Follow-Up Care After Right Breast Simple Mastectomy with Normal Left Breast Mammogram
After a simple mastectomy of the right breast with a normal left breast mammogram, you should perform clinical examinations every 3-6 months for the first 3 years, every 6-12 months for years 4-5, and annually thereafter, combined with annual mammography of the intact left breast only. 1
Clinical Examination Schedule
The cornerstone of post-mastectomy surveillance is regular history and physical examination by a physician experienced in cancer surveillance and breast examination 1, 2:
During each visit, specifically assess for symptoms of recurrence including new lumps at the mastectomy site, bone pain, chest pain, dyspnea, abdominal pain, or persistent headaches 1, 2. The patient should be counseled to report these symptoms immediately between scheduled visits 1.
Mammographic Surveillance
For the intact left breast, perform annual mammography starting one year after the initial diagnostic mammogram 1, 2. This is the only routine imaging recommended for surveillance 1, 2.
For the mastectomy site (right breast), no routine mammography is indicated 1. However, if physical examination reveals concerning findings at the mastectomy site, ultrasound is the appropriate imaging modality 3, 4.
What NOT to Do
The following tests are explicitly not recommended for routine surveillance in asymptomatic patients 1, 2:
- Complete blood counts or chemistry panels 1, 2
- Tumor markers (CEA, CA 15-3, CA 27.29) 1, 2
- Bone scans 1, 2
- Chest radiographs 1, 2
- Liver ultrasounds 1, 2
- CT scans 1, 2
- PET scans 1, 2
- MRI (unless the patient meets high-risk criteria per ACS guidelines for hereditary breast cancer syndromes) 1
These tests do not improve survival or quality of life and increase costs by 2.2 to 3.6 times without clinical benefit 2.
Special Considerations
Genetic counseling referral should be offered if the patient has risk factors for hereditary breast cancer syndromes, including 1:
- Ashkenazi Jewish heritage
- History of ovarian cancer in patient or first/second-degree relatives
- First-degree relative with breast cancer diagnosed before age 50
- Two or more first/second-degree relatives with breast cancer at any age
- History of bilateral breast cancer
- Male relative with breast cancer
- Age ≤60 years with triple-negative breast cancer 1
Gynecologic surveillance is important, particularly if the patient is on tamoxifen therapy, as these patients have increased endometrial cancer risk and should report any vaginal bleeding 1.
Common Pitfalls
Despite mastectomy, 10-15.5% of patients will require subsequent imaging of the mastectomy site for physical examination findings, and 6-8% will undergo biopsy, though malignancy yield is low at approximately 1% 4. Patients should understand that mastectomy does not completely eliminate the need for future surveillance 4.
The evidence supporting this conservative surveillance approach is robust, with ASCO guidelines reaffirmed in 2013 after reviewing 14 new publications, finding no benefit to more intensive surveillance strategies 2. Two large randomized trials involving 2,563 women demonstrated no survival benefit from intensive laboratory and imaging surveillance compared to clinical examination and mammography alone 5.