Updated October 2015
The follow-up of patients who have been treated with curative intent for breast cancer has four main goals:
- Detection of local, regional, or distant recurrence
- Screening for a new breast cancer
- Enhancing adherence to hormone therapy (if applicable)
- Monitoring for and treating late or residual side effects of therapy
All patients who have undergone curative treatment for breast cancer should be seen by a physician every 6 months until 5 years from diagnosis, then annually for a careful history and physical examination including examination of the nodal regions of the head, neck and axilla, breast/chest wall, heart, lung, spine, and abdomen.1 Patients with residual breast tissue should have annual diagnostic mammography to facilitate early detection of any subsequent new ipsilateral or contralateral breast cancer or recurrence.
Regular history and physical examination plus annual mammography should aid in early detection of local, regional, or distant metastases. In addition to regular follow-up, patients are encouraged to seek medical attention between scheduled visits if they develop unexplained and new, persistent symptoms. In the absence of concerning signs or symptoms, no lab or imaging tests, other than annual mammography, are recommended to monitor for recurrence. Detection of asymptomatic metastases by periodic scheduled investigations has not been shown to increase survival or quality of life.2 Instead, clinicians should maintain a low threshold for promptly investigating any new concerning sign or symptom, even if the likelihood that breast cancer has recurred is low. Patients who have been discharged to their primary care physician for follow up can/should be referred back to their oncologist if concern or confirmation of recurrence arises.
Recurrences of triple negative cancer occur most frequently within the first five years following diagnosis and plateau at about 7 years. Hormone receptor breast cancers continue to recur over time, out to and beyond ten years. Her2 positive cancers that are hormone receptor negative appear to have a relapse pattern similar to triple negative cancers, and those that are hormone receptor positive behave more like their her2 negative, hormone receptor positive counterparts.
Location of Recurrence
Selected recurrences have the potential to be cured with appropriate therapy. These include:
- Local recurrence in a breast, which was previously treated by partial mastectomy and axillary node dissection [with or without radiation therapy].
- Local recurrence on the chest wall (and occasionally in the regional nodes) following mastectomy.
- Limited regional recurrence, particularly if resectable and no prior history of nodal radiotherapy
- Isolated solitary or oligo brain metastases following adjuvant therapy of her2+ breast cancer.
Ideally, patients with these types of recurrences should be assessed by a multidisciplinary team to determine curability and plan overall management. If thought to be curable, patients should be treated with surgical excision and radiotherapy (if applicable) for curative intent. A recent study suggests that chemotherapy following local management of local and regional recurrences may improve overall survival and cure rate.3
The most common sites of distant metastases are bone, brain, liver, or lung. These are generally treatable but not curable. Aggressive local therapy may improve long-term survival in select cases with limited burden of metastases. Initial assessment and management by a multidisciplinary team, including the palliative care team as appropriate, is ideal for patients with metastatic disease.
A new primary malignancy in the contralateral breast occurs at a rate of approximately 0.5% to 1% per year. The average 50 year old woman who has had breast cancer once carries approximately a 10-15% risk of a second contralateral breast cancer (invasive or DCIS) over the next 25 years.4
Adjuvant hormone therapy will reduce this risk
Women who have confirmed BRCA2 and BRCA1 mutations and a prior breast cancer carry approximately 35% and 45% risk of a second breast cancer over 25 years respectively, if they do not have bilateral mastectomies or oophorectomy.5
They are also at increased risk of ovarian cancer. Women with confirmed BRCA1 and/or 2 mutations should be referred
to the high-risk hereditary cancer
surveillance program for breast cancer screening with annual MRI followed every six months by mammography.
Patients taking hormone therapy are typically advised to take hormone therapy for 5-10 years after initial treatment. Numerous population-based studies report poor long-term compliance with hormone therapy following early breast cancer, even when a patient does not have to pay for the drug.6 Lack of adherence is associated with poorer survival.6 Physicians should take the opportunity at each visit with a breast cancer patient to ask about adherence to hormone therapy, and explore reasons behind non-compliance. Patients should be reminded of the benefits of adherence in terms of risk reduction for recurrence and contralateral new disease. Means to reduce side effects should be explored when they are a hindrance to adherence.
Long-term side effects may occur as a result of any part of management of breast cancer. Life-threatening late side effects are extremely rare, but many survivors of breast cancer experience side effects that can significantly affect their quality of life, both in the short and long-term. The type and severity of these side effects vary according, in part, to the type of therapy that have been given.
A number of late or chronic side effects are possible from chemotherapy, including early menopause, bone loss, chronic neuropathy, cognitive changes, congestive cardiomyopathy, and secondary leukemia. As a consequence of surgery and radiation, patients may experience long-term intermittent breast or chest wall pain, shoulder pain and reduced range of motion, lymphedema, lung fibrosis, rib fracture, second malignancy of the irradiated area and chest wall/axillary dysesthesia. Hormone therapy can be associated with hot flashes, vaginal dryness or atrophy, depression, postmenopausal bone loss, joint pain, and hyperlipidemia.
There can be great value to detecting these side effects, as some may be amenable to therapeutic intervention if particularly symptomatic. Discussion of management
of post-menopausal symptoms, lymphedema
, and osteoporosis
are discussed below.
- Smith TJ, Davidson NE, Schapira DV, et al. American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. J Clin Oncol 1999; 17:1080-1082
- Grunefeld E, Mant D, Yudkin P, et al. Routine follow-up of breast cancer in primary care: randomized trial. BMJ 1996: 313: 665-669
- Aebi S, Gelber S, Lang I, et al. Chemotherapy prolongs survival for isolated local or regional recurrence of breast cancer: the CALOR trial (chemotherapy as adjuvant for locally recurrent breast cancer; IBCSG 27-02, NSABP B-37, BIG 1-02). Cancer Treatment 2012: 24 suppl 3: abstract S3-3
- Gao X, Fisher SG, and Emami B. Risk of second primary cancer in the contralateral breast in women treated for early stage breast cancer: a population based study. Int J Radiat Oncol Biol Phys 2003; 56:1038-45
- Metcalfe K, Lynch HT, Ghadirian P, et al. Contralateral breast cancer in BRCA1 and BRCA2 mutation carriers. J Clin Oncol 2004; 22:2328-2335
- Hershman DL, Shao T, Kushi LH, et al. Early discontinuation and non-adherence to adjuvant hormonal therapy are associated with increased mortality in women with breast cancer. Breast Cancer Res Treat 2011; 126:529-537
- Partridge AH, LaFountain A, Mayer E, Taylor S, Winer E, Asnis-Alibozek A. Adherence to initial adjuvant anastrozole therapy among women with early-stage breast cancer. J Clin Oncol 2008; 26: 556-562