Follow-Up Care

Introduction
After primary therapy, patients with breast cancer should be followed up for life for at least two reasons: to detect recurrences and to observe the opposite breast for a second primary carcinoma. Local and distant recurrences occur most frequently within the first 2 years. During this period, the patient should be examined every 6 months. Thereafter, examination is done annually. Special attention is paid to the contralateral breast, because 10-20% of patients will develop a new primary breast malignancy. The patient should examine her own breast monthly, and a mammogram should be obtained annually. In some cases, metastases are dormant for long periods and may appear 10-15 years or longer after removal of the primary tumor. Estrogen and progestational agents are rarely used for a patient free of disease after treatment of primary breast cancer, particularly if the tumor was hormone receptor positive. Studies nevertheless have failed to show an adverse effect of hormonal agents in patients who are free of disease. Even pregnancy has not been clearly associated with shortened survival of patients rendered disease free - yet most oncologists are reluctant to advise a young patient with breast cancer that she may become pregnant, and most are less than enthusiastic about prescribing hormone replacement therapy for the postmenopausal breast cancer patient. The use of estrogen replacement therapy may be considered for a woman with a history of breast cancer after discussion of the benefits and risks of such therapy for conditions such as osteoporosis and hot flushes, but is not recommended.

Local Recurrence
The incidence of local recurrence correlates with tumor size, the presence and number of involved axillary nodes, the histologic type of tumor, the presence of skin edema or skin and fascia fixation with the primary tumor, and the type of initial local (breast) therapy. As many as 8% of patients develop local recurrence on the chest wall after total mastectomy and axillary dissection. When the axillary nodes are not involved, the local recurrence rate is less than 5%, but the rate is as high as 25% when they are heavily involved. A similar difference in local recurrence rate was noted between small and large tumors. Factors such as multifocal cancer, in situ tumors, positive resection margins, chemotherapy, and radiotherapy have an effect on local recurrence in patients treated with breast-conserving surgery.

Chest wall recurrences usually appear within the first 2 years but may occur as late as 15 or more years after mastectomy. All suspicious nodules and skin lesions should be biopsied. Local excision or localized radiotherapy may be feasible if an isolated nodule is present. If lesions are multiple or accompanied by evidence of regional involvement in the internal mammary or supraclavicular nodes, the disease is best managed by radiation treatment of the entire chest wall including the parasternal, supraclavicular, and axillary areas and usually by systemic therapy.