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BMJ. Jan 19, 2008; 336(7636): 107–108.
PMCID: PMC2206254

Follow-up after breast cancer

J M Dixon, consultant surgeon and senior lecturer in surgery; clinical director, Edinburgh breakthrough research unit1 and David Montgomery, clinical research fellow2

Should be evidence based, flexible, and tailored to patients’ lifelong needs

More than 1.2 million women and men worldwide are diagnosed with breast cancer each year. In 2007, the 20 year survival rate for breast cancer will be greater than the five year survival rate 30 years ago.1 Breast cancer is now recognised as a chronic disease that can recur even after 20-30 years. Follow-up protocols vary widely—both within and between countries—and are not always evidence based. The challenge is to develop follow-up programmes that reflect current knowledge and meet the ongoing needs of this growing number of people.

Guidelines from the National Institute for Health and Clinical Excellence (NICE) in England and Wales state that the aims of breast cancer follow-up are to detect and treat local recurrence, to deal with adverse effects of treatment, and to provide psychological support.2 Routine surveillance for metastatic disease is not recommended because data from randomised studies have shown no improvement in outcomes for patients who undergo intensive programmes to detect and treat asymptomatic metastatic disease. The guidelines suggest that the aims can be met by two to three years of follow-up, and they conclude that routine long term follow-up is ineffective and unwarranted. The guidelines provide no specific recommendations for mammography; they claim that the yield from mammography is low, and that networks should derive their own evidence based policy on how often mammography should be conducted.

The incidence of metastatic disease peaks around two to three years after diagnosis and stays at 2% annually for up to five years before decreasing, but the pattern is different for treatable locoregional recurrences and contralateral breast cancer. Although true local recurrence after breast conserving surgery falls with time, the development of new cancers in the treated breast increases, so the overall incidence of ipsilateral breast events is constant—at 0.5-1% each year for at least the first 10 years and probably for the rest of the patient’s life. Patients with cancer in one breast have increased risk of contralateral breast cancer—the incidence is 0.3-0.4% each year. If “recurrences” in the treated breast and axilla are combined with new cancers in the other breast, the annual incidence of treatable locoregional disease is constant at 1-1.5% for at least the first 10 years, and 70% of such events occur after the first three years. If NICE is to achieve its aim of detecting and treating local recurrence it clearly cannot be achieved with a three year follow-up.

The value of regular clinical examination to detect treatable recurrences is questionable. In a recent audit of patients treated by breast conservation in our unit, only 15 of 110 treatable locoregional recurrences were detected by clinical examination. In contrast, 56 events were detected by mammography, 37 were detected by the patients themselves, and two were diagnosed incidentally during breast reshaping.3 Importantly, patients with recurrence in the ipsilateral breast that was symptomatic or detected by mammography had a significantly better survival than patients with a clinically detected recurrence (P=0.0002). In an unpublished audit carried out by our unit, annual mammography detected 5.37 ipsilateral and contralateral breast cancers per 1000 mammograms. This compares favourably with the prevalent detection rate in the National Health Service Breast Screening Programme (where women have a mammogram at three yearly intervals) of 4.7 per 1000 women screened in 2003.4 In contrast to NICE’s suggestion, mammography is a very effective way to detect treatable local disease, and fully funded mammographic surveillance programmes specifically for patients with breast cancer are urgently needed.

Psychological concerns after treatment for breast cancer often become apparent during follow-up, although clinic visits are not always helpful in detecting or treating such problems.5 6 Nurses detect more psychological problems than clinicians doing routine follow-up clinics.7 Side effects of drug treatment and unrelated medical problems are other common concerns reported by patients, but these are often underestimated and unrecognised by clinicians.8 9 One solution is to provide patients with self completed quality of life questionnaires, which are reliable and effective at identifying such difficulties. Continued clinical input will be needed for some patients, including those who request revisional or reconstructive surgery, those with serious side effects from treatment, people with signs and symptoms that suggest recurrence, and those suitable for switching to aromatase inhibitors agents after two or five years of tamoxifen. Long term complications of treatment and bone health are other areas where specialist medical management is increasingly required.

The NICE guidelines need urgent revision as they do not meet their stated aims. Clinical examination should be annual for two years. Any unit performing more regular clinical assessments should consider amending their protocols now. Psychological support should be available and focused when patients’ needs are greatest—not only at diagnosis and during treatment but after treatment ends.

Discharging patients from breast units to breast screening programmes after two years is unlikely to meet their specific needs. Follow-up care and the health professionals involved will vary in different settings. One model that meets the aims set out by NICE is annual clinical examination for two years and surveillance by mammography thereafter. Our audit data support annual mammograms. Assessment before these annual visits by note review and postal questionnaires should identify those patients who need medical or nursing input when they attend for mammography. In between visits for mammograms, patients should have direct access to a named breast care nurse, specialist nurse, or doctor and access to prosthesis advice and fitting. Timely investigation of symptoms and communication of test results to patients and primary care doctors will help reduce anxiety and improve ongoing care. Patients’ needs vary, so follow-up programmes for patients with breast cancer need to be evidence based, flexible, and tailored to their lifelong needs.

Notes

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

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2. National Institute for Health and Clinical Excellence. Guidance on cancer services: improving outcomes in breast cancer. Manual update. 2002. www.nice.org.uk/page.aspx?o=csgbcguidance.
3. Montgomery DA, Krupa K, Jack WJL, Kerr GR, Kunkler IH, Thomas J,et al. Changing pattern of the detection of loco-regional relapse in breast cancer: the Edinburgh experience. Br J Cancer 2007;96:1802-7. [PMC free article] [PubMed]
4. National Health Service Cancer Screening Programmes. NHS Breast Screening annual review 2006. www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp-annualreview2006.pdf.
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8. Butler L, Bacon M, Carey M, Zee B, Tu D, Bezjak A. Determining the relationship between toxicity and quality of life in an ovarian cancer chemotherapy clinical trial. J Clin Oncol 2004;22:2461-8. [PubMed]
9. Fromme EK, Eilers KM, Mori M, Hsieh Y, Beer TM. How accurate is clinician reporting of chemotherapy adverse events? A comparison with patient-reported symptoms from the quality-of-life questionnaire C30. J Clin Oncol 2004;22:3485-90. [PubMed]

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