, of developing uterine sarcoma.³⁵ Other potential serious complications are deep venous thrombosis, pulmonary emboli, and stroke. Incidence of these conditions is less than 1% but increase with patient age.³⁶ Cataracts, corneal scarring, and retinal changes have been reported in a few patients.³⁷ Side effects of aromatase inhibitors (e.g., etrozole (Femara), anastrozole (Arimidex), exemestane (Aromasin) may include hot flashes, joint and muscle aches, nausea, constipation, diarrhea, headache, back pain and bone loss. Side effects of SERDs (e.g., fulvestrant (Faslodex)) are similar to those of aromatase inhibitors.³⁸ Postmenopausal women receiving aromatase inhibitors and premenopausal women receiving therapy associated with premature menopause are at high risk of osteoporosis.³⁹

Biological Therapy: Most biological therapies are still considered experimental for treating breast cancer, however, trastuzumab (Herceptin), a monoclonal antibody, has been used since 1998 to treat HER–2 positive cases of advanced breast cancer. In November, 2006 trastuzumab was approved and incorporated to treat earlier stages of breast cancer that overexpresses HER-2.⁴⁰ Most common side effects with trastuzumab are flu-like symptoms, which usually improve after the first treatment. Anemia and infection, primarily mild upper respiratory infection, are also possible side effects, especially in patients receiving trastuzumab with chemotherapy. In rare cases, trastuzumab may cause severe allergic reactions, respiratory distress, or heart muscle damage that can lead to heart failure. Patients considered for trastuzumab should have their heart and lung functions evaluated before beginning treatment. Once on trastuzumab, patients should be closely monitored.⁴¹ For more information on these potentially serious side effects and their symptoms, please see NCI Factsheet: Herceptin® (Trastuzumab): Questions and Answers.

Top

Psychosocial Issues

It is common for patients to have strong emotions as a result of their experience with breast cancer. For some, emotions may be experienced immediately; for others, emotional reactions to the cancer may not surface for months or years later. For all patients, their social and emotional requirements should be continually assessed by the primary care provider (PCP). Beginning with the moment of diagnosis, the PCP should be a resource for referral to information services, support groups, and/or mental health counseling as needed. In addition, the PCP should be prepared to advise consultants of their patients' social and emotional circumstances.⁴² Although the need for support services can occur at any time, the end of primary treatment can trigger a unique confusion of feelings that may include both relief and worry. Feelings of shock, anger, depression and anxiety are not uncommon. Patients may also feel distress over treatment effects, such as pain and fatigue, as well as body image.⁴³ Each patient's experience with breast cancer is different and unique, and so will be her emotional reactions. 

In general, women should be advised not to judge their emotions as something negative. Having strong feelings about cancer is normal. Talking about these feelings with trusted others is usually helpful and should be encouraged. Unexpressed emotions tend to strengthen and last longer.⁴⁴

Support groups that facilitate focused discussion about shared concerns and coping strategies and are especially beneficial for women who feel alone and isolated. However, even those with a strong support network of family and friends can benefit from individual and/or group counseling. Relaxation techniques, such as guided imagery and visualization, as well as exercise (for those who are able), are especially effective for managing worry and anxiety. Similarly, feelings of sadness and loss can be transformed by participation in volunteer activities that reach out to others who are in need of support.

Patients who describe their emotions as overwhelming, patients whose feelings are severe enough to interfere with functioning (for more than a few days), or patients who report any of the following symptoms should be referred for further evaluation to an appropriate specialist.⁴⁵

• thoughts of suicide
• inability to eat or sleep
• lack of interest in usual activities for several days
• inability to experience pleasure in anything
• confusion
• difficulty breathing
• sweating
• severe restlessness
• new or unusual symptoms that cause concern

Several excellent resources are on the web for helping patients cope with the emotional effects of cancer. The National Cancer Institute's Facing Forward Series: Life After Cancer Treatment is one example, available in both English and Spanish. The American Cancer Society also devotes a section of its web site to coping with cancer, as does People Living with Cancer, sponsored by the American Society of Clinical Oncology.  The LiveStrong web site, developed by The Lance Armstrong Foundation, offers an excellent selection of materials on emotional topics, as well as materials on other topics of interest to cancer survivors and those who care for them.

Top

Practical Matters

Breast cancer and its treatments can impact a woman's work, insurance, finances, and other practical aspects of her life. The primary care provider is an important resource for patients needing information about groups and organizations that can help with these types of problems. Below are three of the more common practical issues that breast cancer survivors may encounter.

Employment Discrimination

Breast cancer survivors are at risk for employment discrimination in either their present jobs or when or applying for a new job. The Americans with Disabilities Act of 1990 (ADA) prohibits discrimination on the basis of disability. Persons diagnosed with cancer are covered under its provisions. Specifically, Title I of the ADA makes it unlawful for any employer with 15 or more employees to discriminate against an employee or qualified applicant because of cancer. Moreover, if cancer or the effects of cancer treatments interfere with a person's work, employers may need to provide reasonable accommodations to allow an employee to perform the essential functions of her job.⁴⁶ Additional federal laws protecting cancer survivors' employment rights are The Family Medical Leave Act of 1993⁴⁷ and The Federal Rehabilitation Act of 1973.⁴⁸

To learn more about these employment laws, who to contact about employment discrimination, and steps to take if discriminated against, the LiveStrong web site offers details. The National Cancer Institute's publication Facing Forward: Life After Cancer Treatment also has information on employment and legal rights, as does the American Cancer Society (see Americans with Disabilities Act and What is Cobra?) Patients may also find useful Your Employment Rights As A Cancer Survivor, posted on the web site of National Coalition for Cancer Survivorship.

Health Insurance

Breast cancer survivors may have reasonable concerns about obtaining and keeping adequate health insurance coverage. They may also have concerns about what to do in the case of disputed claims with insurance carriers. Fortunately, there are federal and state laws that address the rights of individuals to obtain and keep health insurance. There are also laws that address benefit disputes, as well as issues of medical privacy. These laws have variable protections, however. They may differ by state of residence, by type of health plan, and by other factors.

For learning about health insurance and patient rights, Getting and Keeping Health Insurance is an excellent consumer guide, made available by the Georgetown University Health Policy Institute. Written by researchers, this resource explains legal protections for group and individual plans for each state in the U.S., including the District of Columbia. Places to contact for more information are included within each state's guide. For a more general overview, the LiveStrong web site provides health insurance information for cancer survivors, offers suggestions, and lists additional resources. Medical Insurance and Financial Assistance for the Cancer Patient on the American Cancer Society web site is another excellent overview with many helpful suggestions. For breast cancer patients in particular, The American Bar Association (ABA) Commission on Women in the Profession (CWP) has prepared a pamphlet about legal rights as they apply to health insurance (see Ten Steps to Protecting the Legal Rights of Breast Cancer Patients). Getting or Keeping Health Insurance After Diagnosis, another CWP posting, briefly describes important provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). More about COBRA is available from the U.S. Department of Labor (DOL). Additionally, the DOL has information on The Health Insurance Portability and Accountability Act of 1996 (HIPAA), an important federal law that provides protections for persons with preexisting medical conditions.

Financial Concerns

Breast cancer can cause significant financial challenges for patients and their families. For those with health insurance, varying percentages of their medical expenses will be paid for by their insurance carriers. Women without insurance and women with insufficient coverage may need assistance with finding programs that are able to help with financial concerns.

Patients seeking financial assistance can find potential resources from the National Cancer Institute web site (see NCI Fact Sheet: Financial Assistance and Other Resources for People With Cancer. Additionally, the NCI Fact Sheet: How To Find Resources in Your Own Community If You Have Cancer offers suggestions for locating community-based programs and services. The Patient Advocate Foundation (PAF), listed by NCI, provides a State by State Financial Resource Guide for finding local assistance with a broad range of needs including housing, utilities, food, transportation to medical treatment, home health care, medical devices, and pharmaceutical agents. An Online form on the PAF web site, allows patients to request personalized help with practical matters (e.g., problems with insurer, employer, and creditors) due to breast cancer and its treatments. CancerCare, also listed by NCI, provides limited grants for certain expenses related to treatment. Likewise, the Patient Access Network Foundation is an independent, non-profit organization dedicated to assisting insured patients who cannot afford the out-of-pocket costs associated with their treatment needs. (See References and Additional Resources page for more support resources.)

Top

Notes

¹Risk for secondary cancers is greatest for women who were diagnosed with breast cancer at a younger age, who have a familial form of breast cancer, and who were treated with radiation therapy as part of their breast cancer treatment, as noted in: American Academy of Family Physicians. Primary Care Follow-Up in Breast Cancer Survivors. American Family Physician. (Apr., 2001). Retrieved Sep. 5, 2006 at: http://www.aafp.org/afp/20010415/tips/8.html

²Mellemkjær, L, Friis, S, Olsen, J, et al, 2006.

³National Cancer Institute.Tamoxifen: Questions and Answers. (reviewed, May 13, 2002). Retrieved Sep. 5, 2006 at: http://www.cancer.gov/cancertopics/factsheet/Therapy/tamoxifen

⁴Grunfeld E, Levine, MN, Julian JA, et al. Randomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care. J Clin Oncol. 2006 Feb;24(6):848-855. Retrieved Apr 12, 2007 at: http://jco.ascopubs.org/cgi/content/full/24/6/848

⁵ Khatcheressian, JL, Wolff, AC, Smith, TJ, et al. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. J Clin Oncol. 2006 Nov; 24(31):5091-5097. Retrieved Apr 12, 2007 at: http://www.jco.org/cgi/content/full/24/31/5091

⁶ If such a transfer occurred, a flow sheet and patient action plan created by the American Society of Clinical Oncology (ASCO) based on the 2006 guidelines could be utilized to assist with the recommended follow-up intervals. (See Breast Cancer Surveillance Flowsheet - toolbox sidebar.) This would be useful for the patient’s own knowledge-base and could be placed in the patient’s chart to track times for needed referrals.

⁷Journal of Oncology Practice. ASCO 2006 Update of the Breast Cancer Follow-Up and Management Summary. (November 2006). Retrieved April 12, 2007 at: http://jop.stateaffiliates-asco.org/November06Issue/317.pdf.pdf

⁸See note 5.

⁹See note 7.

¹⁰See note 1.

¹¹Edge SB, Hurd TC. Best Practice of Medicine: Breast Cancer (Mar., 2003). Merck Medicus. Retrieved Sept. 4, 2006 at: http://merck.micromedex.com/index.asp?page=bpm_brief&article_ id=BPM01ON03

¹²National Cancer Institute. Breast Cancer (PDQ®): Treatment. (last modified, Jul. 11, 2006). Retrieved Sep. 5, 2006 at: http://www.nci.nih.gov/cancertopics/pdq/treatment/breast/health professional

¹³See note 11.

¹⁴Additionally this line of thought notes that most breast cancer recurrences are detected by the patient herself or by physical examination performed by a clinician. Therefore, except for mammographic examination, available evidence does not call for the routine use of any diagnostic or laboratory test, including tumor markers for which the effect on survival is still unclear. (See Palli D, Russo A, Saieva C, et al, 1999.)

¹⁵Early Breast Cancer Trialists' Collaborative Group, 2005.

¹⁶Imaginis. Breast Cancer Recurrence (updated, July, 2006). Retrieved Sep. 11, 2006 at: http://imaginis.com/breasthealth/bcrecurrence.asp

¹⁷See note 1.

¹⁸People Living With Cancer. ASCO Patient Guide: Follow-Up Care for Breast Cancer. Retrieved Sep. 6, 2006 at: http://www.plwc.org/portal/site/PLWC/menuitem.169f5d85214941ccfd
748f68ee 37a01d/?vgnextoid=c78f41eca8daa010VgnVCM100000ed730ad1RCRD

¹⁹People Living With Cancer. PLWC Guide to Breast Cancer:Treatment. Retrieved Sep. 11, 2006 at: http://www.plwc.org/portal/site/PLWC/menuitem.6067beb2271039bcfd748f68ee37a01d/?vgnextoid=
6ec6ea7105daa010VgnVCM100000ed730ad1RCRD&vgnextfmt=cancer

^20-21National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Retrieved Sep. 11, 2006 at: http://www.nccn.org/professionals/physician_gls/default.asp

²²See note 11.

²³American Cancer Society. What Side Effects May Occur With Radiation Therapy to the Breast and Chest Area? (revised, Feb. 7, 2006). Retrieved Sep. 18, 2006 at: http://www.cancer.org/docroot/
MBC/content/MBC_2_3X_ What_Side_Effects_Occur_With_Radiation _Therapy_ to_the_ Breast_
and_Chest_Area.asp?sitearea=MBC

^24-27McCarthy NJ. Care of the breast cancer survivor: increased survival rates present a new set of challenges. Postgrad Med. 2004 Oct;116(4):6-8, 39-46. Retrieved Sep. 18, 2006 at: http://www.postgradmed.com/issues/2004/10_04/comm_mccarthy.htm

²⁸American Cancer Society. Chemotherapy and Concentration: Chemotherapy’s Effect on the Brain (Mar. 24, 1999). Retrieved Sep. 18, 2006 at: http://www.cancer.org/docroot/NWS/
content/NWS_3_1x_ Chemotherapy _and_Concentration.asp

²⁹American Cancer Society. What About My Memory and Thinking? (revised, Jun. 22, 2006). Retrieved Sep. 18, 2006 at: http://www.cancer.org/docroot/ETO/content/ETO _1_7x_What_
about_my_memory_and_ thinking.asp

^{30 - 31}See note 24.

³²See note 20.

³³Imaginis.Coping With the Side Effects of Tamoxifen (updated, Jul., 2006). Retrieved Sept. 18, 2006 at: http://imaginis.com/breasthealth/side_effects.asp

³⁴See note 11.

³⁵See note 3.

³⁶See note 24.

³⁷See note 3.

³⁸Breastcancer.org. Staying on Track with Hormonal Therapy (last modified, Jun. 15, 2006). Retrieved Sep. 20, 2006 at: http://www.breastcancer.org/staying_on_track_hormone_therapy.html

³⁹See note 24.

⁴⁰ National Cancer Institute (NCI). FDA Approval for Trastuzumab (posted, Nov. 17, 2006). Retrieved Apr. 14, 2007 at: http://www.cancer.gov/cancertopics/druginfo/fda-trastuzumab 

⁴¹National Cancer Institute (NCI). Herceptin® (Trastuzumab): Questions and Answers (reviewed, Jun. 13, 2002). Retrieved Sep. 20, 2006 at: http://www.cancer.gov/cancertopics/factsheet/
therapy/herceptin

⁴²See note 11.

⁴³LiveStrong Survivor Care. Aftereffects of Cancer Treatment: Detailed Information. Retrieved Sep. 30, 2006 at: http://www.livestrong.org/site/c.jvKZLbMRIsG/b.670041/k.206/Aftereffects_ of_Cancer_
Treatment_Detailed_Information.htm

⁴⁴LiveStrong Survivor Care. Emotional Effects of Cancer: Suggestions. Retrieved Sep. 30, 2006 at: http://www.livestrong.org/site/c.jvKZLbMRIsG/b.670275/k.1E78/Emotional_Effects_of_Cancer_
Suggestions.htm

⁴⁵American Cancer Society. Coping and Prevention (Mar. 9, 2005). Retrieved Sep. 30, 2006 at: http://www.cancer.org/docroot/MBC/content/MBC_4_1x_Coping_and_Prevention.asp?sitearea=MBC

⁴⁶U.S. Equal Employment Opportunity Commission.The Americans with Disabilities Act of 1990, Titles I and V (last modified, Jan. 15, 1997). Retrieved Sep. 30, 2006 at: http://www.eeoc.gov/policy/ada.html

⁴⁷U.S. Department of Labor. Compliance Assistance - Family and Medical Leave Act (FMLA). Retrieved Sep. 30, 2006 at: http://www.dol.gov/esa/whd/fmla/

⁴⁸U.S. Department of Health and Human Services. Your Rights Under Section 504 of the Rehabilitation Act. Retrieved Sep. 30, 2006 at:http://www.hhs.gov/ocr/504.html

All external links are provided as a service to our visitors for information purposes only. No endorsement is made or implied.

Revised: February 20, 2008.

Top of page