Follow-up Care after Treatment of Breast Cancer
Follow-up after completion of primary treatment of breast cancer has many aspects both medically, functionally, and financially. The individual needs of each patient for support will vary. All patients need some practical guidance. The most important aspect is early diagnosis of local regional relapse.
Usually a 10-year follow-up is performed after primary treatment of breast cancer. A growing tendency is that general practioners have early responsibility for medical follow-up of both breast conservative treatment and mastectomy. All patients must be informed about the risk of local regional relapse or a new tumor in the contralateral breast. The patients must be encouraged to regularly perform breast self-examination. In addition information about the benefit and need of regular mammograms should be provided.
The following groups with more complicated problems should be followed up a a hospital:
- Patients below 35 years
- Patients with primary locally advanced cancer
- Patients with breast cancer related to pregnancy/breastfeeding
Many patients may have torments/problems which may need special consideration the first time after the treatment. This may concern fatigue, problems with concentration/memory, symptoms from lack of estrogen, sexual problems, mental disorder, lymphedema, and regional torments.
Even if there are different ways of organizing the follow-up many of the patients prefer to maintain the connection with the treating hospital. The treatment will also for many of the patients give a medical basis for seeing the patients at some important points of time:
- First year (side effects)
- After 2 years (change of hormone treatment for many)
- After 5 years (usually for ending hormone treatment)
Due to the planned implementation of The Norwegian Breast Cancer Registry (NBCR) it is also reasonable to structure the follow-up to simplify and secure the reports for NBCR. Reporting is planned for 10 years after treatment.
The following guidance for registration should be the minimum:
- The first 2 years: Annual follow-up visit at the treating hospital. Consultation and examination by physician.
- Year 3 and 4: Annual contact with the treating hospital through telephone consultations (nurse or physician) or nurse-driven controls at the treating hospital. Clinical examination (and consultation, if needed) by general practitioner or physician at treating hospital.
- Year 5: Follow-up visit at the treating hospital. Consultation and examination by physician.
- Year 6 - 9: The need for contact with the treating hospital is discussed at the year 5 follow-up visit. If needed, yearly contact with the treating hospital through telephone consultations combined with clinical examination/consultation by general practitioner. If no need for contact with the treating hospital, only follow-up visits with general practitioner.
- Year 10: Follow-up visit at the treating hospital. Consultation and examination by physician.
Mammography is to be carried out annually after primary treatment for stage 1 - 3 have been completed.
- After breast conservative treatment, irrespective of age. Both breast are examined. The first time within a year after preoperative mammography, thereafter annually for 10 years. The examinations should preferably be performed at the treating hospital.
- After mastectomy. Annual follow-up at treating hospital for 10 years. The Norwegian Mammograpy Programme may take care of the mammography biannually after 50 years of age.
Patients being followed up for 10 years and being more than 50 years of age may further follow the breast cancer screening programme. Younger patients should continue their mammography control at the treating hospital until 50 years of age.
The physician should inform women taking tamoxifen on the risk of endometrial proliferation, endometrial hyperplasia and uterine cancer in postmenopausal status. Routine gynelogical examination with ultra sound is not necessary in women without gynecological symptoms. Gynecologic symptoms like for instance vaginal bleeding should be immediately gynecologically examined.
Monitoring of thyroid function
Women treated for breast cancer have an increased risk of hypothyroidism. Irradiation towards supra/infraclavicular lymph nodes may contribute to this. After locoregional irradiation we therefore recommend lifelong testing of FT4 and TSH (or more frequently in case of deviations). During follow-up for women treated for breast cancer, FT4 and TSH should be checked where there is suspicion of hypothyroidism, even for sparse symptoms.
Patients may be offered reconstruction with implant or autologous tissue. Various techniques are applied for transposition of own (autologous) tissue.
Locoregional recurrence after treatment for breast cancer can develop both early and late during the follow-up. A considerable percentage appears during the first 5 years. The frequency of locoregional recurrencies with nodepositive patients is considerably reduced subsequent to routinely application of locoregional radiation
Both the treatment and prognosis varies, depending on both the primary treatment, the location of the locoregional recurrence and the interval from primary surgery. Additionally several other factors may be of importance.
The major groups of locoregional recurrences are:
- Thoracic wall after mastectomy
- Recurrence in regional lymph nodes
- Recurrence in the breast after conservation treatment
- Locoregional recurrence with synchronous metastasis
A well taken anamnesis and careful clinical examination of the locoregional area is most important for the detection of recurrence. When recurrence is suspected additional examinations will be relevant. The clinical picture will decide which examinations shall be performed.
Relevant examinations are:
- Extended hematological profile:
- Hematological tests: creatinine, electrolytes including s-Ca, albumin, and liver tests.
- Possibly tumor markers (MUC1,CEA)
CT, ultrasound and MRI may reveal important information for the diagnoasis of a locoregional diagnosis. In som cases where these examinations are inconclusive, PET can give additional information. The recurrence should always be confirmed by biopsy. Radiation fibrosis can be a differential diagnosis.
- Metastases should be routinely screened for (ultrasound or CT of the liver, bone scintigraphy or MRI).
- CT of the chest (possibly x-ray of the chest) should be considered depending on the type of recurrence.