What monitoring is required for a patient post mastectomy (breast removal surgery)?

Post-Mastectomy Monitoring

Clinical surveillance with physical examination and history every 3-12 months for the first 5 years, then annually thereafter, is the cornerstone of post-mastectomy monitoring—routine imaging of the mastectomy site is not recommended in asymptomatic patients. 1, 2

Clinical Surveillance Schedule

The frequency of clinical visits should be:

• Every 3-12 months for the first 5 years post-mastectomy 1, 2
• Annually after 5 years 1, 2
• Adjust frequency based on individual risk profile (higher stage at diagnosis, positive margins, younger age, triple-negative disease) 2

What to Assess at Each Visit

History components that matter:

• New chest wall masses or lumps—most local recurrences (1-2% annually) present as palpable chest wall masses, not imaging findings 1, 2
• Focal chest wall pain or tenderness 2
• Skin changes including erythema, thickening, or nodularity over the mastectomy site 2
• Adherence to adjuvant endocrine therapy if prescribed, as this directly impacts recurrence risk 2

Physical examination focus:

• Palpate the entire chest wall systematically for masses, nodules, or areas of induration 2
• Examine the mastectomy scar for thickening, retraction, or nodularity 2
• Assess skin for erythema or edema 2
• Examine regional lymph node basins (axillary, supraclavicular, infraclavicular) 1

Imaging Recommendations

For the mastectomy side:

• No routine mammography, ultrasound, MRI, PET/CT, or other imaging in asymptomatic patients 1, 3
• Image only if symptoms or clinical findings suggest recurrence—then diagnostic mammography, ultrasound, or MRI with contrast may be appropriate 1, 3
• The evidence is clear: ASCO, NCCN, and ESMO all recommend against routine imaging for screening distant or locoregional recurrence 1

For the contralateral intact breast:

• Annual screening mammography (2-D or digital breast tomosynthesis) is recommended and provides mortality reduction 1, 3
• Consider annual breast MRI with contrast if the patient meets high-risk criteria: lifetime risk ≥20%, BRCA mutation, strong family history, dense breasts with personal history of breast cancer, or diagnosis before age 50 1, 3

Laboratory Testing

Do not order routine laboratory tests (tumor markers, CBC, liver function tests, etc.) or advanced imaging (bone scans, chest X-rays, CT scans) in asymptomatic patients—randomized trials from the 1980s showed no survival advantage and significant false-positive rates 1

Patient Education

Instruct patients to immediately report:

• Any new chest wall masses or lumps between scheduled visits 2, 3
• Persistent chest wall pain 2
• Skin changes over the mastectomy site 2
• New symptoms suggesting distant recurrence (bone pain, persistent cough, abdominal pain, neurological symptoms) 1

Counsel patients that:

• Most recurrences are detected clinically, not by imaging 1, 3
• Routine imaging of the mastectomy site is not beneficial and is not recommended by major guidelines 1, 3
• Annual mammography is only needed for the remaining breast if unilateral mastectomy 3

Common Pitfalls to Avoid

• Do not order routine imaging (mammography, ultrasound, MRI, PET/CT) of the mastectomy site in asymptomatic patients—this is explicitly not recommended and increases false-positives without survival benefit 1, 3
• Do not order routine tumor markers or blood tests—these have not been shown to improve survival or quality of life 1
• Remember that residual breast tissue can remain after mastectomy and can be a site of recurrence, so any new palpable mass requires tissue diagnosis 2
• Do not assume all chest wall masses are recurrence—early postoperative complications like hematomas, infections, and fat necrosis can present as palpable findings 1
• For high-risk patients with contralateral breast, ensure MRI surveillance is offered, as small studies show cancer detection rates of 10 per 1,000 examinations that would otherwise go undetected 1