Skip to main content
PMC home page
CMAJ : Canadian Medical Association Journal logoLink to CMAJ : Canadian Medical Association Journal
. 1999 Oct 19;161(8):1001–1008.

Preventive health care, 1999 update: 3. Follow-up after breast cancer

L K Temple 1, E E Wang 1, R S McLeod 1
PMCID: PMC1230673  PMID: 10551200

Abstract

OBJECTIVE: To make recommendations to physicians who provide follow-up care for women who have been treated for early-stage breast cancer. OPTIONS: Combination of blood tests, bone scans, liver echography and chest radiography for detection of distant disease; physical examination with or without mammography for detection of contralateral breast cancer; and physical examination with or without mammography for detection of ipsilateral recurrent disease after breast-conserving therapy. OUTCOMES: Survival, disease recurrence and quality-of-life measures for distant disease, local recurrence of disease and disease in the contralateral breast. EVIDENCE: A MEDLINE search for relevant articles published between January 1966 and January 1998 with the MeSH terms "breast neoplasms" and "neoplasm recurrence" (local and distant) with limits to "human" was done. A subsequent MEDLINE search using the MeSH terms "breast neoplasms," "neoplasm recurrence," "local/diagnosis" and "mammography" was done to address issues of mammography. The literature search was reviewed by a medical librarian and 2 breast cancer specialists to ensure completeness. BENEFITS, HARMS AND COSTS: Breast cancer is the most common cancer in Canadian women and is the second leading cause of death after lung cancer. Even with early-stage breast cancer, recurrence after treatment for primary breast cancer is frequent. Traditionally, follow-up has been felt to facilitate early detection and improve survival. Randomized controlled trials (RCTs) have shown that routine screening (blood tests and diagnostic imaging) for distant disease does not alter survival or quality of life over routine physical examination. In an underpowered secondary analysis of RCT data, the detection of contralateral breast cancer did not affect survival. However, there have been no RCTs examining the role of mammography and physical examination and their effect on survival in the detection of contralateral breast cancer. The sensitivity and specificity of mammography after local excision and radiotherapy is unknown. There have been no RCTs examining the role of mammography or physical examination, or both, and their effect on survival in the detection of ipsilateral breast recurrence. VALUES: The strength of evidence was evaluated using the methods of the Canadian Task Force on Preventive Health Care. A high value was placed on interventions that changed survival. When evidence was available, high value was also placed on interventions that affected quality of life. RECOMMENDATIONS: There is good evidence not to include blood work and diagnostic imaging as part of screening for distant disease (grade E recommendation). There is no evidence to suggest that mammography decreases mortality by detecting ipsilateral disease in the conservatively treated breast; however, there is indirect evidence that it may be beneficial (grade C recommendation). There is no direct evidence to suggest that physical examination or mammography, or both, should be used to detect contralateral breast cancer; however, there is indirect evidence that it may be beneficial (grade C recommendation). VALIDATION: The findings of this analysis were reviewed through an iterative process by the members of the Canadian Task Force on Preventive Health Care.

Full Text

The Full Text of this article is available as a PDF (228.9 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Abner A. L., Recht A., Eberlein T., Come S., Shulman L., Hayes D., Connolly J. L., Schnitt S. J., Silver B., Harris J. R. Prognosis following salvage mastectomy for recurrence in the breast after conservative surgery and radiation therapy for early-stage breast cancer. J Clin Oncol. 1993 Jan;11(1):44–48. doi: 10.1200/JCO.1993.11.1.44. [DOI] [PubMed] [Google Scholar]
  2. Baines C. J., Miller A. B., Bassett A. A. Physical examination. Its role as a single screening modality in the Canadian National Breast Screening Study. Cancer. 1989 May 1;63(9):1816–1822. doi: 10.1002/1097-0142(19900501)63:9<1816::aid-cncr2820630926>3.0.co;2-w. [DOI] [PubMed] [Google Scholar]
  3. Calle R., Vilcoq J. R., Zafrani B., Vielh P., Fourquet A. Local control and survival of breast cancer treated by limited surgery followed by irradiation. Int J Radiat Oncol Biol Phys. 1986 Jun;12(6):873–878. doi: 10.1016/0360-3016(86)90379-2. [DOI] [PubMed] [Google Scholar]
  4. Chaudary M. A., Millis R. R., Hoskins E. O., Halder M., Bulbrook R. D., Cuzick J., Hayward J. L. Bilateral primary breast cancer: a prospective study of disease incidence. Br J Surg. 1984 Sep;71(9):711–714. doi: 10.1002/bjs.1800710924. [DOI] [PubMed] [Google Scholar]
  5. Christian M. C., McCabe M. S., Korn E. L., Abrams J. S., Kaplan R. S., Friedman M. A. The National Cancer Institute audit of the National Surgical Adjuvant Breast and Bowel Project Protocol B-06. N Engl J Med. 1995 Nov 30;333(22):1469–1474. doi: 10.1056/NEJM199511303332206. [DOI] [PubMed] [Google Scholar]
  6. Clark R. M., Whelan T., Levine M., Roberts R., Willan A., McCulloch P., Lipa M., Wilkinson R. H., Mahoney L. J. Randomized clinical trial of breast irradiation following lumpectomy and axillary dissection for node-negative breast cancer: an update. Ontario Clinical Oncology Group. J Natl Cancer Inst. 1996 Nov 20;88(22):1659–1664. doi: 10.1093/jnci/88.22.1659. [DOI] [PubMed] [Google Scholar]
  7. Crivellari D., Price K. N., Hagen M., Goldhirsch A., Gelber R. D., Castiglione M., Coates A. S., Rudenstam C. M., Collins J., Lindtner J. Routine tests during follow-up of patients after primary treatment for operable breast cancer. International (Ludwig) Breast Cancer Study Group (IBCSG) Ann Oncol. 1995 Oct;6(8):769–776. doi: 10.1093/oxfordjournals.annonc.a059314. [DOI] [PubMed] [Google Scholar]
  8. Dershaw D. D., McCormick B., Cox L., Osborne M. P. Differentiation of benign and malignant local tumor recurrence after lumpectomy. AJR Am J Roentgenol. 1990 Jul;155(1):35–38. doi: 10.2214/ajr.155.1.2112861. [DOI] [PubMed] [Google Scholar]
  9. Dershaw D. D., McCormick B., Osborne M. P. Detection of local recurrence after conservative therapy for breast carcinoma. Cancer. 1992 Jul 15;70(2):493–496. doi: 10.1002/1097-0142(19920715)70:2<493::aid-cncr2820700219>3.0.co;2-3. [DOI] [PubMed] [Google Scholar]
  10. Fisher B., Anderson S., Redmond C. K., Wolmark N., Wickerham D. L., Cronin W. M. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med. 1995 Nov 30;333(22):1456–1461. doi: 10.1056/NEJM199511303332203. [DOI] [PubMed] [Google Scholar]
  11. Fisher B., Montague E., Redmond C., Barton B., Borland D., Fisher E. R., Deutsch M., Schwarz G., Margolese R., Donegan W. Comparison of radical mastectomy with alternative treatments for primary breast cancer. A first report of results from a prospective randomized clinical trial. Cancer. 1977 Jun;39(6 Suppl):2827–2839. doi: 10.1002/1097-0142(197706)39:6<2827::aid-cncr2820390671>3.0.co;2-i. [DOI] [PubMed] [Google Scholar]
  12. Fisher B., Redmond C., Fisher E. R., Bauer M., Wolmark N., Wickerham D. L., Deutsch M., Montague E., Margolese R., Foster R. Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med. 1985 Mar 14;312(11):674–681. doi: 10.1056/NEJM198503143121102. [DOI] [PubMed] [Google Scholar]
  13. Fisher E. R., Fisher B., Sass R., Wickerham L. Pathologic findings from the National Surgical Adjuvant Breast Project (Protocol No. 4). XI. Bilateral breast cancer. Cancer. 1984 Dec 15;54(12):3002–3011. doi: 10.1002/1097-0142(19841215)54:12<3002::aid-cncr2820541231>3.0.co;2-v. [DOI] [PubMed] [Google Scholar]
  14. Forrest A. P., Stewart H. J., Everington D., Prescott R. J., McArdle C. S., Harnett A. N., Smith D. C., George W. D. Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Scottish Cancer Trials Breast Group. Lancet. 1996 Sep 14;348(9029):708–713. doi: 10.1016/s0140-6736(96)02133-2. [DOI] [PubMed] [Google Scholar]
  15. Fowble B., Solin L. J., Schultz D. J., Rubenstein J., Goodman R. L. Breast recurrence following conservative surgery and radiation: patterns of failure, prognosis, and pathologic findings from mastectomy specimens with implications for treatment. Int J Radiat Oncol Biol Phys. 1990 Oct;19(4):833–842. doi: 10.1016/0360-3016(90)90002-2. [DOI] [PubMed] [Google Scholar]
  16. Gage I., Recht A., Gelman R., Nixon A. J., Silver B., Bornstein B. A., Harris J. R. Long-term outcome following breast-conserving surgery and radiation therapy. Int J Radiat Oncol Biol Phys. 1995 Sep 30;33(2):245–251. doi: 10.1016/0360-3016(95)02001-R. [DOI] [PubMed] [Google Scholar]
  17. Grilli R. A shared effort toward better quality of care. The Consensus Conference on Breast Cancer Follow-up. Consensus Conference Organizing Committee. Ann Oncol. 1995;6 (Suppl 2):5–9. doi: 10.1093/annonc/6.suppl_2.s5. [DOI] [PubMed] [Google Scholar]
  18. Grunfeld E., Mant D., Vessey M. P., Yudkin P. Evaluating primary care follow-up of breast cancer: methods and preliminary results of three studies. Ann Oncol. 1995;6 (Suppl 2):47–52. doi: 10.1093/annonc/6.suppl_2.s47. [DOI] [PubMed] [Google Scholar]
  19. Gulliford T., Opomu M., Wilson E., Hanham I., Epstein R. Popularity of less frequent follow up for breast cancer in randomised study: initial findings from the hotline study. BMJ. 1997 Jan 18;314(7075):174–177. doi: 10.1136/bmj.314.7075.174. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Gutter Z. Cancer of the remaining breast: radiologic contribution to diagnosis. Can Med Assoc J. 1976 Jan 10;114(1):27–30. [PMC free article] [PubMed] [Google Scholar]
  21. Haffty B. G., Goldberg N. B., Rose M., Heil B., Fischer D., Beinfield M., McKhann C., Weissberg J. B. Conservative surgery with radiation therapy in clinical stage I and II breast cancer. Results of a 20-year experience. Arch Surg. 1989 Nov;124(11):1266–1270. doi: 10.1001/archsurg.1989.01410110020003. [DOI] [PubMed] [Google Scholar]
  22. Hassell P. R., Olivotto I. A., Mueller H. A., Kingston G. W., Basco V. E. Early breast cancer: detection of recurrence after conservative surgery and radiation therapy. Radiology. 1990 Sep;176(3):731–735. doi: 10.1148/radiology.176.3.2167500. [DOI] [PubMed] [Google Scholar]
  23. Hislop T. G., Elwood J. M., Coldman A. J., Spinelli J. J., Worth A. J., Ellison L. G. Second primary cancers of the breast: incidence and risk factors. Br J Cancer. 1984 Jan;49(1):79–85. doi: 10.1038/bjc.1984.12. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Kurtz J. M., Spitalier J. M., Amalric R., Brandone H., Ayme Y., Jacquemier J., Hans D., Bressac C. The prognostic significance of late local recurrence after breast-conserving therapy. Int J Radiat Oncol Biol Phys. 1990 Jan;18(1):87–93. doi: 10.1016/0360-3016(90)90271-k. [DOI] [PubMed] [Google Scholar]
  25. Liljegren G., Holmberg L., Adami H. O., Westman G., Graffman S., Bergh J. Sector resection with or without postoperative radiotherapy for stage I breast cancer: five-year results of a randomized trial. Uppsala-Orebro Breast Cancer Study Group. J Natl Cancer Inst. 1994 May 4;86(9):717–722. doi: 10.1093/jnci/86.9.717. [DOI] [PubMed] [Google Scholar]
  26. Maher E. J. Non-surgical management of early breast cancer in the United Kingdom: follow-up. Clinical Audit Sub-committee of the Faculty of Clinical Oncology, Royal College of Radiologists, and the Joint Council for Clinical Oncology. Clin Oncol (R Coll Radiol) 1995;7(4):227–231. doi: 10.1016/s0936-6555(05)80605-3. [DOI] [PubMed] [Google Scholar]
  27. Mellink W. A., Holland R., Hendriks J. H., Peeters P. H., Rutgers E. J., van Daal W. A. The contribution of routine follow-up mammography to an early detection of asynchronous contralateral breast cancer. Cancer. 1991 Apr 1;67(7):1844–1848. doi: 10.1002/1097-0142(19910401)67:7<1844::aid-cncr2820670705>3.0.co;2-w. [DOI] [PubMed] [Google Scholar]
  28. Miller A. B., Baines C. J., To T., Wall C. Canadian National Breast Screening Study: 1. Breast cancer detection and death rates among women aged 40 to 49 years. CMAJ. 1992 Nov 15;147(10):1459–1476. [PMC free article] [PubMed] [Google Scholar]
  29. Miller A. B., Baines C. J., To T., Wall C. Canadian National Breast Screening Study: 2. Breast cancer detection and death rates among women aged 50 to 59 years. CMAJ. 1992 Nov 15;147(10):1477–1488. [PMC free article] [PubMed] [Google Scholar]
  30. Muss H. B., Tell G. S., Case L. D., Robertson P., Atwell B. M. Perceptions of follow-up care in women with breast cancer. Am J Clin Oncol. 1991 Feb;14(1):55–59. doi: 10.1097/00000421-199102000-00013. [DOI] [PubMed] [Google Scholar]
  31. Nyström L., Rutqvist L. E., Wall S., Lindgren A., Lindqvist M., Rydén S., Andersson I., Bjurstam N., Fagerberg G., Frisell J. Breast cancer screening with mammography: overview of Swedish randomised trials. Lancet. 1993 Apr 17;341(8851):973–978. doi: 10.1016/0140-6736(93)91067-v. [DOI] [PubMed] [Google Scholar]
  32. Orel S. G., Fowble B. L., Solin L. J., Schultz D. J., Conant E. F., Troupin R. H. Breast cancer recurrence after lumpectomy and radiation therapy for early-stage disease: prognostic significance of detection method. Radiology. 1993 Jul;188(1):189–194. doi: 10.1148/radiology.188.1.8511295. [DOI] [PubMed] [Google Scholar]
  33. Orel S. G., Troupin R. H., Patterson E. A., Fowble B. L. Breast cancer recurrence after lumpectomy and irradiation: role of mammography in detection. Radiology. 1992 Apr;183(1):201–206. doi: 10.1148/radiology.183.1.1312733. [DOI] [PubMed] [Google Scholar]
  34. Richert-Boe K. E. Heterogeneity of cancer surveillance practices among medical oncologists in Washington and Oregon. Cancer. 1995 May 15;75(10):2605–2612. doi: 10.1002/1097-0142(19950515)75:10<2605::aid-cncr2820751031>3.0.co;2-#. [DOI] [PubMed] [Google Scholar]
  35. Roberts M. M., Alexander F. E., Anderson T. J., Chetty U., Donnan P. T., Forrest P., Hepburn W., Huggins A., Kirkpatrick A. E., Lamb J. Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet. 1990 Feb 3;335(8684):241–246. doi: 10.1016/0140-6736(90)90066-e. [DOI] [PubMed] [Google Scholar]
  36. Rosselli Del Turco M., Palli D., Cariddi A., Ciatto S., Pacini P., Distante V. Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up. JAMA. 1994 May 25;271(20):1593–1597. doi: 10.1001/jama.271.20.1593. [DOI] [PubMed] [Google Scholar]
  37. Rutgers E. J., van Slooten E. A., Kluck H. M. Follow-up after treatment of primary breast cancer. Br J Surg. 1989 Feb;76(2):187–190. doi: 10.1002/bjs.1800760227. [DOI] [PubMed] [Google Scholar]
  38. Senofsky G. M., Wanebo H. J., Wilhelm M. C., Pope T. L., Jr, Fechner R. E., Broaddus W., Kaiser D. L. Has monitoring of the contralateral breast improved the prognosis in patients treated for primary breast cancer? Cancer. 1986 Feb 1;57(3):597–602. doi: 10.1002/1097-0142(19860201)57:3<597::aid-cncr2820570334>3.0.co;2-5. [DOI] [PubMed] [Google Scholar]
  39. Shapiro S., Venet W., Strax P., Venet L., Roeser R. Selection, follow-up, and analysis in the Health Insurance Plan Study: a randomized trial with breast cancer screening. Natl Cancer Inst Monogr. 1985 May;67:65–74. [PubMed] [Google Scholar]
  40. Stomper P. C., Recht A., Berenberg A. L., Jochelson M. S., Harris J. R. Mammographic detection of recurrent cancer in the irradiated breast. AJR Am J Roentgenol. 1987 Jan;148(1):39–43. doi: 10.2214/ajr.148.1.39. [DOI] [PubMed] [Google Scholar]
  41. Tomin R., Donegan W. L. Screening for recurrent breast cancer--its effectiveness and prognostic value. J Clin Oncol. 1987 Jan;5(1):62–67. doi: 10.1200/JCO.1987.5.1.62. [DOI] [PubMed] [Google Scholar]
  42. Veronesi U., Marubini E., Del Vecchio M., Manzari A., Andreola S., Greco M., Luini A., Merson M., Saccozzi R., Rilke F. Local recurrences and distant metastases after conservative breast cancer treatments: partly independent events. J Natl Cancer Inst. 1995 Jan 4;87(1):19–27. doi: 10.1093/jnci/87.1.19. [DOI] [PubMed] [Google Scholar]
  43. van Dongen J. A., Bartelink H., Fentiman I. S., Lerut T., Mignolet F., Olthuis G., van der Schueren E., Sylvester R., Tong D., Winter J. Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer. Eur J Cancer. 1992;28A(4-5):801–805. doi: 10.1016/0959-8049(92)90118-l. [DOI] [PubMed] [Google Scholar]

Articles from CMAJ: Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association

RESOURCES