Accompanying Patients on Their Journey to a Healthier Future

The Koo Foundation Sun Yat-Sen Cancer Center’s post-breast cancer long-term follow-up clinic has been in operation for over a decade. On November 27, 2014, the Long-term Follow-up Multidisciplinary Team was formally established. The aim is to provide comprehensive, integrated follow-up care for patients after their cancer treatments, accompanying them towards a healthier future.

An 85-year-old woman, diagnosed with bilateral breast cancer at our clinic a decade ago, stands as a testament to resilience. Despite her age and concurrent conditions like high cholesterol and high uric acid, she regularly attended follow-ups and medications post her surgery. Sporting sneakers and a backpack on each visit, she radiated strength and vitality. Many would be surprised to learn her age without peeking into her medical records. Without checking her medical records, one would never guess she was 85! She's an incredibly cooperative patient, regularly attending follow-up appointments and collecting her medication. However, as she got older, she would sometimes lament how many of her friends, even those without cancer, had passed away.

About two years ago, an abnormal lesion was found in her lung during a regular follow-up. A biopsy from a pulmonologist showed no anomalies. Without any symptoms like coughing or discomfort, the pulmonologist arranged regular imaging follow-ups. However, this year, the lesion grew, highly suspected to be another cancer: lung cancer. The pulmonologist recommended surgery. At this point, the grandmother felt she was too old for another surgery. The follow-up clinic physician, assessing her good health, felt it would be a waste to forgo the procedure. They spent a lot of time persuading her, explaining the benefits of the surgery with the hope she'd accept it for a full recovery. Feeling the genuine care and concern from the physician, she finally agreed. With her husband by her side, she visited the thoracic surgery clinic, where she was explained the details of the procedure. She underwent minimally invasive surgery in early August, which went smoothly and successfully. It wasn't as invasive or painful as she feared, and it only left a tiny scar. The early-stage lung cancer was confirmed, with a high chance of recovery post-surgery.

Every cancer patient endures immense physical and emotional stress and changes throughout the treatment process. After the treatment concludes, long-term follow-up becomes vital. Many questions arise, such as which doctor to see, how often to revisit, what tests will be done, and how long before normalcy returns. Patients need proactive care and companionship for a smooth road to recovery. To help patients resolve post-

cancer treatment issues and return to a normal life, our hospitals’ integrated long-term follow-up team offers comprehensive medical services based on holistic and all-round care principles. Our aim is to improve the quality of life of our patients and to ensure that care delivery results in outstanding results for the patient.

Features of the Long-term Follow-up Clinic

The care model of KFSYSCC’s post-treatment long-term follow-up clinic adopts the patient-centered concept developed by advanced countries in Europe and the United States in recent years. It provides holistic and all-round care, establishing individualized symptom assessments, treatment summaries, and follow-up plans for each patient. This integrated approach offers a more comprehensive care model.

Currently, the primary focus of the team's long-term follow-up clinic is breast cancer. It's mainly taken care of by a group of internists and advanced nurses trained in breast cancer follow-up. The team also includes psychiatrists, rehabilitation doctors, social workers, nurses, and clinical managers who provide immediate services when necessary. There are also plans to expand to include other cancers such as thyroid, colorectal, gastric, and lung cancers, broadening our patient care spectrum.

Breast Cancer Patient Transfer to the Long-term Follow-up Clinic:

Once breast cancer patients conclude their treatments, they are eligible to move to our long-term follow-up outpatient clinic. We don’t impose strict timelines for this shift. Our hospital's medical system features a reminder to consider this transfer, prompting the primary treatment physician to evaluate if a patient is a good fit for long-term follow-up.

Most patients who transition to this clinic typically fit the following criteria:

• Diagnosed with breast cancer stages 0-3 and have finished their treatments, barring hormone therapy.

• Undergone and finished treatment for local recurrence.

• Patients who are jointly overseen by both their primary treatment physician and our clinic's specialists.

Breast Cancer Long-term Follow-up Clinic Overview:

At our breast cancer long-term follow-up outpatient clinic, a team of six internal medicine physicians and four advanced nurses are dedicated to ensuring consistent patient care. Our approach is thorough: from comprehensive symptom evaluations and physical check-ups to devising individualized treatment plans for each patient. Importantly, our practices align with the National Comprehensive Cancer Network (NCCN) guidelines.

Our care is holistic, addressing patients' needs at every stage. Specific services in the clinic encompass:

• Disease Management: This includes anti-hormonal treatments, monitoring and management of long-term side effects, and addressing chronic illnesses.

• Disease Prevention and Early Diagnosis: We prioritize regular monitoring of disease evolution, cancer screenings, preventative measures against chronic diseases, and when necessary, offer genetic counseling and testing for hereditary cancers.

• Health Maintenance: Beyond treatment, we emphasize overall health. This covers guidance on exercise, nutrition, achieving a healthy weight, and cessation of smoking.

• Mental and Social Well-being: Recognizing that healing is both physical and mental, we cater to patients' psychological needs, addressing issues like fatigue, anxiety, depression, and cognitive challenges. Moreover, we facilitate their smooth reintegration into daily life, work, and family. Additionally, we organize events such as health seminars and anxiety support groups.

While regular health checks and follow-ups are a mainstay, patients are always welcome to report any unfamiliar or concerning symptoms they might experience.

Currently, between 20-30% of our patients also have chronic conditions alongside their primary diagnosis. Diabetes tops the list at 13.1%, followed by ailments related to lungs, liver, and gastric ulcers. Our integrated approach underscores a patient-centric model, emphasizing both convenience and holistic care.

Guidelines for Patients Post-treatment

Post-cancer treatment often sees patients grappling with a range of symptoms, from fatigue and menopausal discomforts to memory lapses, pain, and neurological challenges. Our team is here to help manage and mitigate these challenges. We encourage patients to actively engage with their doctors, sharing concerns and partaking in medical decisions. Beyond scheduled appointments, it's imperative for patients to be alert to any bodily changes. Notable symptoms, like new breast lumps, persistent bone or chest pains, respiratory issues, ongoing cough, exhaustion, stomach pains, chronic headaches, inexplicable weight reduction spanning more than two weeks, or any other anomalies, should be immediately reported. Our team is primed to respond swiftly, arranging prompt check-ups and ensuring every concern is addressed, always keeping the patient's well-being and peace of mind at the forefront.

Genetic Cancer Consultation and Testing

Should patients consider undergoing genetic testing for hereditary cancers and a cancer risk assessment? Our long-term follow-up clinic offers specialized genetic counseling sessions led by expert physicians. Based on each patient's individual circumstances, they will assess the need for genetic testing, discuss with the patient, and provide subsequent recommendations.However, it's important to note that even if a patient's risk for hereditary cancer is not high, it doesn't mean they won't develop cancer. This is because the majority of cancer cases are not due to genetic reasons.

Family Hereditary Cancer Risk:

Approximately 5-10% of cancer patients develop the disease due to inheriting certain mutated genes. When should one consider the possibility of hereditary cancer? There are several key indicators:

• Diagnosed with cancer at a very young age.

• An individual has more than one type of cancer.

• More than two family members in the same lineage have the same or related cancers.

Below are risk factors for two relatively common hereditary cancer syndromes:

1. Hereditary Breast and Ovarian Cancer Syndrome (Most commonly due to BRCA1 and BRCA2 genes):

   • More than two family members (in the same lineage) diagnosed with breast or ovarian cancer.

   • Diagnosed with breast cancer before the age of 40.

   • Diagnosed with ovarian cancer.

   • Bilateral breast cancer.

   • Triple-negative breast cancer.

   • Male breast cancer.

2. Hereditary Non-Polyposis Colorectal Cancer (HNPCC), also known as Lynch Syndrome (Typically associated with MMR category genes):

• Diagnosed with colorectal cancer before the age of 50.

• Has two Lynch-related cancers.

• Multiple family members (in the same lineage) diagnosed with Lynch-associated cancers (e.g., colorectal cancer, endometrial cancer, ovarian cancer, gastric cancer, bile duct cancer, pancreatic cancer, small intestine cancer, urological cancers, brain cancer), especially if diagnosed before the age of 50.

If patients have any of the aforementioned risk factors, it's crucial to discuss them with their primary care physician or to directly schedule a genetic counseling session.

Holistic Care: Body, Mind, and Soul

Upon completing cancer treatment, as patients physically recover and their lives gradually return to normal, many still grapple with intangible stresses. Concerns might range from the anxiety of disease recurrence, adjusting to changes in body image, shifts in marital and familial roles, to the capability of returning to work. At this stage, the emotional and spiritual well-being of patients is a focal point of care and concern for the long-term follow-up outpatient team. Many patients express comfort in the integrated consultation approach. It's common to hear patients mention that in addition to breast cancer, the clinic also helps with regular follow-ups for other chronic illnesses, bolstering their confidence in their recovery journey. The holistic care model ensures they feel their emotional needs are also addressed. They feel reassured to consult the outpatient physicians about any health concerns, appreciating the doctors' patient and professional responses to resolve their daily life troubles.

One case involved a young, unmarried teacher: outwardly charming and gentle. However, in her initial consultations, she seemed reticent and uneasy. It was discovered that before her breast cancer diagnosis, she was an optimistic and cheerful person, popular among her peers. But post-diagnosis, her self-confidence was shattered, turning her withdrawn, pessimistic, and even self- deprecating. After her treatment, her spirits remained low, unable to regain her self-esteem. At this juncture, she met someone she liked but was conflicted about reciprocating the affection due to her history of breast cancer. Worries about recurrence, doubts about deserving a normal life, and potential future happiness weighed her down. During one visit, she finally opened up about her inner turmoil and anxieties. The clinic's doctor provided professional advice and guidance, and she left the session visibly lighter. Half a year later, she returned to the clinic, beaming with joy, sharing that she found someone who truly loves her, expressing gratitude for the warmth and care provided by the follow-up team.

Later, during one of her follow-up sessions, an anomaly was detected in her other breast, necessitating further tests. Although terrified, she had faith in the early detection and treatment provided by the regular follow-ups. Fortunately, the tests only identified benign calcifications, and she was advised for periodic follow-ups. Upon leaving, she expressed her heartfelt gratitude, saying, "Thank you all. You genuinely care for your patients, and the fact that you always schedule follow-ups efficiently puts my mind at ease!"