Follow-Up of Long-Term Survivors
There is no consensus among oncologists as to the appropriate and optimal follow-up routine for long-term breast cancer survivors. Recommendations for follow-up testing vary. The vast majority of relapses, both locoregional and distant, occur within the first 3 years. Surveillance is most intensive in the initial 5 years; thereafter, the frequency of follow-up visits and testing is reduced (Table 2).
History and physical examination
Surveillance methods include a detailed history and physical examination at each office visit. They are performed every 4 to 6 months for 5 years after completion of initial therapy, then annually thereafter. Patients at higher risk of recurrence or complications of treatment may require surveillance at shorter intervals. Patients who have been treated by mastectomy can be seen in the office annually after they have been disease-free for 5 years. Patients who were treated with breast-conserving surgery and radiotherapy can be followed at 6-month intervals until they have been disease-free for 6 to 8 years, after which time they can be assessed annually.
Approximately 71% of breast cancer recurrences are detected by the patients themselves, and they will report a change in their symptoms when questioned carefully. In patients who are asymptomatic, physical examination will detect a recurrence in another 15%. Therefore, a patient's complaint on history or a new finding on physical examination will lead to the detection of 86% of all recurrences.
Mammography should be performed annually in all patients who have been treated for breast cancer. For patients who have undergone breast-conserving surgery, the first follow-up mammogram should be performed approximately 6 months after completion of radiation therapy. The risk of developing contralateral breast cancer is approximately 0.5% to 1% per year. In addition, approximately one-third of IBTRs in patients who have been treated by conservation surgery and radiotherapy are detected by mammography alone. As the time interval between the initial therapy and follow-up mammography increases, so does the likelihood that local breast recurrence will develop elsewhere in the breast rather than at the site of the initial primary lesion.
Routine chest radiographs detect between 2.3% and 19.5% of recurrences in asymptomatic patients and may be indicated on an annual basis.
Liver function tests
Liver function tests detect recurrences in relatively few asymptomatic patients, and their routine use has been questioned. However, these tests are relatively inexpensive, and it may not be unreasonable to obtain them annually.
There is no evidence that tumor markers, such as carcinoembryonic assay, CA-15-3, and CA-57-29, provide an advantage in survival or palliation of recurrent disease in asymptomatic patients. Therefore, use of tumor markers to follow long-term breast cancer survivors is not recommended.
Postoperative bone scans are also not recommended in asymptomatic patients. In the NSABP B-09 trial, in which bone scans were regularly performed, occult disease was identified in only 0.4% of patients.
Liver and brain imaging
Imaging studies of the liver and brain are not indicated in asymptomatic patients. Position emission tomography scans are not routinely recommended. Their utility is primarily as an adjunct study, often to establish the extent of metastatic disease.
Women with intact uteri who are taking tamoxifen(Drug information on tamoxifen) should have yearly pelvic examinations because of their risk of tamoxifen-associated endometrial carcinoma, especially among postmenopausal women. The vast majority of women with tamoxifen-associated uterine carcinoma have early vaginal spotting, and any vaginal spotting should prompt rapid evaluation. However, since neither endometrial biopsy nor ultrasonography has demonstrated utility as a screening test in any population of women, routine use of these tests in asymptomatic women is not recommended.
Premenopausal women who become permanently amenorrheic from adjuvant chemotherapy and postmenopausal women who are treated with an aromatase inhibitor are at increased risk for bone fracture from osteopenia/osteoporosis. These patients should undergo monitoring of bone health every 1 to 2 years.