General Considerations for Follow-Up

With advances in screening, early detection, and treatment modalities, most women who are diagnosed with and treated for localized early-stage breast cancer will be long-term survivors. From 1989 to 2017, the breast cancer death rate continued to decline, dropping by 40% overall. The 5-year survival rate of localized breast cancer after treatment is about 90%. Survivorship may mean different things to different people, but it is the process of living with, through, and beyond cancer and its treatment. Apart from the patient themselves, family members, caregivers, and friends are also affected by the cancer. Regular follow-up with a health care provider is essential after completion of treatment for breast cancer, not only to promptly recognize the local and distant recurrences or a second primary cancer through regular recommended surveillance, but also to manage the long-term side effects of therapy and the myriad of social, vocational, physical, spiritual, emotional, and psychological affects faced by many of the cancer survivors. Although there are many evidence-based clinical guidelines for screening, diagnosis, and treatment, relatively few studies address survivors by cancer type for long-term follow-up care and survivorship. Nonetheless, the current recommendations for follow-up care for breast cancer survivors as detailed by American Society of Clinical Oncology (ASCO) and American Cancer Society (ACS) based on available expert consensus are listed in Box 72.1 .

Box 72.1

2016 ASCO and ACS Recommendations for Follow-Up for Breast Cancer Survivors

From Runowicz CD, Leach CR, Henry NL, et al. American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. CA Cancer J Clin . 2016;66:43–73.

Target population: Female adult breast cancer survivors
Target audience: Primary care providers, medical oncologists, radiation oncologists, and other clinicians caring for breast cancer survivors
Methods: An expert panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature

Surveillance for Breast Cancer Recurrence

History and Physical Examination

Recommendation 1.1: It is recommended that primary care clinicians (a) should individualize clinical follow-up care provided to breast cancer survivors based on age, specific diagnosis, and treatment protocol and as recommended by the treating oncology team (LOE=2 A); and (b) should make sure the patient receives a detailed cancer-related history and physical examination every 3 to 6 months for the first 3 years after primary therapy, every 6 to 12 months for the next 2 years, and annually thereafter (LOE=2 A).

Screening the Breast for Local Recurrence or a New Primary Breast Cancer

Recommendation 1.2: It is recommended that primary care clinicians (a) should refer women who have received a unilateral mastectomy for annual mammography on the intact breast and, for those with lumpectomies, an annual mammography of both breasts (LOE=2 A); and (b) should not refer for routine screening with MRI of the breast unless the patient meets high-risk criteria for increased breast cancer surveillance as per ACS guidelines (LOE=2 A).

Laboratory Tests and Imaging

Recommendation 1.3: It is recommended that primary care clinicians should not offer routine laboratory tests or imaging, except mammography if indicated, for the detection of disease recurrence in the absence of symptoms (LOE=2 A).

Signs of Recurrence

Recommendation 1.4: It is recommended that primary care clinicians should educate and counsel all women about the signs and symptoms of local or regional recurrence (LOE=2 A).

Risk Evaluation and Genetic Counseling

Recommendation 1.5: It is recommended that primary care clinicians (a) should assess the patient’s cancer family history; and (b) should offer genetic counseling if potential hereditary risk factors are suspected (e.g., women with a strong family history of cancer [breast, colon, endometrial] or age 60 years or younger with triple-negative breast cancer; LOE=2 A).

Endocrine Treatment Impacts, Symptom Management

Recommendation 1.6: It is recommended that primary care clinicians should counsel patients to adhere to adjuvant endocrine (antiestrogen) therapy (LOE=2 A).

Screening for Second Primary Cancers

Cancer Screenings in the Average-Risk Patient

Recommendation 2.1: It is recommended that primary care clinicians (a) should screen for other cancers as they would for patients in the general population; and (b) should provide an annual gynecologic assessment for postmenopausal women on selective estrogen receptor modulator therapies.

Assessment and Management of Physical and Psychosocial Long-Term and Late Effects of Breast Cancer and Treatment

Body Image Concerns

Recommendation 3.1: It is recommended that primary care clinicians (a) should assess for patient body image/appearance concerns (LOE=0); (b) should offer the option of adaptive devices (e.g., breast prostheses, wigs) and/or surgery when appropriate (LOE=0); and (c) should refer for psychosocial care as indicated (LOE=IA).

Lymphedema

Recommendation 3.2: It is recommended that primary care clinicians (a) should counsel survivors on how to prevent/reduce the risk of lymphedema, including weight loss for those who are overweight or obese (LOE=0); and (b) should refer patients with clinical symptoms or swelling suggestive of lymphedema to a therapist knowledgeable about the diagnosis and treatment of lymphedema, such as a physical therapist, occupational therapist, or lymphedema specialist (LOE=0).

Cardiotoxicity

Recommendation 3.3: It is recommended that primary care clinicians (a) should monitor lipid levels and provide cardiovascular monitoring, as indicated (LOE=0); and (b) should educate breast cancer survivors on healthy lifestyle modifications, potential cardiac risk factors, and when to report relevant symptoms (shortness of breath or fatigue) to their health care provider (LOE=I).

Cognitive Impairment

Recommendation 3.4: It is recommended that primary care clinicians (a) should ask patients if they are experiencing cognitive difficulties (LOE=0); (b) should assess for reversible contributing factors of cognitive impairment and optimally treat when possible (LOE=IA); and (c) should refer patients with signs of cognitive impairment for neurocognitive assessment and rehabilitation, including group cognitive training if available (LOE=IA).

Distress, Depression, Anxiety

Recommendation 3.5: It is recommended that primary care clinicians (a) should assess patients for distress, depression, and/or anxiety (LOE=I); (b) should conduct a more probing assessment for patients at a higher risk of depression (e.g., young patients, those with a history of prior psychiatric disease, and patients with low socioeconomic status; LOE=III); and (c) should offer in-office counseling and/or pharmacotherapy and/or refer to appropriate psycho-oncology and mental health resources as clinically indicated if signs of distress, depression, or anxiety are present (LOE=I).

Fatigue

Recommendation 3.6: It is recommended that primary care clinicians (a) should assess for fatigue and treat any causative factors for fatigue, including anemia, thyroid dysfunction, and cardiac dysfunction (LOE=0); (b) should offer treatment or referral for factors that may impact fatigue (e.g., mood disorders, sleep disturbance, pain, etc.) for those who do not have an otherwise identifiable cause of fatigue (LOE=I); and (c) should counsel patients to engage in regular physical activity and refer for cognitive behavioral therapy as appropriate (LOE=I).

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