Learning Objectives:After participating in this continuing professional development activity, the provider should be better able to:
1. Outline comprehensive care of women who have survived cancer.
2. Distinguish current recommendations and best practices in care of cancer survivors, including screening for secondary malignancies such as breast cancer.
3. Identify high-risk patients who require more rigorous screening schedules.
More than 40,000 women of reproductive age are diagnosed with cancer in the United States annually. Improvements in cancer treatment have led to increased survival rates of over 80% for young patients. Therefore, practitioners must be prepared to provide comprehensive follow-up care to these patients, often for many years. Cancer survivors have a unique set of risks based upon the therapy they received, including chemotherapy and radiation.1 These late effects may include endocrine disorders, infertility, cardiovascular or bone density concerns, and secondary malignancies.
Well-woman care may be provided at periodic well-woman visits or at visits specifically directed to discuss an aspect of a patient's medical history. Preventative health visits are recommended on a regular basis, even when certain aspects of the physical examination, such as cervical cancer screening, are not indicated at that specific visit. These visits are especially important for cancer survivors, as they provide a time to discuss reproductive health and goals, screen for age-related and history-related diseases based on individual risk factors, and counsel regarding healthy lifestyle and recommended interventions.
Cancer survivors have a unique set of needs based upon their specific cancer history. For example, some cancer survivors may require more frequent screening for certain malignancies whereas others will require hormone replacement therapy (HRT) for late effects of cancer treatment. Well-woman care ensures that female cancer survivors are provided with holistic care, addressing their unique needs throughout the reproductive lifespan and beyond. Although mental health care, psychological care and counseling, family-based therapy, and sex therapy are other critically important aspects of cancer survivorship, they are outside the scope of this article and are not discussed in detail here.
Cancer survivors may seek well-woman care through their primary care (PCP) or family medicine provider, whereas others may choose to seek care with their gynecologist or reproductive endocrinologist based on their individual needs. Some large medical systems offer shared-care cancer survivorship programs that coordinate survivorship care. Although ideal in their scope and reach, these programs are not available to every patient based on location and care system. There are several broad categories of organized survivorship care including specialist-led, shared programs, PCP-led, and nurse-led; although the majority of survivorship in the United States continues to be provided in a specialist-led setting, there is evidence to suggest equivalent outcomes for shared care, PCP-led, and nurse-led models.2 This article is designed to guide the primary care, gynecology, or specialist provider who is seeing a female cancer survivor for well-woman care.
Breast Cancer Screening
Guidelines for routine breast cancer screening for average-risk women vary between organizations. The US Preventive Services Task Force (USPSTF) recommends screening mammography every 2 years for women ages 50 to 74; the decision to screen women ages 40 to 49 should be made based on the patient's personal priorities. On the other hand, the American College of Radiology (ACR) and the American College of Obstetricians and Gynecologists (ACOG) recommend that women begin annual screening mammography starting at age 40 and continue up to age 74. Breast cancer screening appears to be beneficial for those with a life expectancy of greater than 10 years.
History of Breast Cancer
For patients with a history of breast cancer, atypical ductal hyperplasia, and lobular neoplasia before 40 years old, ACR recommends yearly mammography starting at the time of diagnosis. Annual MRI should be performed for those with a history of breast cancer and either dense breast tissue or diagnosis before age 50, and MRI should be considered for those with atypical ductal hyperplasia or lobular neoplasia. Breast cancer patients who have undergone lumpectomy should receive annual mammography of both breasts. Those who have undergone unilateral mastectomy should receive annual mammography of the contralateral breast. MRI may also be considered in patients who have undergone lumpectomy or unilateral mastectomy. Those who have undergone bilateral mastectomy do not require further screening.3
History of Chest Radiation
For patients with a history of mantle field (a large area encompassing the chest, neck, and axilla) or chest radiation therapy, most studied among Hodgkin disease survivors, there is consistent evidence to demonstrate an increased risk of breast cancer, which does not seem to plateau over time. As such, the standard recommendation is to begin annual mammography starting at age 25 or 8 years after radiation, whichever is later, for those who have received 20 Gy or more before age 30. Additionally, adjunct screening with MRI should be considered in patients with a history of mantle-field or chest radiation therapy, given data demonstrating a higher incremental cancer detection rate of 4.4% with combined mammography and MRI.4
Further studies have also demonstrated that those who have received whole lung radiation with 10 to 19 Gy, generally used to treat pulmonary metastases of solid malignancies, have also been found to have a similar cumulative incidence of breast cancer in comparison to Hodgkin lymphoma survivors. Thus, ACR also recommends annual screening mammography for individuals who have received chest radiation of 10 Gy or more before age 30.3 Similarly, patients who received total body irradiation (TBI) as conditioning for a bone marrow transplant, particularly before age 30 at the time of radiation exposure, were found to have a significantly increased risk of breast cancer; thus, consideration should be given to offering increased screening to patients who received TBI before age 30.5
Genetic Predisposition
For patients with a genetic predisposition to breast cancer, specifically those with BRCA1 or BRCA2 mutations, ACR recommends starting annual screening MRI at 25 years with the addition of annual mammography at 40 years.3 These guidelines reflect increasing data demonstrating superiority of MRI for detecting breast cancer in young patients with genetic predisposition and the low yield of adjunct mammography in individuals below age 40.
Colorectal Cancer Screening
The USPSTF, American College of Gastroenterology, and ACOG recommend routine colorectal cancer screening in low-risk individuals ages 45 to 75. Those between 76 and 85 years should also be considered for screening, with the greatest benefit for those who have never been screened. Screening interval is based on the modality used: high sensitivity guaiac fecal occult blood test or fecal immunochemical test (FIT) every year, stool DNA-FIT every 1 to 3 years, CT colonography every 5 years, flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy every 10 years plus annual FIT, and colonoscopy every 10 years. Similar to breast cancer, screening for colorectal cancer is only beneficial for those with a life expectancy of greater than 10 years.
History of Colorectal Cancer
For patients with a history of colorectal cancer, screening colonoscopy should be performed 1 year after surgical resection. If the initial colonoscopy is benign, screening should be repeated in 3 years. If subsequent screening is benign, screening should be repeated in 5 years. Screening intervals should not exceed 5 years.6 Patients with localized rectal cancer who have not undergone total mesorectal excision or those with locally advanced rectal cancer who did not receive neoadjuvant chemoradiation followed by total mesorectal excision should receive flexible sigmoidoscopy or endoscopic ultrasound every 3 to 6 months after surgery for 2 to 3 years in addition to annual colonoscopy as above. Surveillance with FIT or DNA-FIT is not appropriate for this patient population.6
History of Abdominal Radiation
For individuals with a history of abdominal radiation of 30 Gy or more, screening colonoscopy should be performed every 5 years starting at 10 years after radiation therapy or at 35 years, whichever is later. Even for those who received less than 30 Gy, there are data to demonstrate the benefit of screening colonoscopy at the same timing and interval.7 In addition, those with Crohn's disease with colonic involvement or ulcerative colitis should undergo screening colonoscopy 8 to 10 years after diagnosis and then every 1 to 3 years.8
Family History of Colorectal Cancer
Individuals with a first-degree relative with colorectal cancer should initiate screening starting at 40 years of age or 10 years before the earliest diagnosis in the family, whichever comes first.8 Those with a first-degree relative with hereditary colon cancer should also initiate earlier screening depending on the syndrome, which is briefly summarized below. Patients with negative genetic testing can be screened at the same frequency as the average-risk population.
Individuals with a first-degree relative with Lynch syndrome should receive screening colonoscopy every 1 to 2 years starting between ages 20 and 25. Those with MSH6 or PMS2 mutations may delay surveillance until ages 25 to 30 due to lower associated risk. Additionally, patients with a personal history of Lynch syndrome are recommended to receive endometrial cancer screening with annual endometrial sampling and transvaginal ultrasonography beginning at age 30 to 35 years. Those with a first-degree relative with familial adenomatous polyposis (FAP) should receive annual flexible sigmoidoscopy or colonoscopy beginning at 10 to 12 years old. Testing may be delayed until late teenage years in those with a family history of attenuated FAP. Those who have undergone prophylactic colectomy with remaining rectum or ileal pouch should receive endoscopic surveillance every 6 months to 2 years. Patients with MUTYH-associated polyposis should receive colonoscopy every 2 to 3 years starting at age 25 to 30. If polyps are found, screening frequency should be increased to every 1 to 2 years.9
Patients with hamartomatous polyposis syndrome (eg, Peutz-Jeghers syndrome and juvenile polyposis syndrome) also require earlier screening. Individuals with Peutz-Jeghers and juvenile polyposis syndromes should initiate screening colonoscopy every 2 to 3 years by the late teens. In addition to colorectal cancer screening, patients with Peutz-Jeghers should receive the following: annual mammography and breast MRI starting at 25 years, annual cervical cancer screening and transvaginal ultrasound starting at 18 years, and magnetic resonance cholangiopancreatography/endoscopic ultrasound of the pancreas every 1 to 2 years starting at 30 years.9
Cervical Cancer Screening
Per USPSTF, American Society for Colposcopy and Cervical Pathology (ASCCP), and ACOG guidelines, average-risk individuals are recommended to initiate cervical cancer screening with cytology alone every 3 years starting at age 21 through age 29. Those ages 30 to 65 should be screened with cytology alone every 3 years, high-risk human papillomavirus (HPV) testing alone every 5 years, or cytology with high-risk HPV cotesting every 5 years.
Immunocompromised Patients
Screening should be performed at greater frequency for patients who are immunocompromised due to decreased capacity for viral clearance. Solid organ and stem cell transplant recipients should be screened at higher frequencies with cytology every year or for individuals 30 years or older, cotesting every 3 years. Immunocompromised patients should be screened for cervical cancer throughout their lifetime, even past age 65. Similarly, individuals exposed to diethylstilbestrol in utero should also receive surveillance at the same frequency-annual cytology from ages 21 to 29 and cotesting for those 30 years or older throughout their life.10
History of Cervical Dysplasia or Cancer
Patients who have had a total hysterectomy should discontinue cervical cancer screening unless they were diagnosed with cervical intraepithelial neoplasia 2 and 3 or cervical cancer before hysterectomy. After treatment for CIN 2 and 3 with loop electrosurgical excision procedure, cold knife cone, or hysterectomy, patients should receive cytology and HPV cotesting 6 months after the procedure. If testing is negative, cotesting should be performed annually for 3 years and then every 3 years for at least 25 years. Any positive results should be managed per the most recent ASCCP guidelines. Individuals with a history of cervical cancer should receive increased surveillance with physical examination every 3 to 6 months for the first 2 years and then every 6 to 12 months for 5 years after initial treatment. Afterward, they may be monitored yearly.11 Cervical/vaginal cytology should be performed annually, though the recurrence detection rate has been found to be low.
It is important to note that individuals who have a history of gynecologic surgery or pelvic radiation may experience vaginal stenosis, which can make speculum examination for cervical cytology difficult and painful. HPV-only testing can be performed using a small cotton swab placed into the vagina, which can even be self-administered. Given the updates to the ASCCP guidelines, which now include the option for HPV testing alone every 5 years in women ages 30 to 65, consideration can be given to performing HPV screening alone for women with vaginal stenosis for whom a complete speculum examination with cervical cytology may be prohibitive.
Osteoporosis Risk and Screening
The prevalence of osteoporosis worldwide is thought to be greater than 200 million people, and around 40% of postmenopausal women will experience a fragility fracture. Therefore, the USPSTF and ACOG recommend screening dual-energy x-ray absorptiometry (DEXA) scans every 1 to 2 years starting at age 65 for all postmenopausal women. Additionally, ACOG recommends screening be initiated before age 65 if patients are at increased risk of osteoporosis, as determined by the Fracture Risk Assessment Tool (FRAX).
Risk Factors
Cancer patients can be at increased risk of bone loss because of the disease itself or due to treatment. Chronic inflammation in cancer can impair bone formation and increase bone resorption, which can lead to bone loss. Malnourishment due to nausea, weight loss, and cancer-related fatigue can also contribute to bone loss. Cancer treatment also can contribute significantly to bone loss; for example, hypoestrogenism can result from use of gonadotropin releasing hormone analog therapy during cancer treatment, and chemotherapeutics can also lead to primary ovarian insufficiency (POI) and subsequent estrogen deficiency, which is a risk factor for low bone density. Radiation treatments can also have a direct effect on bone in the treated field, which leads to bone atrophy.
Bone loss that occurs as a result of cancer treatment is oftentimes more rapid and severe than age-related osteoporosis. Women with breast cancer treated with aromatase inhibitors seen to have a 2-to-4-fold increase in bone loss compared with physiologic postmenopausal bone loss and fracture incidence of 20% after 5 years of follow up.12
Screening Guidelines
Due to the increased risk of osteoporosis, the American Society of Clinical Oncology (ASCO) released guidelines in 2019 on osteoporosis screening in adult cancer survivors with nonmetastatic disease. ASCO recommends that patients with nonmetastatic cancer regardless of age with one or more risk factors for osteoporotic fracture should be offered bone density testing with central/axial DEXA.13 These risk factors included advanced age, current cigarette smoking, excessive alcohol consumption, history of nontraumatic fractures in adulthood, hypogonadism, impaired mobility, increased risk of falls, long-term exposure to glucocorticoids, low body weight, parental history of hip fracture, and postmenopausal status. ASCO also recommends that patients with nonmetastatic cancer who are prescribed treatment that could cause bone loss, or whose baseline bone density test is near the threshold of treatment, should be offered bone density testing every 2 years or more frequently. Testing should not be conducted more than annually.13
Interventions
To reduce the risk of osteoporotic fractures, ASCO recommends that clinicians encourage patients to consume a diet high in calcium (1000-1200 mg/d) and vitamin D (800-1000 IU/d) and to provide supplements if that is not being consumed. Furthermore, other lifestyle recommendations include engaging in weight-bearing exercises, minimizing the risk of falls, and encouraging behaviors such as tobacco cessation and limiting alcohol consumption.13
Use of bone-modifying agents is recommended if patients have a FRAX score with a 10-year risk of hip fracture at 3% or greater, or 10-year risk of non-hip fracture at 20%. Also, if bone density testing with DEXA demonstrates osteoporosis or the clinical scenario indicates a significant risk for osteoporotic fracture, then a bone-modifying agent should be initiated. Bisphosphonates or denosumab is the preferred bone-modifying agents for cancer patients.13
Infertility Screening
Per the American Society for Reproductive Medicine and ACOG, evaluation for infertility for average-risk women should be initiated after 12 or more months of unprotected intercourse in those younger than 35 years and after 6 months of unprotected intercourse in those 35 years and older; however, screening may be initiated early for patients with irregular or absent menses or other risk factors for infertility. Infertility screening should include assessment of ovarian reserve, uterine structure, tubal patency, and semen analysis. Ovarian reserve can be assessed with cycle day 3 serum follicle-stimulating hormone (FSH) and estradiol, early follicular phase antral follicle count, or serum anti-Mullerian hormone (AMH) level. Of note, low AMH should be considered in conjunction with other tests of ovarian reserve, given that an isolated low AMH does not necessarily predict inability to conceive. Uterine anomalies are typically assessed using ultrasound or pelvic MRI, and tubal patency is classically evaluated with hysterosalpingography.
Risk Factors
Individuals at higher risk for infertility include childhood cancer survivors. Specifically, exposure to high doses of alkylating agents, defined as a cyclophosphamide equivalent dose of more than 4000 mg/m2, is associated with increased risk of POI.14 Likewise, radiation with doses of more than 5 Gy to the ovaries or more than 30 Gy to the hypothalamus or pituitary gland is also associated with menstrual abnormalities, hypothalamic-pituitary-gonadal axis dysfunction, and infertility.15
Prepubertal Screening
Screening for these patients before puberty should include annual growth Tanner stage monitoring and baseline luteinizing hormone (LH), FSH, and estradiol at 13 years of age. Individuals who do not undergo pubertal changes by 13 years or do not appropriately progress through puberty should receive repeat FSH and estradiol testing and be referred to a pediatric or reproductive endocrinologist. Additionally, if a patient does not begin menarche by 16 years, they should be referred to a reproductive endocrinologist.16
Postpubertal Screening
For postpubertal patients, it is expected that menstruation will normalize within 1 to 2 years after completion of treatment, assuming the patient has not developed POI. Baseline LH, FSH, estradiol, and AMH levels should be obtained 1 year after therapy. Individuals who do not resume their menses after 2 years, experience menstrual changes, or have abnormal ovarian reserve testing should receive repeat testing and be referred to reproductive endocrinology for further management.16 Moreover, it is important to note that not all patients after cancer treatment are infertile, so contraception would still be recommended if these patients are not planning to become pregnant.
Hormone Replacement Therapy and Primary Ovarian Insufficiency
Young women who undergo gonadotoxic cancer treatment including chemotherapy, pelvic radiation, and surgical resection are at increased risk of POI. POI is characterized by menopausal levels of FSH and absent or irregular menstrual cycles. POI itself can have numerous health complications primarily due to the lack of estrogen activity in the body. Complications can include menopausal symptoms, decreased bone density and increased risk of fractures, early progression of cardiovascular disease, and psychological impact including depression and anxiety.17
Hormone Replacement Therapy
Because of these potential complications, it is recommended that women with POI be prescribed HRT. Young women with POI require long-term ovarian sex corticosteroid replacement and could be on HRT for decades. Young women with POI should continue treatment until the average age of natural menopause, around age 50 to 51, and then the dose may be tapered to postmenopausal levels or stopped depending on an individual's risk profile and symptoms.17 Unfortunately, not all young women with POI are identified and prescribed HRT, and a recent study showed that more than half (52%) of young women with POI either never take HRT, start HRT years after their diagnosis, and/or discontinue HRT use before age 45.18
The goal of HRT in young women with POI is to mimic normal ovarian function. Therefore, the recommendation is to start HRT with transdermal or transvaginal estradiol therapy as first-line therapy,17 as these formulations mimic the daily ovarian production rate of estradiol and achieve average serum estradiol levels of 100 pg/mL.19 An equivalent dose of oral estradiol can be used, but the patient should be counseled that due to first-pass liver metabolism and increase in prothrombotic factors, the risk of venous thromboembolism is increased in oral formulations compared with transdermal/vaginal estrogen. Oral contraceptives provide supraphysiologic levels of synthetic estrogen (ethinyl estradiol) and progestin and therefore give more hormone than is required to replace ovarian production rates. Further, contraceptive pills can also be associated with an increased risk of thromboembolism, stroke, increase in blood pressure, and unfavorable lipid profiles.17 A randomized controlled trial in young women with POI compared the cardiovascular effects of transdermal estradiol plus cyclic progestin to treatment with a combination oral contraceptive and found that the patients using transdermal physiologic HRT had significantly lower blood pressure, better renal function, and reduced activation of the renin-angiotensin-aldosterone system after 12 months of use.20 This suggests that transdermal or transvaginal estradiol therapy with cyclic progestin should be considered first line for women with POI, although oral contraceptives can be used as second line, especially if women want to avoid pregnancy.17
Endometrial Protection
Cyclical or continuous progestin is also recommended for endometrial protection in young women with POI that still have an intact uterus (ie, have not had a hysterectomy). Oral medroxyprogesterone acetate (MPA, 10 mg/day for 12 days/month) is recommended.17 Oral micronized progesterone and the progestin-containing intrauterine device (IUD) can also be used, although current literature notes a lack of evidence for effectiveness of oral micronized progesterone and progestin-containing IUDs to induce secretory endometrium and fully protect against endometrial hyperplasia when used in conjunction with full replacement doses of estradiol.17 On the other hand, there are other studies that suggest an improvement in venous thromboembolism risk and breast cancer risk with micronized progesterone as compared with synthetic progestins such as MPA. Therefore, many clinicians prescribe cyclic micronized progesterone as part of their HRT regimen, and this was discussed as a reasonable alternative to MPA in the 2017 recommendations of the North American Menopause Society.21 If a clinician chooses to prescribe micronized progesterone for HRT, sufficient doses should be used for endometrial protection; for example, oral micronized progesterone 12 to 14 consecutive days per month at 200 mg/day.
History of Hormone-Responsive Cancer
In women who have a history of breast or other hormone-responsive tumors, the recommendation is to avoid systemic estrogen/progestin as HRT. Previous randomized controlled trials of breast cancer patients using estrogen/progestins as HRT for treatment of vasomotor symptoms were stopped early due to increased risk of breast cancer recurrence. Alternative methods are recommended, including lifestyle changes to decrease cardiovascular risks, calcium/vitamin D and weight-bearing exercise for bone health, and antidepressants for depressed mood. For vasomotor symptoms, a variety of low-dose antidepressants or gabapentin could be used. Studies of venlafaxine, paroxetine, fluoxetine, and citalopram have all shown a benefit in reducing vasomotor symptoms compared with placebo.22 For breast cancer patients who are taking tamoxifen, there is concern that the use of pure selective-serotonin reuptake inhibitors could interfere with tamoxifen metabolism and block the drugs therapeutic benefit, but this interference does not appear to be present in serotonin-norepinephrine reuptake inhibitors such as venlafaxine.23 There is little information regarding the long-term effect of herbal products for menopausal symptoms in women with breast cancer. For breast cancer patients with symptoms of vaginal atrophy, nonhormonal methods such as nonhormonal vaginal lubricants and moisturizers should be considered first-line therapy.24 This is due to varying rates of estrogen absorption by vaginal estrogens, and there is a lack of data as to whether transient increases in estradiol from vaginal estrogen are clinically significant in these patients and whether the effects of long-term exposure would increase recurrence risk. However, in patients with severe refractory symptoms who are not considered at high risk for breast cancer recurrence, it is reasonable for short-term use of hormonal methods after appropriate counseling for potential risks.24
Laboratory Screening
For average-risk patients, the USPSTF recommends diabetes screening every 3 years for overweight or obese adults ages 35 to 70 with fasting plasma glucose, hemoglobin A1c, or oral glucose tolerance test. Additionally, although hyperlipidemia screening with a fasting lipid profile may be considered in adults ages 21 to 39, the USPSTF recommends initiating screening at age 40 at a frequency of at least every 5 years.
Childhood cancer survivors, however, have been found to be at higher risk for metabolic syndrome-especially among those who received abdominal or total body radiation. As a result, the Children's Oncology Group (COG)25 recommends that recipients of abdominal or total body radiation receive screening for diabetes and hyperlipidemia at least every 2 years after completion of treatment. Individuals who have received cranial radiation and are at increased risk of growth hormone deficiency do not require additional laboratory screening. Rather, the COG25 recommends annual monitoring of their height, weight, and blood pressure.
Certain chemotherapy drugs including alkylating agents, topoisomerase inhibitors, and anthracyclines have been associated with leukemia. Although screening guidelines are not well-established, it is reasonable to screen for leukemia symptoms and obtain annual complete blood count with differential.
The USPSTF does not offer a recommendation for thyroid dysfunction screening in average-risk adults. In contrast, the American Thyroid Association recommends screening every 5 years beginning at age 35 with thyroid-stimulating hormone (TSH) levels. For survivors of head and neck cancers, it is recommended that TSH levels be monitored every 6 to 12 months due to elevated risk of developing hypothyroidism.26
Additionally, patients with a history of gestational trophoblastic neoplasia should be monitored with monthly [beta]-human chorionic gonadotropin for at least 12 months after treatment. During this time, a reliable form of contraception should be used due to high risk of recurrence.27
Immunizations
The 3-dose hepatitis B series is recommended for medically stable neonates starting within 24 hours of life. Individuals 6 months and older should receive an influenza vaccine annually. Although the live, attenuated influenza vaccine is an option for those ages 2 to 49 years, it should not be administered to immunocompromised patients. At 1 year, infants are recommended to receive the 2-dose hepatitis A vaccine series. Those 5 and older are currently recommended to receive 2 doses of the coronavirus disease-2019 (COVID-19) vaccine, whereas current recommendations for individuals 12 and older also include a COVID-19 vaccine booster when eligible.
The HPV vaccine is recommended for those 9 to 45 years old-2 doses for patients younger than 15 years, and 3 doses for patients 15 years and older. Those 11 years and older should receive an initial Tdap (tetanus, diphtheria, pertussis) vaccine followed by a booster every 10 years. Individuals born after 1957 are recommended to receive a single measles, mumps, and rubella (MMR) vaccine, and those born after 1980 are recommended to receive the 2-dose varicella series. Additionally, individuals 50 and older should receive the 2-dose zoster series, and those 65 and older should receive the pneumococcal polysaccharide (PPSV23) vaccine.28
Asplenic Patients
For those with anatomic or functional asplenia, a single dose of the Haemophilis influenzae type B (Hib) vaccine is recommended. Those with anatomic or functional asplenia are also recommended to receive the 2-dose meningococcal A, C, W, and Y vaccine series and then a booster every 5 years. Additionally, they should receive meningococcal B vaccine series, followed by a booster 1 year later and then every 2 to 3 years.28 Furthermore, adults with immunocompromising conditions, including those with anatomic or functional asplenia and people living with HIV, are recommended to receive the pneumococcal conjugate (PCV13) vaccine as early as age 19-one dose of the PCV13 vaccine, followed by the PPSV23 vaccine after 8 weeks, an additional dose of the PPSV23 vaccine 5 years later, and then standard vaccination at age 65. When applicable in asplenic patients, these vaccines should be administered either 2 weeks before elective splenectomy or at least 2 weeks after emergency splenectomy.29
Immunocompromised Patients
The 3-dose Hib vaccine series is recommended for hematopoietic stem cell transplant recipients starting at 6 to 12 months after transplant. People living with HIV should receive the 2-dose hepatitis A series and 2- or 3-dose hepatitis B series. Alternatively, they may receive the 3-dose hepatitis A and hepatitis B combination vaccines. Additionally, the 3-dose series of the HPV vaccine is recommended regardless of age of initial dose. Moreover, if their CD4 counts are 200 cells/mm3 or more, the 2-dose series of the MMR and varicella vaccines are also recommended. Lastly, the COVID-19 vaccines have been found to be well-tolerated among immunocompromised individuals, specifically among people living with HIV and hematopoietic stem cell transplant recipients and as such are recommended to prevent development of severe COVID-19 illness.30 In January 2022, the Centers for Disease Control and Prevention recommended a fourth dose for moderately to severely immunocompromised individuals, to be administered 5 months after completion of the 3-dose primary series.
Conclusion
Cancer survivors have a unique set of risks. As a result of their disease process and the therapy they receive, which may include radiation and chemotherapy, they are at increased risk of endocrine disorders, infertility, cardiovascular disease, and secondary malignancies. This review outlines the current recommendations for comprehensive well-woman care for this population. A summary of recommendations based upon disease process and exposures can be found in Table 1.
References