Table 2.

ASCO Recommendations for Breast Surveillance, and Verbal and Written Comments^*

Test	Frequency	Comments to Discuss With the Patient (a script)
Recommended		My professional society has made recommendations on what should be generally recommended for women in your situation; this group wrestled with the issues for 18 months and will update these yearly or whenever new information becomes available
History/eliciting of symptoms and physical examination	Every 3 to 6 months for 3 years, then every 6 to 12 months for 2 years, then annually	Careful history and examination, like we just did, should be done every 3 to 6 months; if you have concerns, write them down, and call me in between visits; women find more than three quarters of all recurrences in between physician visits, so call me if you suspect something
BSE	Monthly	BSE is recommended; do it monthly (congratulate her if she is, and urge her to do it if not); would you like instructions?
Mammography	Annually	Mammography is recommended; get it done each year at the same place (I have a table on my chart to remind me about this, pelvic and rectal examinations, colonoscopy, and other preventive health care procedures)
Pelvic examination	Annually	Pelvic examinations and PAP smears should be done yearly because you are receiving tamoxifen (or not); endometrial biopsies are not needed because the risk of uterine cancer is so low—only one in 100—but report any abnormal bleeding
Patient education regarding symptoms of recurrence	NA	There are specific things I want you to watch for, the most common spots of recurrence; call me if you notice these things (point to the area in the guidelines that has these bullet points): Lumps or bumps anywhere but especially on the breast or chest wall Bones that hurt without trauma, especially the spine or hips Headaches out of the ordinary Shortness of breath, especially if receiving tamoxifen Leg swelling, especially if receiving tamoxifen
Coordination of care	NA	You only need to see one physician, not three or four, but it needs to be someone experienced in breast cancer examinations; I can alternate with your surgeon, Dr X, and your radiotherapist, Dr Y, or you can choose one person, but you need to see someone every 3 to 6 months for the first 3 years; it can be your primary care physician, Dr Z
Not recommended		Our professional society has recommended that some tests not be done, because it could not find evidence that the tests were helpful; I do these tests, but only to diagnose something, not for screening; we should concentrate on making sure that you undergo the tests that we know make a difference (point to the list of tests not recommended)
CBC and chemistry studies		These never detect an early or curable recurrence
Chest films		Chest x-ray rarely if ever finds an early or curable recurrence
Bone scan		Same for the bone scan; it detects arthritis and stress fractures but not curable disease; it is more important that you report any new bone pain
Ultrasound of the liver; CT of the chest, abdomen, or pelvis; PET scans		Same for liver ultrasound and CT scans; a large trial of > 1,000 women in Italy showed no benefit to doing yearly liver ultrasounds and bone scans for routine surveillance, so they are not recommended; they find too many nuisances, and do not detect early curable cancer
Tumor markers CA 15-3, CA 27.29, CEA		I wish I had a perfect blood test that would tell me whether you have breast cancer cells left; every biotech company would, too; but none of the current tests are good enough to do routinely; the ASCO expert panel found that there was too much of a problem of missed cancer and falsely showing cancer was there, and it could not find any evidence that finding the cancer a few weeks or months earlier would lead to better treatment
		This is an area where the tests are getting better; at the present time, I do not order any of these tests, but if new evidence shows that these tests are helpful, ASCO will review the evidence when it comes out and change the guideline; for now, we should concentrate on doing the tests we know make a difference and not doing others

Abbreviations: ASCO, American Society of Clinical Oncology; BSE, breast self-examination; CA, cancer antigen; CBC, complete blood count; CEA, carcinoembryonic antigen; CT, computed tomography; NA, not applicable; PAP, Papanicolaou; PET, positron emission tomography.

^*I write directly on a printed copy of the surveillance guidelines and fax a copy to the primary care physician.