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 This is an original JCO publication from 2012. Please visit the JCO website to access the full article.


Breast Cancer Follow-Up and Management After Primary Treatment


 

 Authors
James L. Khatcheressian, Patricia Hurley, Elissa Bantug, Laura J. Esserman, Eva Grunfeld, Francine Halberg, Alexander Hantel, N. Lynn Henry, Hyman B. Muss, Thomas J. Smith, Victor G. Vogel, Antonio C. Wolff, Mark R. Somerfield, and Nancy E. Davidson 

THE BOTTOM LINE

Intervention

  • Modes of surveillance for patients with breast cancer who have completed primary therapy with curative intent.

Target Audience

  • Medical Oncologists, Primary Care Providers, Oncology Nurses, Surgical Oncologists, Pathologists, Nuclear Medicine Specialists

Key Recommendations

  • Regular history, physical examination, and mammography are recommended.
  • Examinations should be performed every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter.
  • For women who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed.
  • Use of CBCs, chemistry panels, bone scans, chest radiographs, liver ultrasounds, computed tomography scans, [18F] fluorodeoxyglucose–positron emission tomography scanning, magnetic resonance imaging, or tumor markers (carcinoembryonic antigen, CA 15-3, and CA 27.29) is not recommended for routine breast cancer follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination.

Methods

  • A comprehensive systematic review of the literature was conducted and an Update Committee was convened to review the evidence and develop guideline recommendations. 

SUMMARY OF RECOMMENDATIONS

Mode of

Surveillance

Recommendations*

RECOMMENDED

 

History/physical examination

All women should have a careful history and physical examination every 3 to 6 months for the first 3 years after primary therapy, then every 6 to 12 months for the next 2 years, and then annually.

 

The history and physical examination should be performed by a physician§ experienced in the surveillance of cancer patients and in breast examination.

Patient education

regarding symptoms

of recurrence

Physicians should counsel patients about the symptoms of recurrence including new lumps, bone pain, chest pain, dyspnea, abdominal pain, or persistent headaches. Helpful Web sites for patient education include www.cancer.net and www.cancer.org.

Referral for genetic counseling

Women at high risk for familial breast cancer syndromes should be referred for genetic counseling in accordance with clinical guidelines recommended by the US Preventive Services Task Force.18 Criteria to recommend referral include the following: Ashkenazi Jewish heritage; history of ovarian cancer at any age in the patient or any first- or second-degree relatives; any first-degree relative with a history of breast cancer diagnosed before the age of 50 years; two or more first- or second-degree relatives diagnosed with breast cancer at any age; patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative.

Breast self-examination

All women should be counseled to perform monthly breast self-examination.

Mammography

Women treated with breast-conserving therapy should have their first post-treatment mammogram no earlier than 6 months after definitive radiation therapy. Subsequent mammograms should be obtained every 6 to 12 months for surveillance of abnormalities. Mammography should be performed yearly if stability of mammographic findings is achieved after completion of locoregional therapy.

Pelvic examination

Regular gynecologic follow-up is recommended for all women. Patients who receive tamoxifen therapy are at increased risk for developing endometrial cancer and should be advised to report any vaginal bleeding to their physicians. Longer follow-up intervals may be appropriate for women who have had a total hysterectomy and oophorectomy.

Coordination of care

The risk of breast cancer recurrence continues through 15 years after primary treatment and beyond. Continuity of care for breast cancer patients is recommended and should be performed by a physician experienced in the surveillance of cancer patients and in breast examination, including the examination of irradiated breasts. Follow-up by a PCP seems to lead to the same health outcomes as specialist follow-up with good patient satisfaction.

 

If a patient with early-stage breast cancer (tumor < 5 cm and < 4 positive nodes) desires follow-up exclusively by a PCP, care may be transferred to the PCP approximately 1 year after diagnosis. If care is transferred to a PCP, both the PCP and the patient should be informed of the appropriate follow-up and management strategy. Re-referral for further oncology assessment may be considered, as needed, especially for patients who are receiving adjuvant endocrine therapy.

NOT RECOMMENDED

Routine blood tests

CBC testing is not recommended for routine breast cancer surveillance.

Automated chemistry studies are not recommended for routine breast cancer surveillance.

Imaging studies

Chest x-rays are not recommended for routine breast cancer surveillance.

Bone scans are not recommended for routine breast cancer surveillance.

Ultrasound of the liver is not recommended for routine breast cancer surveillance.

CT scanning is not recommended for routine breast cancer surveillance.

FDG-PET scanning is not recommended for routine breast cancer surveillance.

Breast MRI is not recommended for routine breast cancer surveillance.

Breast cancer

tumor marker

testing

The use of CA 15-3 or CA 27.29 is not recommended for routine surveillance of breast cancer patients after primary therapy.

CEA testing is not recommended for routine surveillance of breast cancer patients after primary therapy.

Abbreviations: PCP, primary care physician, FDG-PET, [18F] fluorodeoxyglucose–positron emission tomography; MRI, magnetic resonance imaging; CEA, carcinoembryonic antigen; CBC, complete blood count

*All recommendations remain the same as those published in 2006.2 The Panel concluded that there was no new evidence that warranted changing any of the recommendations. The 2006 guideline provides a detailed discussion and rationale for the recommendations.

§Although the evidence is lacking, it seems likely that history as well as physical and breast exams may also be conducted by experienced non-physician providers (eg, Nurse Practitioners, Physician Assistants) under the supervision of an experienced physician.

Expert consensus-based recommendations are available with criteria relevant to patients with cancer (eg, from the National Comprehensive Cancer Network [www.nccn.org]). These recommendations include similar criteria as those from the USPSTF as well as other criteria such as diagnosis of triple negative breast cancer, or a combination of breast cancer and other specific cancers. 

 

   

 

 

ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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