Cancer Follow-Up and Management After Primary Treatment:
American Societyof Clinical Oncology Clinical Practice Guideline Update
Published in Journal of Clinical
Oncology, Vol 3, Issue 7 (March), 2013: 961-965
James L. Khatcheressian, Patricia Hurley, Elissa Bantug, Laura J. Esserman, Eva
Grunfeld, Francine Halberg, Alexander Hantel, N. Lynn Henry, Hyman B. Muss,
Thomas J. Smith, Victor G. Vogel, Antonio C. Wolff, Mark R. Somerfield, and
Nancy E. Davidson
To provide recommendations on the
follow-up and management of patients with breast cancer who have completed
primary therapy with curative intent.
To update the 2006 guideline of the
American Society of Clinical Oncology (ASCO), a systematic review of the
literature published from March 2006 through March 2012 was completed using
MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed
the evidence to determine whether the recommendations were in need of updating.
There were 14 new publications that
met inclusion criteria: nine systematic reviews (three included meta-analyses)
and five randomized controlled trials. After its review and analysis of the
evidence, the Update Committee concluded that no revisions to the existing ASCO
recommendations were warranted.
Regular history, physical
examination, and mammography are recommended for breast cancer follow-up. Physical examinations
should be performed every 3 to 6 months for the first 3 years, every 6 to 12
months for years 4 and 5, and annually thereafter. For women who
have undergone breast-conserving surgery, a post-treatment mammogram should be
obtained 1 year after the initial mammogram and at least 6 months after
completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly
mammographic evaluation should be performed. The use of complete
blood counts, chemistry panels, bone scans, chest radiographs, liver
ultrasounds, pelvic ultrasounds, computed tomography scans, [18F]
fluorodeoxyglucose–positron emission tomography scans, magnetic resonance
imaging, and/or tumor markers (carcinoembryonic antigen, CA 15-3, and CA 27.29)
is not recommended for routine follow-up in an otherwise asymptomatic patient
with no specific findings on clinical examination.
To help doctors give their patients the best possible care, the American
Society of Clinical Oncology (ASCO) developed evidence-based recommendations
for follow-up care for patients with breast cancer. In 2012, ASCO reviewed the
results of new research studies, and no changes to the recommendations were
needed based on the current research findings. This guide for patients explains
the ASCO recommendations.
care for breast cancer includes managing the short-term side effects of
treatment and watching for long-term side effects or a return of the
recommendations for follow-up care include regular visits to your doctor
with breast cancer should talk with their doctors about a follow-up care
plan and how to coordinate this care between the oncologist and their
primary care or family doctor.
After treatment for breast cancer, follow-up care is important to help
maintain good health, which includes managing any side effects from treatment
and watching for long-term
side effects (called late effects) or signs of a cancer recurrence
(cancer that comes back after treatment). A follow-up care plan may include
regular physical examinations and other medical tests to monitor your recovery
for the coming months and years. To help keep track of the cancer treatment you
received and work with your doctor to develop a survivorship care plan, ASCO
offers cancer treatment summary forms.
Many survivors feel worried or anxious that the cancer will come back after
treatment. While it often does not, it’s important to talk with your doctor
about the possibility of the cancer returning. Most breast cancer recurrences
are found by patients between doctor visits. Tell your doctor if you notice any of the
following symptoms, as they may be signs of a cancer recurrence:
New lumps in the breast
Shortness of breath or difficulty
Rash on breast
Nipple discharge (liquid coming from
ASCO recommends the schedule of tests and procedures listed below after
treatment for breast cancer. About a year after diagnosis, you may continue to
visit your oncologist or transfer your care to a primary care doctor. Women
receiving hormonal therapy should talk with their oncologist about how often to
schedule follow-up visits for re-evaluation of their treatment.
Medical history and physical examination. Visit your doctor every
three to six months for the first three years after the first treatment, every
six to 12 months for years four and five, and every year thereafter.
Schedule a mammogram one year after the first mammogram that led to your
diagnosis. However, if you have had radiation therapy, wait six months after
your last treatment. Obtain a mammogram every six to 12 months thereafter.
Breast self-examination. Perform a breast self-examination every
month. This procedure is not a substitute for a mammogram.
Pelvic examination. Continue to visit a gynecologist regularly.
Because the drug tamoxifen (Nolvadex) increases the risk of uterine
cancer, women taking this drug should tell their doctors about any
abnormal vaginal bleeding.
Genetic counseling. Another important part of follow-up care is to
tell your doctor if you have a history of cancer in your family because you may
benefit from genetic counseling. The following risk factors may indicate that
breast cancer could run in the family:
or family history of ovarian cancer
first-degree relative (mother, sister, daughter) diagnosed with breast
cancer before age 50
more first-degree or second-degree relatives (grandparent, aunt, uncle)
diagnosed with breast cancer
or family history of breast cancer in both breasts
breast cancer in a male relative
tests are not currently recommended by ASCO for regular
follow-up care because they have not been shown to lengthen the life
of a person with breast cancer. Learn more about why these tests may not be
blood count (CBC) test and liver and kidney function tests
The recommendations for follow-up care for breast cancer include regular
physical examinations, mammograms, and breast self-examinations. The follow-up
care may be provided by your oncologist or primary care doctor, as long as your
primary care doctor has talked with your oncologist about appropriate follow-up
care and the possible late effects. In addition, patients with a possible or
known family history of breast cancer may want to visit a genetic counselor.
Use these guideline recommendations to talk with your doctor about an appropriate
follow-up care plan for you.
Questions to Ask the Doctor
To learn more about follow-up care for breast cancer, consider asking your
doctor the following questions:
follow-up care plan would you recommend for me?
the chance that the cancer will recur?
do you recommend? Why?
my personal and family medical history, do I need to visit a genetic
I find more information about follow-up care?
I know most oncs do not believe in routine scans. This is just my personal experience. My first onc didn't follow the standard guidelines. She liked to scan her TNBC patients yearly for the first 3 years. So 13 months after finishing chemo, I had a routine PET scan that found my recurrence to a regional node (stage 3). I was feeling great, no symptoms at all, blood work normal, tumor markers normal. If I had waited till I had symptoms, I'm sure my prognosis would have been much more grim.
DX IDC TNBC 6/09 age 49, Stage 1,Grade 3, 1.5cm,0/5Nodes,KI-67 48%,BRCA-,6/09bi-mx, recon, T/C X4(9/09) 11/10 Recur IM node, Gem,Carb,Iniparib 12/10,MRI NED 2/11,IMRT Radsx40,CT NED11/13,MRI NED3/15
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