Opinions from US and European regulatory guidelines; including recommendations from ASCO (American Society of Clinical Oncology), NCCN (National Cancer Consortium Network), European Society of Oncology, Canadian Breast Cancer Diagnostic and Treatment Committee, etc.
Screening Frequency
Recommended
History (symptoms) and examination 3-6 months/year for the first 3 years, 1 time in 6-12 months for 4-5 years, and 1 time per year thereafter.
Breast self-examination Once a month.
Mammography and breast ultrasound once a year.
Pelvic exam (for those taking tamoxifen drugs) 1 time per year.
Not recommended
Complete blood count
Blood biochemistry
Chest camera
Bone scan
Liver ultrasound
Chest, abdomen, pelvis CT
Tumor markers CEA, CA-53, CA27, 29.
Chinese version of NCCN guidelines (The Breast Cancer Branch of Chinese Anti-Cancer Association referred to the US NCCN guidelines and combined with the actual situation of clinical diagnosis and treatment of breast cancer in China to develop the Chinese version of clinical workup guidelines): In terms of follow-up review, it is basically consistent with the opinions in Europe and America.
Why do we not need to do a lot of examinations?
Our purpose: 1. to detect tumor recurrence and metastasis as early as possible; 2. to intervene in time for treatment once recurrence and metastasis are detected, so as to strive for longer survival and higher quality of life.
Can we achieve the purpose?
Let’s take a look at the available experimental basis.
1. A clinical trial conducted by the American Interdisciplinary Cancer Therapy Evaluation Group (GIVIO investigators).
1320 patients with stage I, II, and III unilateral primary breast cancer were randomized into an intensive surveillance group and a clinical surveillance group. Patients in both groups had a physical examination every 3 months for the first 2 years and every 6 months for the next 3 years.
The intensive surveillance group also did.
(1) Laboratory tests (alkaline phosphatase, glutamyl transpeptidase) every 3 months for the first 2 years and every 6 months for the next 3 years.
(2) Chest X-rays every 6 months for 5 years.
(3) Bone scan once a year for 5 consecutive years.
(4) Ultrasound of the liver once a year for 5 years.
The clinical monitoring group does not do these examinations!
Health-related quality of life was evaluated at months 6, 12, 24, and 60 for both groups.
There were no differences in overall health and quality of life between the two groups.
There was no difference in overall quality of survival or overall survival time between the two groups.
2. Italian experts did a clinical trial on post-treatment monitoring of primary breast cancer.
They did bone scans every 6 months for 5 years in the intensive group monitoring, and the rest of the indicators were roughly the same as the design of the American GIVIO researchers. A total of 1,243 patients were enrolled in the pilot study, which was initially designed to observe patient survival after 5 years.
The results of the follow-up at 5 years showed that
There was no difference in 5-year survival between the two groups.
3. Study on the detection of recurrence at various sites
The US GIVIO researchers reported that the majority of patients with intensive follow-up had their first recurrence in the bone (41%), lung (19%), liver (10%), other sites (15%), and multiple sites (15%).
Bone: NSABP conducted a retrospective study of 2697 patients with positive lymph nodes in a prospective clinical trial to assess the role of routine bone scan examinations. Bone scans were routinely performed once every 6 months for 3 years and annually thereafter.
RESULTS: A total of 7984 bone scans were performed in these patients, and only 82 cases had confirmed bone metastases; thus, the rate of bone metastasis diagnosis by bone scan examination in the asymptomatic setting was only 0.6 percent.
Lung: A retrospective analysis of X-ray surveillance data for asymptomatic lung metastases found that only 8 of 1091 patients who had chest X-rays had asymptomatic metastatic lung cancer. Another intensive surveillance clinical trial reported that only 9 out of 148 patients were found to have single lung metastases.
Liver: Breast cancer metastasis to the liver alone is rare. 2.1% of patients in the GIVIO intensive surveillance group, who underwent liver ultrasound once a year for 5 years, had liver as the first metastatic site.
Tumor-related antigens and antibodies: Common tumor markers for breast cancer include carcinoembryonic antigen (CEA), cancer antigen CA15-3, cancer antibodies CA27 and 29, and serum c-erb-b2 protein. Several studies have demonstrated that abnormal tumor markers can predict tumor recurrence before metastatic cancer is confirmed. The average advance of this time is 3-5 months.
In conclusion: Combining the results of the above trials, we can see that a large number of intensive tests have found a very low chance of distant metastasis and recurrence.
Some patients have disagreed that despite the low chance of detection, earlier detection is always better than later detection.
Unfortunately, this is a wrong view. Current studies confirm that most breast cancer recurrences are detected by patients’ clinical symptoms and that intensive surveillance detects distant metastatic recurrences on average 3-5 months earlier than the onset of symptoms, however, the detection of asymptomatic breast cancer recurrences does not improve quality of life and overall survival time, as has been confirmed by studies in the United States and Italy. There are other trial data confirming that the detection of distant metastases earlier than the onset of symptoms and earlier therapeutic interventions resulted in a survival benefit of no more than 1 month for patients.
There is no data to suggest that prediction by intensive monitoring, detection of distant metastases earlier improves the final outcome of patients.
In summary, the odds of finding distant metastases by the large number of tests we do are extremely low, and even if they are occasionally found, early detection does not lead to an eventual benefit, then they are not beneficial.
So, why do we need to follow up and review?
The truly meaningful findings
1. Detection of contralateral breast cancer
Survivors of primary breast cancer have a significantly increased risk of second primary breast cancer, a risk that is 3-5 times higher than the risk of first primary breast cancer in all groups of women.
Several retrospective reports have confirmed that breast cancer survivors with a primary tumor in their contralateral breast detected by physical examination and mammography have more favorable prognostic factors at diagnosis than their first primary breast cancer, and that effective surveillance enhances the likelihood of curing the second breast cancer.
2.Detection of ipsilateral breast tumor recurrence after breast-conserving surgery
Recurrence of ipsilateral breast cancer can be detected by self-examination, professional mammography and mammography. Usually these three methods are recommended for clinical use.
3.Local area recurrence after mastectomy
The risk of chest wall recurrence after mastectomy is related to the size of the primary tumor and the number of lymph nodes involved in the axilla. Early detection of chest wall metastases can improve the chances of local lesion control and cure, and most recurrences are superficial and easily detectable.
4.Non-breast cancer primary cancer
Some patients with breast cancer are at risk of developing treatment-related malignancies. The relative risk of endometrial cancer increases 2-3 times in patients taking tamoxifen. Most patients with endometrial cancer can be diagnosed early by evaluating the patient’s symptoms (vaginal bleeding and local symptoms) and by an annual pelvic exam.
Summary
Follow-up review after breast cancer treatment is essential.
Detection of local recurrence, detection of new cancer in the contralateral breast, timely detection of ipsilateral breast tumor recurrence after breast-conserving surgery, and early detection of endometrial cancer are the fundamental purposes of detection, and timely detection of these recurrences allows us to achieve a cure and thus improve survival.
These objectives can be achieved through history taking, clinical physical examination and mammography (breast ultrasound).
In contrast, intensive testing has little role in the detection of the above mentioned goals.
Intensive testing intended for early detection of distant metastases does not prolong survival and improves quality of life but brings disadvantages.
1. Most breast cancer recurrence is predicted by the patient’s symptoms.
2. Once metastatic cancer reaches a sufficient level that can be detected by laboratory or radiological examination, breast cancer is incurable with the current level of technology.
3. The interval between the detection of asymptomatic recurrence and the appearance of clinical symptoms is only 3-5 months, and it is extremely difficult to improve the condition of asymptomatic patients.
4. Intensive detection may have adverse effects on some patients. Frequent screening precisely suggests the possibility of recurrence, and worries about the possibility of recurrence may reduce the quality of life of patients.
5.The detection of asymptomatic recurrence may destroy the patient’s life in advance.
6.Putting a huge physical and financial burden on the patient.
Now, let’s take a look at the normative clinical guidelines again.
Screening Frequency
Recommended
History (symptoms) and examination 3-6 months/time in the first 3 years, 1 time in 6-12 months in 4-5 years, and 1 time per year thereafter.
Breast self-examination Once a month.
Mammography and breast ultrasound once a year.
Pelvic exam (for those taking tamoxifen drugs) 1 time per year.
Not recommended
Complete blood count
Blood biochemistry
Chest camera
Bone scan
Liver ultrasound
Chest, abdomen, pelvis CT
Tumor markers CEA, CA-53, CA27, 29.
My usual practice.
After the completion of radiotherapy and chemotherapy, patients are asked to follow up every six months for the first three years, and asked in detail whether they have any special discomfort and physical examination.
If there is no special discomfort, breast ultrasound will be performed once a year, and pelvic ultrasound will be performed once a year for those taking tamoxifen and toremifene endocrine therapy. For those with specific clinical manifestations, further targeted examinations were performed.
After three years, annual outpatient follow-up examinations will be performed, breast ultrasound will be performed, and pelvic ultrasound will be performed for those taking tamoxifen and toremifene endocrine therapy. For those with special clinical manifestations, further targeted examinations will be performed.