Follow Up Regime
Once patients have completed their interventions, they should be followed up closely for the next 5 years. What is not known is whether specialist, general practitioner or nurse follow up is required.
Patients should be reviewed:
- Every 3-6 months with history and physical examination for 2-3 years,
- then every 6-12 months with history and physical examination for a further 2-3 years
- Some clinicians advocate yearly follow up after 5 years
- Receive yearly mammograms and ultrasounds for the ipsilateral and/or contralateral breast (depending on mastectomy)
- If on hormonal therapy with an aromatase inhibitor, undergo yearly bone density testing
With the improved survival associated with breast cancer, this intensive follow up is becoming a major burden on practitioners. Some have suggested that GP or nurse led follow up is sufficient and randomised studies have not shown significant differences in survival outcomes (although these are criticised for being underpowered). Breast cancer follow up in the future may move away from specialist oncology clinics to nurse led 'superclinics' with oncologists as backup for complicated patients.
Recurrence of disease
Recurrence may be local, regional or systemic.
Local Recurrence
The management of a local recurrence depends on the initial treatment:
- For patients who had a wide local excision and radiotherpay, a total mastectomy and axillary clearance is warranted.
- For patients who have had a mastectomy with radiation, surgical excision of the lesion should be done
- For patients who have had a mastectomy without radiation, surgical excision should be performed and chest wall radiation applied
Systemic chemotherapy should then be considered, depending on the receptor status.
Regional Recurrence
Patients who relapse in the axillary, supraclavicular or inframammary nodes should have these regions irradiated following maximal surgical resection (if not done previously). Systemic chemotherapy is then required.
Distant Recurrence
Distant relapse is managed as per metastatic disease; consideration of endocrine therapy resistance must be done if the relapse has occurred whilst on tamoxifen or an aromatase inhibitor. This may warrant a change of endocrine therapy or institution of ovarian ablation (in pre-menopausal women).
Long Term Toxicity
Radiation Toxicity
The following toxicities are seen:
- Poor cosmetic outcome in 25% of patients, due to fibrosis or telangiectasia of the skin.
- Lymphoedema in patients who receive axillary or supraclavicular treatment:
- The risk is < 5% without axillary treatment
- 10% with surgical axillary clearance OR axillary radiotherapy
- > 15% with both surgery and radiotherapy
- Second malignancies (about 1/100 risk, depending on patient age and BRCA status)
- Radiation pneumonitis in 1% or less of patients, which is usually transitory and manageable with steriods
- Increased cardiovascular death rate (with older treatment techniques); the relative risk was 2 in older studies but has not been confirmed for modern treatment.
Very rare long term effects include brachial plexus damage (if supraclavicular fossa is treated).
