1. medical history and physical examination 1-4 times per year as clinically reasonable for 5 consecutive years, then once per year.
2. regular screening for changes in family history and referral to genetic counseling if necessary.
3. education, monitoring and counseling for lymphedema management.
4. mammography once every 12 months.
5. routine breast imaging reconstruction is inappropriate
6. absence of indications for laboratory or imaging screening transfer in the absence of clinical signs and symptoms suggestive of disease recurrence
7. women taking tamoxifen: 1 gynecologic evaluation every 12 months if a uterus is present
8. women taking aromatic inhibitors or treatment-induced secondary ovarian failure should have bone mineral density measured at baseline and periodically thereafter to monitor bone health
9. assess and encourage adherence to adjuvant endocrine therapy.
Evidence suggests that an active lifestyle, a healthy diet, limiting alcohol intake, and achieving and maintaining an ideal weight (BMI 20-25) may lead to the best breast cancer outcomes.
Studies have shown that for surveillance of breast cancer patients undergoing breast-conserving surgery plus radiation therapy 1 mammogram per year is a reasonable frequency, and there is no clear advantage to shorter imaging intervals. Patients should wait 6 to 12 months after the completion of radiation therapy before starting their 1-time per year mammography surveillance. Suspicious findings on physical examination or imaging surveillance may be a valid reason to shorten the mammography interval.
The use of estrogen, progesterone, or selective estrogen receptor modulators to treat osteoporosis or bone loss in women with breast cancer is discouraging. It is acceptable to use bisphosphonates or denosumab to maintain or increase bone mineral density. The optimal duration of either treatment has not been determined. Duration beyond 3 years is not known. Factors to consider during anti-osteoporosis treatment include bone mineral density, treatment response, and risk factors for continued bone loss or fracture. Women receiving one of the bisphosphonates or denosumab should receive a prophylactic dental exam prior to the start of treatment and should take calcium and vitamin D supplements.
Principles of breast-specific MRI screening
See the NCCN Breast Cancer Screening and Diagnosis Guidelines for indications for MRI screening in women at increased risk for breast cancer.
Personnel, proficiency and equipment
1. Breast MRI exams should be performed with intravenous contrast and judged by a dedicated breast imaging team in conjunction with a multidisciplinary treatment team.
Breast MRI requires a dedicated breast coil and a breast imaging radiologist skilled in the details of optimal time series and other image interpretation techniques. The imaging center should have the ability to perform MRI-guided needle aspiration and/or place MRI-detectable metal locating wires.
Clinical indications and applications
1. It can be used to clarify the staging assessment of the extent of cancer or the presence of multifocal or multicentric cancer in the ipsilateral breast or as a screening test for contralateral breast cancer at the time of initial diagnosis (level 2B). There is no information demonstrating that the use of MRI can help local treatment decisions to improve local recurrence or survival at a high level.
2. It may be useful to assess before and after preoperative systemic treatment of breast cancer to clarify the extent of the lesion, its efficacy, and the possibility of breast-conserving treatment.
It may be useful in identifying primary tumors in women with adenocarcinoma of the axillary lymph nodes or in women who are unsure of primary papillary Paget’s disease on mammography, ultrasound or physical examination.
4. There are often false positive findings on breast MRI. Surgical decisions should not be based on MRI findings alone. Additional tissue biopsy of the area of interest found on breast MRI is recommended.
5. The utility of MRI in the follow-up screening of women with previous breast cancer is unclear. It is usually only considered in those with a lifetime risk of >20% of second primary breast cancer based on a risk model that depends primarily on family history such as those with a genetic predisposition to breast cancer.