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Recommendations for Follow-up after Early Breast Cancer Diagnoses



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Am Fam Physician. 2007 Dec 15;76(12):1864-1872.

Background: More than 200,000 invasive breast cancer diagnoses are expected in 2007, and primary care physicians often encounter issues with screening for recurrence, familial risk, and complications of breast cancer or treatment. Hayes reviewed evidence-based guidelines from various organizations on the specific health needs in patients with early breast cancer and summarized major recommendations for follow-up in these patients.

Recommendations: In general, patients with breast cancer should be evaluated every four to six months during the year after diagnosis. After the first year, patients should receive annual evaluations if they are no longer receiving therapy, mammograms, and assessments for symptoms of recurrence.

In patients with a history of breast cancer, annual screening with mammography is the standard of care for detecting new primary breast cancer. Magnetic resonance imaging or high-resolution ultrasonography may be useful in high-risk patients, although the role of these tests in other patients has not been determined. Screening for local recurrence in patients who had breast-conserving therapy (e.g., lumpectomy) is identical to screening for new primary cancer in the contralateral breast. However, the reviewing radiologist should be notified of the patient's history because surgery or irradiation may leave residual findings on the mammogram. Patients with a history of breast cancer should receive routine age-specific screening for colon and cervical cancers.

More than 25 percent of all metastases occur five years or more after the initial diagnosis of breast cancer; therefore, patients should be routinely assessed for symptoms of metastatic disease (e.g., neurologic symptoms, bone pain, dyspnea, jaundice). Because specialized testing for metastasis (e.g., blood testing, tumor marker screening, radiographic imaging) may have false-positive rates of up to 50 percent, they should be reserved for patients with symptoms or signs that are associated with recurrence.

Breast cancer treatments may increase the risk of other cancers (e.g., endometrial carcinoma from tamoxifen [Nolvadex, brand no longer available] use; leukemia from chemotherapy; angiosarcoma from irradiation). Routine screening for treatment-related cancers is not recommended because the incidence of these cancers is less than 1 percent five years after treatment; however, patients should be educated about relevant signs and symptoms, and physicians should ask about these signs and symptoms at follow-up visits.

Although genetic testing is not recommended for all women with breast cancer, it may be useful in high-risk patients (see accompanying table). In patients without risk factors for familial cancer syndromes, the risk of carrying a mutation in a tumor suppressor gene such as BRCA1 or BRCA2 is less than 1 percent.

Patients have a greater risk of osteoporosis if they are treated with aromatase inhibitors (e.g., anastrozole [Arimidex], letrozole [Femara], exemestane [Aromasin]) because these drugs have antiestrogenic effects. Bone mineral density testing should be performed before initiation of aromatase inhibitor therapy, and testing should be performed every one to two years in other patients with a history of breast cancer. Bisphosphonate therapy is preferred in these patients because raloxifene (Evista) may limit the effectiveness of aromatase inhibitors. Similarly, raloxifene should be avoided if a patient has received five years of tamoxifen therapy, because these drugs have similar mechanisms and because of the risk of breast cancer recurrence with prolonged tamoxifen use.

Cardiovascular screening and prevention measures, including regular exercise and monitoring of blood pressure and lipid levels, are important. No special testing is recommended; however, physicians should be aware of therapies that may increase the risk of cardiovascular disease. Chemotherapy with anthracyclines or trastuzumab (Herceptin) may reduce cardiac function in up to 5 percent of patients, and radiation therapy to the left chest wall may increase long-term cardiovascular risk by up to 30 percent. Tamoxifen therapy has also been associated with a threefold increase in the risk of thromboembolic and cerebrovascular diseases and should be avoided in patients with a history of these conditions.

Table

Indications for Genetic Counseling in Patients with a History of Breast Cancer

Age younger than 40 years at diagnosis

Ashkenazi Jewish heritage

Personal history of ovarian cancer or first- or second-degree relative with a history of ovarian cancer

Personal history of bilateral breast cancer or a first- or second-degree relative with a history of bilateral breast cancer

First-degree relative who was younger than 50 years when diagnosed with breast cancer

Two or more first- or second-degree relatives who were diagnosed with breast cancer at any age

Any male relative with a history of breast cancer


Adapted with permission from Hayes DF. Follow-up of patients with early breast cancer. N Engl J Med 2007;356:2506.

Table   Indications for Genetic Counseling in Patients with a History of Breast Cancer

View Table

Table

Indications for Genetic Counseling in Patients with a History of Breast Cancer

Age younger than 40 years at diagnosis

Ashkenazi Jewish heritage

Personal history of ovarian cancer or first- or second-degree relative with a history of ovarian cancer

Personal history of bilateral breast cancer or a first- or second-degree relative with a history of bilateral breast cancer

First-degree relative who was younger than 50 years when diagnosed with breast cancer

Two or more first- or second-degree relatives who were diagnosed with breast cancer at any age

Any male relative with a history of breast cancer


Adapted with permission from Hayes DF. Follow-up of patients with early breast cancer. N Engl J Med 2007;356:2506.

Source

Hayes DF. Follow-up of patients with early breast cancer. N Engl J Med. June 14, 2007;356:2505–13.



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