What is the best screening method for a patient with a history of breast cancer in remission to check for relapse?

Surveillance Screening for Breast Cancer Recurrence

Annual mammography is the best screening method for detecting breast cancer recurrence in patients with a history of breast cancer in remission, with demonstrated mortality reduction compared to those who do not undergo annual surveillance. 1, 2

Primary Surveillance Modality

Mammography is the gold standard for post-treatment surveillance because it is the only breast imaging examination proven to reduce breast cancer mortality in this population. 1, 3 The most common presentation of recurrent or second breast cancer is an abnormal mammogram in an otherwise asymptomatic patient, with mammography detecting approximately 91-97% of recurrences. 1, 2

Timing and Frequency

• First post-treatment mammogram: Perform at 6-12 months after completion of radiation therapy (for breast conservation patients) or 12 months after the last mammogram. 1, 4
• Subsequent surveillance: Annual mammography thereafter, as long as the patient remains in good health with life expectancy ≥10 years. 2, 4
• Critical timing note: Imaging before 12 months is not beneficial and leads to unnecessary additional imaging due to acute breast changes from treatment. 1

Both ASTRO and NCCN guidelines support this annual mammographic surveillance protocol. 1, 4

Screening vs. Diagnostic Mammography

The choice between screening and diagnostic mammography depends on time since diagnosis:

• First 2 years: Most radiologists (49%) recommend diagnostic mammography. 1
• Years 2-5: 33% recommend diagnostic mammography during this period. 1
• Beyond 5 years: Transition to screening mammography is appropriate. 1

This approach is justified because most locoregional recurrences occur within 5 years after diagnosis, with peak risk at 2-3 years after initial therapy. 1, 3

Enhanced Mammographic Techniques

Digital breast tomosynthesis (DBT) added to standard 2D mammography reduces recall rates and indeterminate findings without significantly changing cancer detection rates. 1, 4 This can be considered as an alternative or complement to standard mammography. 3

More Frequent Imaging: Not Recommended

Six-month surveillance intervals provide no benefit over annual screening. Two studies showed no advantages to more frequent imaging, and one study suggesting lower-stage detection at 6-month intervals was confounded by decreased compliance in the annual group, with insufficient follow-up to assess mortality differences. 1

Role of MRI Surveillance

Routine MRI is NOT recommended for standard surveillance in patients with a history of breast cancer. 1, 2 However, MRI should be considered for:

• Patients meeting high-risk criteria (BRCA1/2 mutation, >20% lifetime risk of second primary). 2, 5
• Patients diagnosed with breast cancer before age 50. 5
• Patients with personal history of breast cancer AND dense breasts. 5

Clinical Examination Protocol

Beyond imaging, the American Society of Clinical Oncology recommends structured clinical follow-up:

• Years 1-3: History and physical examination every 3-6 months. 2
• Years 4-5: History and physical examination every 6-12 months. 2
• Beyond 5 years: Annual history and physical examination. 2

Physical examinations should be performed by physicians experienced in cancer surveillance and breast examination. 2

What NOT to Do

Avoid routine use of the following in asymptomatic patients:

• Laboratory tests (CBC, chemistry panels, tumor markers like CEA, CA 15-3, CA 27.29). 2
• Bone scans, chest radiographs, liver ultrasounds, CT scans, or PET scans. 2
• FDG-PET breast imaging (no supporting literature). 1
• Ultrasound as primary surveillance modality (not proven to reduce mortality). 3

Critical Pitfalls to Avoid

• Never delay the first post-treatment mammogram beyond 12 months after the last mammogram, as this is when surveillance should begin. 3
• Never rely on ultrasound alone for surveillance, as it misses microcalcifications and architectural distortion that mammography detects. 3
• Never dismiss palpable clinical findings based on negative imaging alone, as 10-15% of breast cancers can be mammographically occult. 3
• Be aware of compliance issues in younger women (<45-50 years), older women (>65 years), African Americans, other underrepresented minorities, and women without recent physician visits. 1

Patient Education

Educate patients to report symptoms of recurrence between scheduled visits, including new lumps, bone pain, chest pain, abdominal pain, persistent headaches, and dyspnea. 2