What are the key components to assess when taking a post-mastectomy history in a female patient with a history of breast cancer?

Post-Mastectomy History Taking

Perform a detailed cancer-related history and physical examination every 3-6 months for the first 3 years, every 6-12 months for years 4-5, and annually thereafter, focusing specifically on detecting locoregional recurrence through clinical assessment rather than imaging. 1

Frequency and Timing of Clinical Surveillance

• Schedule visits every 3-12 months for the first 5 years post-mastectomy, then annually thereafter. 1
• The frequency should be determined by individual risk profile, with higher-risk patients requiring more frequent assessment. 1
• Physical examinations must be performed by physicians experienced in cancer surveillance and breast examination. 2

Essential History Components

Symptoms of Locoregional Recurrence

• Specifically ask about new chest wall masses or lumps, as most local recurrences after mastectomy present clinically as palpable chest wall masses rather than being detected by imaging. 1
• Inquire about focal chest wall pain or tenderness. 1
• Ask about skin changes over the mastectomy site, including erythema, thickening, or nodularity. 1

Symptoms of Distant Metastatic Disease

• Question patients about bone pain, chest pain, abdominal pain, persistent headaches, and dyspnea, as these may indicate distant recurrence. 2
• Document any new neurological symptoms or unexplained weight loss. 2

Contralateral Breast Symptoms

• Ask about new lumps, nipple discharge, or skin changes in the remaining breast. 1, 2
• Inquire about breast pain or focal tenderness. 2

Treatment-Related Complications

• Assess for lymphedema symptoms, including arm swelling, heaviness, or tightness on the operative side. 3
• Document shoulder and arm mobility limitations, particularly if axillary surgery was performed. 4
• Screen for chronic pain syndromes, including phantom breast pain and axillary web syndrome. 3, 5
• Ask about fatigue severity and impact on daily function. 4, 3

Psychosocial and Quality of Life Assessment

• Screen for depression and anxiety symptoms. 3
• Inquire about body image concerns and sexuality issues. 3
• Assess cognitive function, as cognitive dysfunction can occur post-treatment. 3

Physical Examination Focus

Mastectomy Site Examination

• Carefully palpate the entire chest wall for masses, nodules, or areas of induration, as locoregional recurrence rates range from 1-3% after 10 years and are typically detected clinically. 1
• Examine the mastectomy scar for thickening, retraction, or nodularity. 1
• Assess for skin changes including erythema or edema. 1

Regional Lymph Node Assessment

• Thoroughly palpate the axilla, supraclavicular, and infraclavicular regions for lymphadenopathy. 1
• Document size, consistency, and mobility of any palpable nodes. 1

Contralateral Breast Examination

• Perform complete clinical breast examination of the remaining breast. 1, 2
• Examine for masses, skin changes, nipple discharge, or asymmetry. 1

Functional Assessment

• Evaluate shoulder range of motion and arm strength on the operative side. 4, 3
• Assess for signs of lymphedema, including arm circumference measurements if indicated. 3

Treatment History Documentation

Original Cancer Characteristics

• Document original cancer stage, grade, hormone receptor status, and HER2 status. 1
• Record whether the patient had DCIS, invasive cancer, or microinvasion. 1
• Note if the patient had multifocal or multicentric disease, as this increases recurrence risk. 1

Prior Treatments Received

• Document type of mastectomy performed (simple, modified radical, nipple-sparing). 1
• Record whether reconstruction was performed and the type (implant vs. autologous). 1
• Note completion of adjuvant therapies including chemotherapy, radiation, and endocrine therapy. 1
• Specifically assess adherence to adjuvant endocrine therapy, as this impacts recurrence risk. 2

Risk Stratification Elements

High-Risk Features Requiring Enhanced Surveillance

• Age at diagnosis (younger age increases recurrence risk). 1
• Higher grade DCIS with necrosis. 1
• Dense breast tissue in the contralateral breast. 6
• Genetic risk factors (BRCA1/2 mutations, strong family history). 2

Genetic Counseling Assessment

• Offer risk evaluation and genetic counseling to patients with suspected hereditary risk factors, including strong family history or triple-negative breast cancer diagnosed at age ≤60. 2

Patient Education and Counseling

Self-Monitoring Instructions

• Educate patients to immediately report any new chest wall masses, lumps, or concerning symptoms between scheduled visits rather than waiting for routine follow-up. 1, 2
• Instruct on self-examination of the contralateral breast. 2
• Provide written information about signs and symptoms of recurrence. 2

Imaging Expectations

• Counsel patients that routine imaging of the mastectomy site is not recommended in asymptomatic patients, as there is no evidence supporting screening mammography, CT, PET, or MRI for the mastectomy side. 1, 6
• Explain that annual mammography is only needed for the contralateral intact breast. 1, 6, 2
• Discuss that MRI of the contralateral breast may be appropriate if high-risk criteria are met. 6, 2

Common Pitfalls to Avoid

• Do not order routine laboratory tests (CBC, chemistry panels, tumor markers) or imaging studies (bone scans, CT, PET) in asymptomatic patients, as major guidelines recommend against this practice. 1, 2
• Avoid dismissing vague symptoms without thorough questioning, as patients may not recognize subtle signs of recurrence. 1
• Do not assume all chest wall findings are benign; any new palpable mass requires tissue diagnosis. 1
• Remember that residual breast tissue can remain after mastectomy (present in 30-51% of cases, especially with nipple-sparing procedures), which can be a site of recurrence. 1