Postoperative Breast Cancer Surveillance
For patients who have completed primary breast cancer treatment (lumpectomy or mastectomy), routine surveillance should consist exclusively of regular history and physical examination plus annual mammography—no additional laboratory tests or imaging studies are recommended for asymptomatic patients. 1, 2
Clinical Examination Schedule
Follow a time-based algorithm for physical examination frequency:
- Years 1-3: Every 3-6 months 1, 2, 3
- Years 4-5: Every 6-12 months 1, 2, 3
- Year 6 onward: Annually 1, 2, 3
The examining clinician must be experienced in cancer surveillance and breast examination, including assessment of irradiated breasts. 1 Either oncology specialists or primary care physicians may perform these examinations, with transfer to primary care appropriate approximately 1 year after diagnosis for patients with early-stage disease (tumor ≤5 cm, ≤4 positive nodes) who are not receiving ongoing endocrine therapy. 1, 4
Mammographic Surveillance Protocol
For patients who underwent breast-conserving surgery:
- First post-treatment mammogram: 1 year after initial diagnostic mammogram AND at least 6 months after completing radiation therapy 1, 2
- Subsequent mammograms: Every 6-12 months until stability is achieved, then annually 1, 2
For all patients (including mastectomy): Annual bilateral mammography is the cornerstone of surveillance, detecting 91-97% of recurrent disease. 2 The contralateral breast requires the same surveillance frequency. 3
Patient Symptom Education
Counsel patients to report these specific symptoms immediately, as 69% of recurrences present between scheduled follow-up visits: 1
- New breast lumps 1, 4
- Bone pain 1, 4
- Chest pain or dyspnea 1, 4
- Abdominal pain 1, 4
- Persistent headaches 1, 4
Monthly breast self-examination should be taught, though it does not replace mammography. 1, 4
Tests NOT Recommended for Routine Surveillance
ASCO explicitly recommends against the following in asymptomatic patients: 1, 2
- Complete blood counts 2, 4
- Chemistry panels or liver function tests 2, 4
- Tumor markers (CEA, CA 15-3, CA 27.29) 1, 2, 4
- Bone scans 1, 2, 4
- Chest radiographs 1, 2, 4
- Liver ultrasounds 1, 2, 4
- CT scans 1, 2, 4
- PET scans 1, 2, 4
- MRI (except for high-risk genetic patients with lifetime risk >20%, BRCA mutations, or strong family history) 2, 4
These tests have not demonstrated improvements in survival or quality-of-life outcomes and increase costs by 2.2 to 3.6 times without benefit. 2
Special Circumstances Requiring Continued Oncology Follow-Up
Maintain oncology-led surveillance when:
- Patient is receiving endocrine therapy (tamoxifen or aromatase inhibitors) requiring monitoring 2, 3
- High-risk genetic features are present (BRCA mutation, Ashkenazi Jewish heritage, personal/family history of ovarian cancer, first-degree relative with breast cancer before age 50, or ≥2 first- or second-degree relatives with breast cancer) 1, 2, 4
- Patient preference for oncology-led care 2
For patients on tamoxifen, add annual gynecological examination. 3 For those on aromatase inhibitors, include regular bone density assessment. 3
Recurrence Detection Patterns
Approximately 75% of recurrent DCIS presents as microcalcifications on mammography, and most local recurrences after breast-conserving surgery occur in the same quadrant as the original tumor. 2 Recurrences detected solely by mammography are associated with lower tumor stage, non-invasive histology, and longer disease-free survival compared to clinically detected recurrences. 2, 5
Common Pitfalls to Avoid
Do not order "routine" surveillance labs or imaging studies in asymptomatic patients—this represents the most common deviation from evidence-based guidelines and increases costs without improving outcomes. 1, 2 The ASCO guidelines were reaffirmed in 2013 after reviewing 14 new publications, confirming that the conservative surveillance strategy remains appropriate. 2