Laboratory Testing for Breast Cancer Survivors
Routine laboratory tests should NOT be performed for surveillance in asymptomatic breast cancer survivors—the only recommended screening test is annual mammography. 1
What NOT to Order
The American Cancer Society and American Society of Clinical Oncology explicitly recommend against routine laboratory and imaging surveillance because these tests have not improved survival outcomes or quality of life in asymptomatic patients: 1
- No routine tumor markers (CEA, CA 15-3, CA 27.29) 2
- No routine blood counts or chemistry panels 1, 2
- No routine imaging beyond mammography: bone scans, chest X-rays, CT scans, PET scans, liver ultrasounds 1, 3
- No routine alkaline phosphatase, liver enzymes, or other biochemical markers 4, 5
This recommendation is based on randomized trials from the 1980s and subsequent meta-analyses showing no survival advantage with intensive laboratory or imaging surveillance, but significant rates of false-positive findings leading to unnecessary additional testing and biopsies. 1
What TO Do Instead
Clinical Surveillance Schedule
Perform a detailed cancer-related history and physical examination: 1, 2
- Every 3-6 months for the first 3 years after primary therapy
- Every 6-12 months for years 4-5
- Annually thereafter
Mammography Only
- Annual mammography of both breasts for patients who had lumpectomy 1, 2
- Annual mammography of the intact breast for patients with unilateral mastectomy 1, 2
- MRI screening is NOT routine unless the patient meets high-risk criteria (>20% lifetime risk of second primary, such as BRCA1/2 mutation carriers or strong family history) 1, 2
Context-Specific Laboratory Testing
When Labs ARE Indicated
For patients on endocrine therapy, routine blood tests are appropriate to monitor treatment-related side effects: 1
- Lipid profile monitoring for patients on any endocrine therapy 1
- Bone density evaluation for patients on aromatase inhibitors 1
- Annual gynecologic examination (possibly with ultrasound) for postmenopausal women on tamoxifen 1
When to Order Diagnostic Testing
Order laboratory tests and imaging only when clinically indicated by: 1, 3
- New symptoms reported by patient: bone pain, chest pain, dyspnea, abdominal pain, persistent headaches 1, 2
- Physical examination findings: new lumps (underarm, neck), rash or skin changes on breast/chest wall, swelling of breast or arm 1, 2
Critical Patient Education Component
Educate all patients about signs and symptoms of recurrence and instruct them to seek immediate medical attention if symptoms develop between scheduled visits: 1, 2
- New lumps in underarm or neck
- Bone pain
- Chest pain or dyspnea
- Abdominal pain
- Persistent headaches
- Rash or skin changes on breast or chest wall
- Changes in breast contour, shape, or size
- Swelling of breast or arm
Patient-reported symptoms are more effective at detecting recurrence early than routine laboratory or imaging surveillance. 1, 6
Common Pitfalls to Avoid
- Ordering tests "just to be safe": This approach increases false positives without improving survival and causes patient anxiety 3, 7
- Following historical practice patterns: Older practices included routine chest X-rays and tumor markers, which evidence has proven ineffective 3, 8
- Assuming intensive surveillance equals better care: Multiple randomized trials and meta-analyses consistently show no survival benefit from intensive testing in asymptomatic patients 1, 7
- Failing to assess family history: Patients with strong family history or triple-negative breast cancer diagnosed at age ≤60 should be referred for genetic counseling 1, 2
Additional Surveillance Considerations
- Cardiovascular monitoring as clinically indicated, particularly for patients who received anthracyclines or trastuzumab 1
- Vaccination recommendations: Flu shot (not nasal), pneumonia vaccine anytime; zoster vaccine when not receiving chemotherapy 1
- Adherence counseling for adjuvant endocrine therapy 1, 2