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Primary Care Follow-Up in Breast Cancer Survivors

Am Fam Physician. 2001 Apr 15;63(8):1615-1616.

Currently, an estimated 2 million women in the United States have a diagnosis of breast cancer. As a result of early and more aggressive screening, about 180,000 new cases of breast cancer are diagnosed annually. A woman's lifetime risk of breast cancer is now 12.6 percent, and the risk of death from this disease is 3.6 percent. Eighty percent of women who undergo treatment for invasive breast cancer can expect to survive at least five years, as can women with carcinoma in-situ of the breast. All of these women require regular follow-up surveillance to detect recurrent disease and contend with the short- and long-term side effects of surgery, chemotherapy and radiation. Burstein and Winer reviewed current recommendations for follow-up care of women who survive breast cancer.

Most breast cancer recurrences are detected in the first five years, but recurrent disease beyond 10 years is not unusual. Suggestive symptoms of recurrence include musculoskeletal pain, weight loss, persistent cough, adenopathy and changes in the breast or chest wall. Studies have found that more than 75 percent of recurrences are manifested by specific symptoms, necessitating close follow-up and physical examination for all patient complaints. Unfortunately, surveillance diagnostic studies have not proved effective for the detection of recurrent disease. Routine chest radiographs, laboratory testing, including serum tumor markers, and bone scans detect only a small number of recurrences. In addition, earlier detection has not translated to improved survival. However, screening mammography is important in detecting new disease in the affected or contralateral breast.

Worth noting is that women who survive breast cancer are at risk for secondary malignancies. The estimated risk is about 1 percent annually and is greater in women who are diagnosed with a first cancer at a younger age, who have a familial form of breast cancer or who received radiation as part of their breast cancer treatment. Screening for ovarian, cervical or colorectal cancer should be in accordance with the current national guidelines (see accompanying table).

Hormone replacement therapy has been contraindicated in breast cancer survivors in view of the known relationship between estrogen and this type of cancer. Data showing that estrogen antagonism with tamoxifen decreases the incidence of cancer in the contralateral breast further strengthen this relationship. There are no good data that actually prove that estrogen alters the recurrence of breast cancer. However, most clinicians will not recommend estrogen therapy because it is thought that the risks of exacerbation or death from breast cancer outweigh the benefits of hormone replacement therapy. The authors note that the short-term use of 0.625 mg of conjugated estrogen daily with or without progesterone may be beneficial in select patients at low risk for recurrence who have debilitating symptoms related to estrogen deprivation. It is certainly prudent to recommend calcium (1,000 to 1,500 mg per day) and vitamin D (400 to 800 IU per day) supplementation, along with smoking cessation and weight-bearing exercise for breast cancer survivors.

Recommendations for Follow-Up Care After Breast Cancer*

Procedure Frequency

History taking or elicitation of symptoms and examination

Every 3 to 6 months for 3 years, then every 6 to 12 months for 2 years, then annually

Breast self-examination

Monthly

Mammography

Annually

Pelvic examination

Annually

Routine laboratory testing (complete blood count, liver function tests, automated blood chemical studies, measurement of tumor markers such as carcinoembryonic antigen and CA 15-3 [CA 27.29])

Not recommended

Routine radiologic studies (bone scanning, computed tomography, ultrasonography of liver, chest radiography, pelvic or transvaginal ultrasonography)

Not recommended

Screening for other cancers (e.g., colon, ovarian)

According to recommended guidelines for the general population†


*—The recommendations are adapted from those of the American Society of Clinical Oncology.

†—Women at risk for hereditary breast or ovarian cancer syndromes may merit additional surveillance for ovarian cancer, including pelvic ultrasonography and measurement of serum CA-125 levels, although the benefits of such surveillance are not known.

Reprinted with permission from Burstein HJ, Winer EP. Primary care for survivors of breast cancer N Engl J Med 2000;343:1087.

Recommendations for Follow-Up Care After Breast Cancer*

View Table

Recommendations for Follow-Up Care After Breast Cancer*

Procedure Frequency

History taking or elicitation of symptoms and examination

Every 3 to 6 months for 3 years, then every 6 to 12 months for 2 years, then annually

Breast self-examination

Monthly

Mammography

Annually

Pelvic examination

Annually

Routine laboratory testing (complete blood count, liver function tests, automated blood chemical studies, measurement of tumor markers such as carcinoembryonic antigen and CA 15-3 [CA 27.29])

Not recommended

Routine radiologic studies (bone scanning, computed tomography, ultrasonography of liver, chest radiography, pelvic or transvaginal ultrasonography)

Not recommended

Screening for other cancers (e.g., colon, ovarian)

According to recommended guidelines for the general population†


*—The recommendations are adapted from those of the American Society of Clinical Oncology.

†—Women at risk for hereditary breast or ovarian cancer syndromes may merit additional surveillance for ovarian cancer, including pelvic ultrasonography and measurement of serum CA-125 levels, although the benefits of such surveillance are not known.

Reprinted with permission from Burstein HJ, Winer EP. Primary care for survivors of breast cancer N Engl J Med 2000;343:1087.

Other issues discussed by the authors in this paper include the local and late complications (lymphedema and secondary leukemia) of breast cancer treatment, management of menopausal symptoms, lifestyle changes and psychosocial issues that all cancer survivors must contend with. Because of the complexity and chronic nature of most of these problems, the authors advocate on-going follow-up by the oncologist and the primary care physician, who should be capable of the surveillance and treatment.

Burstein HJ, Winer EP. Primary care for survivors of breast cancer. N Engl J Med. October 12, 2000;343:1086–93.


Copyright © 2001 by the American Academy of Family Physicians.
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