A patient who underwent a right‑sided lumpectomy (breast‑conserving surgery) on [date] and was followed by oncology until [date] with no recurrence, does she need continued oncology follow‑up or are annual clinical breast exams and mammograms sufficient?

Breast Cancer Surveillance After Lumpectomy

Annual mammography and clinical breast exams are sufficient for routine surveillance in this patient—continued oncology follow-up is not required if she remains asymptomatic and has no high-risk features. 1, 2

Recommended Surveillance Strategy

The American Society of Clinical Oncology (ASCO) explicitly states that regular history, physical examination, and annual mammography are the only routine surveillance investigations needed after primary breast cancer treatment. 1, 2 This conservative approach has been reaffirmed multiple times, most recently with 2013 guidelines concluding no revisions were warranted after reviewing 14 new publications. 2

Clinical Examination Schedule

For patients beyond 5 years post-treatment (as in this case):

• Annual clinical breast examination is sufficient 1
• Examinations should be performed by a physician experienced in cancer surveillance and breast examination 1
• The primary care clinician can perform these examinations in collaboration with or independent of oncology 1

Mammography Protocol

• Annual mammography of both breasts is the cornerstone of surveillance 1, 2
• Mammography detects 91-97% of recurrent disease 1, 2
• More frequent mammography is only warranted for evaluation of a suspicious finding, not routine surveillance 1
• MRI screening is not recommended unless the patient meets high-risk criteria (lifetime risk >20%, BRCA mutation, or strong family history) 1

What NOT to Do

ASCO explicitly recommends against routine laboratory tests and imaging studies in asymptomatic patients: 1, 2

• No complete blood counts, chemistry panels, or liver function tests 2
• No tumor markers (CEA, CA 15-3, CA 27.29) 1, 2
• No bone scans, chest radiographs, CT scans, PET scans, or MRI (except for high-risk patients) 1, 2

These tests have not been shown to improve survival outcomes or quality of life in asymptomatic patients. 1

When to Seek Immediate Evaluation

Patients should be counseled to report these symptoms immediately, which would warrant urgent evaluation: 2

• New breast lumps or masses
• Bone pain
• Chest pain or dyspnea
• Abdominal pain
• Persistent headaches

Cost-Effectiveness Evidence

Non-guideline compliant follow-up costs 2.2 to 3.6 times more than guideline-compliant surveillance, with a one-third decrease in expenditures per patient after introducing surveillance guidelines. 2 This supports the conservative approach without compromising outcomes.

Clinical Pearls and Caveats

• Most recurrences after breast-conserving surgery occur in the same quadrant as the original tumor 1
• 75% of recurrent DCIS presents as microcalcifications on mammography 1
• Detection of recurrence on mammography alone is associated with lower tumor stage, noninvasive histology, and longer disease-free survival 1
• The majority of local recurrences occur within the first 5 years, but late recurrences can occur well into the second decade 3

Who Should Continue Oncology Follow-Up

Continued oncology follow-up would only be necessary if:

• The patient has ongoing endocrine therapy requiring monitoring 1
• High-risk genetic features requiring specialized surveillance 1
• Patient preference for oncology-led care 1

For this patient with no issues since discharge from oncology, annual mammography with clinical breast exams by her primary care physician is the evidence-based standard of care. 1, 2