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Practice Guidelines for Breast Cancer Follow-Up After Primary Treatment

Practice Guidelines for Breast Cancer Follow-Up After Primary Treatment

The current recommendations from the American Society of Clinical Oncology (ASCO) for the follow-up and management of patients with breast cancer who have completed treatment with the intent to cure are sound, according to a review of new publications by the Update Committee for ASCO.1

In 1997, the first ASCO guideline on breast cancer follow-up and management in asymptomatic patients after primary curative therapy was published. Updated guidelines were then published in 1999 and 2006. After reviewing and analyzing new data from 14 new publications that met inclusion criteria, the Update Committee concluded that the evidence was not compelling enough to warrant any changes to the 2006 guideline recommendation.2 All of these recommendations, which are highlighted in the Table, are designed not only to improve cancer care but also to reduce cost.

The Update Committee did identify a need for studies of the clinical usefulness of breast cancer tumor marker testing, which ultimately would lead to the development of tumor marker testing guidelines that are risk-based or tumor subtype specific (eg, triple-negative breast cancer). Another area needing more research is the effectiveness and quality of different models of survivorship care and ways to identify which patients would benefit from a specific models of care or from a new model of care tailored to the needs of a patient.

Table. Breast Cancer Follow-Up and Management Guidelines

Mode of SurveillanceRecommendation
Recommended
 
History/physical examinationCareful history and physical examination every 3-6 mo for the first 3 y after primary therapy, then every 6-12 mo for the next 2 y, then annually
Patient educationCounsel patients about symptoms of recurrence (eg, new lumps, bone pain, chest pain, dyspnea, abdominal pain, persistent headaches)
Referral for genetic counselingRefer women at high risk for familial breast cancer syndromes for genetic counseling according to the US Preventive Services Task Force recommendations3
Breast self-examinationShould be performed monthly
MammographyFirst post-treatment mammogram should occur no earlier than 6 mo after definitive radiation therapy. Order subsequent mammograms every 6-12 mo for surveillance of abnormalities. Yearly mammograms are recommended if stability of mammographic findings is achieved after completion of locoregional therapy
Pelvic examinationRegular gynecological follow-up is recommended for all women. Those who received tamoxifen are at increased risk for endometrial cancer and should report any vaginal bleeding to their physician. Longer follow-up intervals okay for women with a total hysterectomy and oophorectomy
Coordination of careRisk continues for 15-plus yr after primary treatment. Continuity of care is recommended and should be performed by a physician with experience in surveillance of patients with cancer and breast examination; follow-up by a PCP is okay 1 yr after diagnosis, especially in patients with early-stage breast cancer
Not Recommended 
Routine blood testsComplete blood cell count and automated chemistry studies are not recommended
Imaging studiesChest x-ray films, bone scans, ultrasound of the liver, CT scanning, fluorodeoxyglucose-positron emission tomography scanning, and breast MRI are not recommended for routine surveillance
Breast cancer tumor marker testingCancer antigen 15-3 and cancer antigen 27.29, as well as carcinoembryonic antigen testing, are not recommended for routine surveillance

Adapted from Khatcheressian JL, Hurley P, Bantug E, et al. J Clin Oncol. 2012.1

Pertinent Point:
- After analysis of the new studies available since 2006, the ASCO guidelines from 2006 remain relevant and require no updating.

References

1. Khatcheressian JL, Hurley P, Bantug E, et al. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2012 Nov 5. [Epub ahead of print.]
2. Khatcheressian JL, Wolff AC, Smith TJ, et al. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol. 2006;24:5091-5097.
3. Schnipper LE, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol. 2012;30:1715-1724.
 
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