Hospital  >  Care Programs  >  Odette Cancer Program  >  Breast cancer care  >  Breast Cancer Well Follow-Up and Survivorship Program

Breast Cancer Well Follow-Up and Survivorship Program

What is the focus of the program?

This specialized program helps women with curative breast cancer manage any ongoing issues related to their cancer diagnosis and treatment after active treatment. The program offers support on living a healthy and balanced lifestyle.

Program hours are:

  • 9am - 5pm every Friday in person
  • 12pm - 5pm every Tuesday by Zoom

Program lead:

Dr. Muna Al-Khaifi, GP Oncologist

What is “well follow-up and survivorship” in breast cancer?

The breast cancer treatment experience has many steps. The stage, subtype, your age, if you are in menopause and other health issues will be taken into account for treatment. Based on these factors, the treatment path for curative (early stage/non-metastatic) breast cancer may include:

  • surgery
  • radiation
  • chemotherapy (before or after surgery)
  • anti-hormone treatment (pills, injections)
  • other targeted treatments

Treatment is done to lower the chance of the cancer coming back and/or spreading in other parts of the body, and to improve the chance of breast cancer cure.

Following treatment, most women are ready to move into the “survivorship” phase of the cancer experience. This is usually two or more years after surgery and following completion of all intravenous chemotherapy or targeted treatments. In this phase, many women who had estrogen-sensitive cancer will still be on anti-hormone treatments (tamoxifen, anastrazole, letrozole, exemestane). These are usually continued for five to seven years, and sometimes up to ten years. Some younger women may also be on injections to bring on menopause (Lupron®, Zoladex®). Some menopausal patients will start or complete a few rounds of an intravenous bone-strengthening treatment (zoledronic acid/Zometa®) to help keep good bone health and further prevent cancer from coming back.

During the survivorship and well follow-up phase, women can have health issues due to anti-hormone treatments and/or chemotherapy recovery. They may also have new concerns about healthy lifestyles, diet, weight management, and mental health or coping issues. Some may not have any concerns. Most women want to get back to the health status and lives they had before cancer. Receiving guidance and advice from a doctor, like a family physician, can be beneficial.

What services does the program provide?

Sunnybrook’s Well Follow-up and Survivorship Program is led by a family doctor who is an expert in cancer. This doctor, who gives care to women with breast cancer, offers a comprehensive approach to well breast cancer patients.

Services may include:

  • Surveillance for breast cancer recurrence (screening mammograms)
  • Bone health and treatment (bone density scans) if not already done through a patient’s own family doctor or other specialist
  • Management of any physical and psychological effects of anti-hormone treatment and/or post-chemotherapy side effects
  • Patient self-management support
  • Healthy lifestyle education
  • Support for a patient’s overall well-being

Patients are followed for a short amount of time based on their needs, treatment and monitoring surveillance plan. Recommendations from a patient’s oncologist are also reviewed by the survivorship clinic doctor.

What happens after receiving care through this program?

Patients will go back to receiving care through their family doctor. If the cancer comes back, or there are questions about the cancer treatment plan, the patient can be sent back for review with the breast oncology team at any time.

Some patients will be booked back for review with their medical oncologist to finalize their plan of care (ie. after five years of anti-hormone therapy).

Do all breast cancer patients get care in the program?

No. Some patients can go back to their family doctor without going through the Well Follow-up and Survivorship Program.

Some breast cancer patient resources:


General information:


Hereditary breast cancer:

Breast reconstruction:

Bras, camisoles and prosthesis:

  • After Breast Cancer/Premier Jour (free bra/camisole/breast prosthesis):
  • Solac (provides women with limited financial resources with bras, camisoles and breast prosthesis at no cost to them after mastectomy or lumpectomy

Support groups:

Genetic risks and screening:

Mental health:



Work and finance:


  • Nanny Angel Network (trained volunteer professionals who donate their time to assist caring for children up to age 12)
  • Mealtrain (pre-arranged meals and assistance with errands)

Helpful Apps:

  • Stop, Breathe & Think (basic use is free and offers short activities that are tuned to your emotions)
  • Calm (basic use is free and offers help with meditation and sleep)
  • Headspace (first ten lessons are free and offers help with meditation, sleep, stress and anxiety)