What is the recommended surveillance plan for a patient with stage II (yT2N0M0) invasive ductal carcinoma (IDC)?

Surveillance for Stage II (yT2N0M0) Invasive Ductal Carcinoma

For Stage II invasive ductal carcinoma, surveillance should consist of history and physical examination every 3-6 months for the first 5 years, then annually thereafter, with annual mammography; routine cross-sectional imaging (CT, MRI, PET) is not recommended in asymptomatic patients. 1

Surveillance Schedule

Clinical Follow-Up:

• Years 1-5: History and physical examination every 3-6 months 1
• After Year 5: Annual history and physical examination 1
• The more frequent interval (every 3 months) should be considered for patients at higher risk of recurrence within this stage II category 1

Imaging:

• Annual mammography is the primary surveillance imaging modality 2
• No routine CT, MRI, or PET-CT scans should be performed in asymptomatic patients 1, 2
• Cross-sectional imaging should only be obtained when clinical examination or symptoms suggest recurrence 1, 2

Components of Each Surveillance Visit

History:

• Focus on symptoms of recurrence including new breast masses, bone pain, chest pain, abdominal pain, persistent cough, or neurological symptoms 1
• Review of systems targeting common sites of breast cancer recurrence (bone, lung, liver, brain) 1

Physical Examination:

• Breast examination of both the treated breast and contralateral breast 1
• Examination of regional lymph node basins (axillary, supraclavicular, infraclavicular) 1
• Abdominal examination to assess for hepatomegaly 1

Laboratory Testing

• No routine tumor markers (such as CA 15-3, CA 27.29, or CEA) are recommended for surveillance in asymptomatic patients 1
• Laboratory studies should only be performed when clinically indicated by symptoms or examination findings 1

Critical Surveillance Principles

Symptom-Driven Approach:

• Approximately 41-83% of recurrences are detected by patient-reported symptoms, making patient education about warning signs essential 3
• Physical examination detects 35-68% of recurrences 3
• One-third of second breast cancers are interval cancers not detected by routine mammography, so new symptoms warrant immediate evaluation even with recent negative imaging 4

Timing of Recurrence Risk:

• Most recurrences in breast cancer occur within the first 3 years after treatment, justifying more intensive early surveillance 3
• The highest risk period for relapse is within the first 2-4 years 1

When to Modify Surveillance

Patients Who Should NOT Undergo Routine Surveillance:

• Patients with severe comorbid conditions who are not candidates for surgery or systemic therapy should not undergo surveillance testing 1
• Surveillance intensity should be guided by functional status and ability to tolerate treatment for recurrent disease 1

When to Obtain Cross-Sectional Imaging:

• New or worsening symptoms suggestive of metastatic disease 1, 2
• Abnormal physical examination findings 1
• Rising tumor markers if they were initially elevated (though routine marker testing is not recommended) 1
• Abnormal findings on mammography requiring further characterization 2

Common Pitfalls to Avoid

• Do not order routine PET scans for surveillance outside of clinical trials 1
• Do not falsely reassure patients with recent negative mammograms who present with new breast symptoms or changes, as interval cancers account for one-third of second breast cancer events 4
• Avoid overuse of imaging in asymptomatic patients, as this contributes to false-positive findings, increased costs, patient anxiety, and unnecessary invasive procedures without proven survival benefit 2
• Do not reduce surveillance intensity based solely on favorable tumor biology, as the evidence does not support changing surveillance intervals for different subgroups 4