What are the recommended follow-up investigations for a patient with a history of carcinoma (cancer) of the breast?

Follow-up Investigation for Carcinoma Breast

Regular history, physical examination, and annual mammography are the only recommended routine surveillance investigations for breast cancer patients after primary treatment—extensive laboratory tests and imaging studies should not be performed in asymptomatic patients. 1

Recommended Surveillance Strategy

Clinical Examination Schedule

The American Society of Clinical Oncology (ASCO) provides clear guidance on examination frequency 1:

• Years 1-3: Every 3-6 months 1
• Years 4-5: Every 6-12 months 1
• Year 6 onwards: Annually 1

These examinations must be performed by a physician experienced in cancer surveillance and breast examination, including evaluation of irradiated breasts. 1

Mammography Protocol

For patients who underwent breast-conserving surgery 1:

• First post-treatment mammogram: 1 year after initial diagnostic mammogram AND at least 6 months after radiation therapy completion 1
• Subsequent mammograms: Annually once stability is achieved 1

For all breast cancer survivors: Annual mammography is the cornerstone of surveillance, detecting 91-97% of recurrent disease. 1

Patient Education Components

Counsel patients to report these specific symptoms immediately 1:

• New breast lumps
• Bone pain
• Chest pain
• Dyspnea (shortness of breath)
• Abdominal pain
• Persistent headaches

Additional Recommended Surveillance

Gynecologic follow-up 1:

• Regular pelvic examinations for all women
• Patients on tamoxifen must report any vaginal bleeding immediately due to increased endometrial cancer risk 1

Genetic counseling referral for high-risk patients 1:

• Ashkenazi Jewish heritage
• Personal or family history of ovarian cancer at any age
• First-degree relative with breast cancer diagnosed before age 50
• Two or more first- or second-degree relatives with breast cancer
• History of bilateral breast cancer
• Male relative with breast cancer

Investigations NOT Recommended for Routine Surveillance

The following tests should NOT be performed routinely in asymptomatic patients 1:

Laboratory Tests

• Complete blood counts (CBC) 1
• Chemistry panels 1
• Liver function tests 1
• Tumor markers (CEA, CA 15-3, CA 27.29) 1

Imaging Studies

• Bone scans 1
• Chest radiographs 1
• Liver ultrasounds 1
• Pelvic ultrasounds 1
• CT scans 1
• PET scans 1
• MRI (except for high-risk genetic patients) 1
• Breast ultrasound 1

Evidence Supporting This Conservative Approach

The ASCO guidelines were reaffirmed in 2013 after reviewing 14 new publications (9 systematic reviews and 5 randomized controlled trials), concluding that no revisions to the conservative surveillance strategy were warranted. 1

Key evidence from randomized trials 2:

• Intensive follow-up with laboratory and imaging tests showed no survival benefit compared to clinical examination and mammography alone (HR 0.98,95% CI 0.84-1.15) 2
• No difference in disease-free survival (HR 0.84,95% CI 0.71-1.00) 2
• No difference in quality of life between intensive versus minimal surveillance 2

Cost-effectiveness data 1:

• Non-guideline compliant follow-up costs 2.2 to 3.6 times more than guideline-compliant surveillance 1
• Introduction of surveillance guidelines resulted in one-third decrease in expenditures per patient with no change in health outcomes 1

Critical Clinical Pearls

Most recurrences are detected by patient-reported symptoms or clinical examination, not by routine imaging or laboratory tests. 3 The most common presentation of second breast cancer is an abnormal mammogram in an otherwise asymptomatic patient. 1

Interval cancers occur more frequently in breast cancer survivors compared to women without breast cancer history, even with appropriate surveillance mammography (sensitivity 65.4%, specificity 98.3%). 4 This does not justify more intensive imaging but emphasizes the importance of patient education about symptoms. 4

Common pitfall: Ordering extensive "routine" surveillance tests in asymptomatic patients wastes resources and does not improve outcomes. 5, 3 Imaging should only be performed when findings would change treatment decisions and potentially improve survival or quality of life. 5

Alternative care models: Follow-up by trained general practitioners in organized practice settings is as effective as hospital-based specialist care for overall survival, recurrence detection, and quality of life. 2