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National Collaborating Centre for Cancer (UK). Early and Locally Advanced Breast Cancer: Diagnosis and Treatment [Internet]. Cardiff (UK): National Collaborating Centre for Cancer (UK); 2009 Feb. (NICE Clinical Guidelines, No. 80.)

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Early and Locally Advanced Breast Cancer: Diagnosis and Treatment [Internet].

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9.1. Introduction

Follow-up of patients after treatment for early breast cancer includes clinical and radiological options for assessment of both the treated and the contralateral breast. It incorporates supervision of ongoing adjuvant treatment and potential side effects, and review of patients who are in clinical trials. Follow-up should also include advice on general health, diet and exercise. Further demand for follow-up of patients with early invasive breast cancer has been created by the increasing duration and sequencing of adjuvant therapy.

How follow-up should be carried out has been the subject of controversy and there is variation in England and Wales as to who should undertake this, and where this should be performed. This has led to pressures on service provision.

9.2. Follow-up Imaging

Invasive breast cancer

Patients treated for early invasive breast cancer are at risk of developing local recurrence and are also at increased risk of developing a further new primary breast cancer. It is currently common practice for women being followed-up after treatment for early breast cancer to return to the National Health Service Breast Screening Programme (NHSBSP)/Breast Test Wales Screening Programme (BTWSP) after five years of follow-up or when they reach 50 years of age. The NHSBSP/BTWSP invites women between 50 and 70 years of age for mammographic screening every three years (7 screening events over 21 years). Younger women are only eligible for screening if they have a significant increased risk, in which case they are usually offered annual mammography between 40 and 50 years of age. Women over 70 years of age are not invited for screening mammography but can attend by self-referral every three years. The NHSBSP will extend the age of invitation from 47 to 73 years of age (two additional screening events – 9 screening events over 27 years) to be fully implemented by 2012 in England. The screening interval will remain at three years but there is concern about whether this interval is appropriate for extended surveillance (i.e. after 5 years) in patients treated for breast cancer.

Local recurrence

The rationale for early detection of local recurrence is that treatment may be more effective and there may be a survival benefit. The risk of local recurrence is determined by the prognostic factors of the primary tumour and the type of treatment given. Overall the risk of local recurrence in the treated breast is between 0.5% and 1% per annum when new primaries are included (and is lifelong). Local recurrence can be detected by regular surveillance, (clinical examination and breast imaging) or, most commonly, by the patient presenting with new symptoms or signs between scheduled follow-up visits. It is currently routine practice for all patients treated for early breast cancer to be offered regular surveillance, although the method, duration and frequency is variable. Patients who have had breast reconstruction may have particular follow-up requirements.

Mammography is widely used as part of surveillance and up to a third of local recurrences are detected by mammography alone. It is most likely to detect recurrence in the conserved breast. The recurrence usually has similar mammographic features to the original primary disease. It is not effective in detecting superficial and skin recurrence either in the conserved breast or on the chest wall following mastectomy. Mammography may detect recurrence with better prognostic factors than clinical examination.

Surveillance ultrasound may detect some recurrences that are not detectable on mammography, particularly in the dense breast or when the primary tumour was occult on mammography. Magnetic resonance imaging (MRI) can be expected to have significantly higher sensitivity for recurrence than other imaging techniques but is also likely to have a high false positive rate with a high proportion of benign biopsies. MRI is not currently recommended for routine surveillance but is used for further assessment and problem solving when other investigations have equivocal findings. Both mammography and MRI are more likely to result in false positive findings in the conserved breast in the first 18 months after radiotherapy.

Contralateral breast cancer

Patients treated for early breast cancer are also at increased risk of developing a cancer in the other breast, compared to women without breast cancer. The risk is estimated to be in the region of just under three per thousand per annum. The current rationale for offering regular mammography to all women treated with breast cancer at least up to the age at which population screening is routinely available, is that earlier diagnosis of a second breast cancer may result in more effective treatment and possibly improved survival. Mammography is the most effective modality for detecting contralateral breast cancers. Ultrasound and MRI are not currently used for routine contralateral breast surveillance.

Ductal Carcinoma in Situ (DCIS)

Patients treated for DCIS are at risk of local recurrence and also at increased risk of developing a new primary invasive breast cancer in either breast. The risk of local recurrence is determined by factors including the grade of the DCIS and the use of radiotherapy, following breast conserving surgery. Mammography is the most effective modality for detecting DCIS. Ultrasound is not effective for detection of DCIS and MRI is currently not used for routine surveillance after treatment for DCIS.


  • Offer annual mammography to all patients with early breast cancer, including DCIS, until they enter the NHSBSP/BTWSP. Patients diagnosed with early breast cancer who are already eligible for screening should have annual mammography for 5 years.

Qualifying statement: This recommendation is based on evidence from observational studies and GDG consensus.

  • On reaching the NHSBSP/BTWSP screening age or after 5 years of annual mammography follow-up we recommend the NHSBSP/BTWSP stratify screening frequency in line with patient risk category.

Qualifying statement: This recommendation is based on evidence from observational studies, and GDG consensus that these patients are at a risk of recurrence and at higher risk of new primaries than other patients in the NHSBSP/BTWSP, and of at least equivalent risk as patients at a higher risk as a result of their family history.

  • Do not offer mammography of the ipsilateral soft tissues after mastectomy.

Qualifying statement: This recommendation is based on evidence from observational studies

  • Do not offer ultrasound or MRI for routine post-treatment surveillance in patients who have been treated for early invasive breast cancer or DCIS.

Qualifying statement: There is insufficient evidence to support the routine use of ultrasound or MRI imaging modalities in post-treatment surveillance.

Clinical Evidence

Invasive breast cancer

Evidence from three systematic reviews of observational studies does not confirm that routine follow-up mammography directly improves survival in patients treated for breast cancer, even though one included observational study is suggestive of improved 5 year survival for patients in whom ipsilateral recurrence is detected by mammography (McGahan and Noorani, 2000; Temple et al., 1999; Grunfeld et al,. 2002 and Montogomery et al., 2007).

Evidence from one RCT suggests that in the first 18 months of follow-up, further tests prompted by mammography are more frequent in patients treated initially with breast conserving surgery plus radiotherapy compared to patients who received breast conserving surgery alone (Holli et al., 1998).

Estimates of the proportion of cases of recurrent breast cancer that are detected first by follow-up mammography come from observational studies, but there is wide variation. Two systematic reviews of observational studies summarise this proportion. For ipsilateral local recurrence, the proportion detected first by follow-up mammography had a range of 8%–50% (Grunfeld et al., 2002 and McGahan and Noorani 2000) and median values of 26% (McGahan and Noorani, 2000) and 27% (Grunfeld et al., 2002). For contralateral breast cancer, the proportion detected first by follow-up mammography had a range of 8%–80% (Grunfeld et al., 2002 and McGahan and Noorani, 2000) and median values of 36% (McGahan and Noorani, 2000) and 45% (Grunfeld et al., 2002).

Evidence from a systematic review of observational studies suggests that the sensitivity of mammography in detecting ipsilateral local recurrence has a range of 38%–74% and a specificity of 39%–60%. Sensitivity and specificity for the detection of contralateral breast cancer was provided for physical examination plus mammography combined, with sensitivity (range) 81%–88% and specificity (range) 96.5%–99.9% (Temple et al., 1999).

Evidence on the role of MRI in the follow-up of patients treated for breast cancer comes from observational studies and suggests that the sensitivity and specificity of MRI in detecting locally recurrent breast cancer are potentially high. In severn diagnostic studies of follow-up MRI, sensitivity had a range of 85.7%-100%. Specificity had a range of 82%–100% (Aichinger et al., 2002; Bone et al., 1995; Buthiau et al., 1995; Coulthard et al., 1999; Heywangkobrunner et al., 1993; Preda et al., 2006 and Viehweg et al., 1998). Follow-up MRI can detect multifocal tumours, multicentric tumours and DCIS (Bone et al., 1995) and also incidental breast cancer tumours in the contralateral breast in patients treated for breast cancer but in whom the contralateral is clinically and mammographically asymptomatic (Liberman et al., 2003). There is some evidence that follow-up MRI has higher diagnostic performance when the interval from radiotherapy to MRI is longer (Heywangkobrunner et al., 1993 and Viehweg et al., 1998).

Evidence on the role of ultrasound in the follow-up of patients treated for breast cancer comes from observational studies and shows the sensitivity of ultrasound in detecting locally recurrent breast cancer had a range of 70.6%–90.9% and specificity had a range of 82%–98.3%.


A very small volume of poor quality evidence was identified on follow-up mammography in patients treated initially for DCIS, in two retrospective studies (Liberman et al., 1997 and Weng et al., 2000). These two studies suggest that follow-up mammography is able to detect locally recurrent breast cancer in some patients treated initially for DCIS.

Health Economic Evaluation

A joint literature review was conducted to assess (a) the cost effectiveness of breast imaging modalities (mammography, ultrasound, MRI, mammoscintigraphy positron emission tomography (PET) and CT) in the follow-up of patients with invasive breast cancer, and (b), to assess the cost effectiveness of mammography, ultrasound and MRI in the follow-up of patients with DCIS. From 347 references initially identified through the search, 333 were excluded on the grounds of the title and abstract, and 14 references were considered further. All the retrieved papers were finally excluded: 4 studies did not include an economic analysis (Emens et al., 2003; Grilli, 1995; Khandekar, 1996; Sakorafas et al., 2000), 1 did not consider the relevant PICO question (Mould, 2004), 3 did not consider the relevant PICO interventions (Coleman et al., 1990; Mapelli et al., 1995 and Schapira et al., 1991), 1 did not consider the relevant PICO comparator (Mandelblatt et al., 2006) and 1 was written in a foreign language (Lamy et al., 2005). Therefore, no evidence was available to assess the cost effectiveness of breast imaging modalities in the follow-up of invasive breast cancer patients and in patients with DCIS, so no further economic modelling was undertaken.

Research recommendation

  • For patients who have been treated for early invasive breast cancer or ductal carcinoma in situ (DCIS), what is the optimal frequency and length of surveillance of follow-up mammography?

9.3. Clinical Follow-up

Currently not all patients have the choice of where their clinical follow-up takes place. Given choice, some women will opt for follow-up in primary care, others for follow-up in secondary care, or even a shared system. It is important that choice, as with other treatment decisions, is explored and patient preferences respected.

Clinical follow-up (hospital based)

The follow-up of breast cancer patients has been a topic of controversy for many years and each breast unit has had to formally develop follow-up policies as part of cancer guidance. These policies will have been agreed with primary care in some cases but all will have been agreed across cancer networks. Although, as noted above, the rationale for early detection of local recurrence is that treatment may be more effective and there may be a survival benefit, there is no robust evidence that follow-up in any specific setting reduces the rate of recurrence or improves survival.

In the hospital setting patients are able to undergo clinical and radiological review, prosthetic follow-up, supportive care and review of treatment plans particularly where adjuvant therapies are prolonged or sequential.

Where breast care nurse specialists are now holding breast care clinics patients also have the advantage of seeing the same person. Some patients may gain considerable reassurance from being reviewed in a specialist setting with healthcare professionals who have been responsible for their care from the beginning.

Clinical follow-up (General Practice (GP) based)

An average practice of 10,000 patients will have around 23 registered patients who consult their GP regarding their breast cancer each year. Most GPs wish to provide follow-up for their patients with breast cancer if their concerns about increased workload can be met, if clear guidelines for follow-up can be given, and if assurances are given that patients will be seen urgently by the specialist on an open access basis. The quality outcome framework [QOF] part of the GP contract 20031 requires GPs to produce a register of cancer patients and to document a review of patients within 6 months of confirmed diagnosis. The review includes an assessment of support needs and co-ordination of arrangements with secondary care. Fully computerised problem based records are almost universal in primary care and greatly facilitate this process.

GP follow-up of women with breast cancer in remission is not associated with increase in time to diagnosis of recurrence, increase in anxiety, or deterioration in health related quality of life. Most recurrences are detected by women as interval events and present to the GP, irrespective of continuing hospital follow-up. GPs should be well placed to provide continuity of care within the patients’ socioeconomic background and taking account of other comorbidities.

Studies have shown no difference in outcome of patients followed up in GP practice or in the hospital setting. NICE guidance (NICE 2002) advised that breast cancer patients should be followed up in hospital setting for a minimum of 3 years. Some units, however, according to local policy continue to review patients in the hospital-based setting, after this time for clinical and mammographic surveillance.


  • After completion of adjuvant treatment (including chemotherapy, and/or radiotherapy where indicated) for early breast cancer, discuss with patients where they would like follow-up to be undertaken. They may choose to receive follow-up care in primary, secondary, or shared care.
  • Patients treated for breast cancer should have an agreed, written care plan, which should be recorded by a named healthcare professional (or professionals), a copy sent to the GP and a personal copy given to the patient. This plan should include:
    • – designated named healthcare professionals
    • – dates for review of any adjuvant therapy
    • – details of surveillance mammography
    • – signs and symptoms to look for and seek advice on
    • – contact details for immediate referral to specialist care, and
    • – contact details for support services, for example support for patients with lymphoedema.

Qualifying statement: These recommendations are based on GDG consensus in the absence of any good quality data

Clinical Evidence

There is a reasonable volume of evidence available that is related to follow-up of patients with breast cancer. A systematic review of mixed study design (Collins et al., 2004) found that most patients expressed a preference for attending regular follow-up sessions, even when asymptomatic. Although patients reported that the anticipation of attending these routine sessions provoked anxiety, reduced fear of recurrence and less physical and psychological distress was experienced after attending their routine visit. A report on follow-up of a UK breast cancer charity focus group (Breakthrough Breast Cancer, 2007) concluded that patients should be given the information and support they need if they want to consider opting out of follow-up care.

With respect to optimal frequency of follow-up, one systematic review of RCTs concluded that the available trials are unable to indicate an ideal frequency of follow-up (Montgomery et al., 2007). However the review cited trials that suggest detection of recurrence is not affected by 3 monthly versus 6 monthly follow up, nor by scheduled follow-up versus that available to patients on demand.

A Cochrane review (Rojas et al., 2000) found no statistically significant difference in 5 year overall survival arising from routine follow-up versus intensive (increased frequency and testing) follow-up regimens.

With respect to evidence about where follow-up should take place and who should perform follow-up, one systematic reviews of RCTs concluded that traditional routine clinic visits are an inefficient method of safeguarding against recurrent disease. No difference in either total recurrences detected in hospital, versus by the GP was reported, or in serious clinical events, or total number of deaths (Montgomery et al., 2007). There was also no evidence for a difference in either the total number of recurrences detected, or overall survival, when follow-up is performed by a doctor, compared to a breast care nurse specialist (Montgomery et al., 2007). RCT evidence indicated that satisfaction is higher in patients followed up by nurses than in those followed up by doctors, but that quality of life is similar.

Evidence from qualiatative studies also provided insight into the topic of effective follow-up care for patients who had been treated for breast cancer. These studies broadly described that checking for recurrence offering reassurance and providing information were key elements required in follow up care (Adewuyi-Dalton et al., 1998; Beaver et al., 2005; Jiwa et al., 2006; Kelly et al., 2006; Renton et al., 2002 and Vanhuyse et al., 2007).

Health Economic Evaluation

The GDG did not consider this topic as a health economic priority; therefore the cost effectiveness literature on this topic has not been reviewed.


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Copyright © 2009, National Collaborating Centre for Cancer.

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Bookshelf ID: NBK11631


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