Surveillance for Breast Caner Recurrence
Cancer care providers will need to focus on optimizing survivorship outcomes for female cancer survivors. Long-term survival rates after a diagnosis of breast cancer are steadily rising with an improvement in the 5-year survival rate to 87%.
A recurrence may be local, which means cancer has come back in the same breast or chest area as the original cancer was located; regional, which means it has returned in an area near the original location, in lymph nodes in the armpit (axillary lymph nodes) or collarbone area; or distant, where breast cancer spreads away from the original tumour to the lungs, bones, brain or other parts of the body. This is metastatic cancer often referred to as stage 4 breast cancer.
Symptoms of a local recurrence include a new lump in the breast or the chest wall, an area of the breast that feels unnaturally firm, swelling of all or part of the breast, skin irritation or redness in the breast area, flattening or other nipple changes, skin pulling or swelling near the original breast cancer surgery site or thickening of surgery scars. The symptoms of a regional recurrence are: a lump or swelling in the lymph nodes under the arm, above the collarbone or near the breastbone pain, swelling, or numbness in one arm or shoulder constant chest pain.
It’s important to mention that, after breast cancer surgery and radiation therapy, the breast area may be swollen and red for a few months after those treatments are completed.
All breast cancer survivors should have follow-up visits with primary care providers every six months for the first five years after treatment completion. These appointments should include a thorough history, screening for signs and symptoms of local or distant recurrence, and treatment of side effects.
Clinical History: All breast cancer survivors should be screened for fatigue, depression, and anxiety, as one-third of ambulatory cancer patients report moderate to severe depressive symptoms, and fears around recurrence create considerable distress and anxiety.
Clinical examination: Clinical examinations should be performed every six months for two years then annually thereafter. Should specifically include examination of the breast(s)/chest wall, supraclavicular and axillary lymph nodes in addition to routine clinical examination. Patients may perform self-examination of their breasts and axillae every month.
Diagnostic mammography of intact breast(s) should be performed annually. First post-treatment mammogram should be one year after diagnostic mammogram/surgery . Reconstructed breasts (autologous tissue or implants) or non-reconstructed chest wall post-mastectomy do not require any form of imaging surveillance.
No other routine surveillance investigations (e.g. lab work, tumour markers, diagnostic imaging) are recommended for asymptomatic patients.
Patients presenting with any symptoms or signs of recurrence should be investigated and if recurrence confirmed, referred back to the cancer centre. The table below presents these potential symptoms of breast cancer recurrence and recommended actions:
New mass in breast
ultrasound +/- mammography +/- biopsy +/- Refer to a surgeon or interventional radiology for consideration of biopsy
New suspicious rash or nodule on chest wall
refer to surgeon or interventional radiology for consideration of biopsy
New palpable lymphadenopathy
order an ultrasound/refer to surgeon or interventional radiology for biopsy
New persistent bone pain
plain x-ray of affected site(s) and bone scan
New persistent cough or dyspnea
chest x-ray and/or CT chest
New hepatomegaly or RUQ abdominal pain or jaundice
ultrasound and/or CT scan of abdomen and liver enzymes
New persistent headache or new concerning neurologic deficits
New onset seizures
seizure management (as required) and CT/MRI brain