Follow-up surveillance
Ongoing assessment for toxicities/late effects (Practice Point)
In patients with breast cancer ensure that follow-up care includes ongoing assessment and supportive care for possible long-term toxicities and late effects of adjuvant treatments (including secondary cancers, cardiovascular toxicity, lymphoedema, mental health (including distress, depression, anxiety, body image), sexual health, premature menopause, infertility, fatigue, weight gain, impaired cognitive function, musculoskeletal health, pain and neuropathy, and bone health).
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process. The practice point was informed by a source recommendation in the ESO-ESMO 2017 consensus guidelines that was designated as ‘Expert Opinion’ and also by various recommendations in the ACS/ASCO breast cancer survivorship care guideline (2016) related to the assessment and management of physical and psychosocial long‐term and late effects of breast cancer and its treatment.
Follow-up schedule (Recommendation)
Patient history and clinical examination should occur every 3-6 months for the first 2 years, every 6-12 months for the next 3 years and annually after 5 years.
How this guidance was developed
This recommendation was adopted from the CA 2010 guidelines (Australia). The source recommendation was based on a systematic review of the evidence conducted to January 2008 and was not graded by the source guideline authors. The source recommendation was accepted with minor stylistic changes but with no changes to the meaning or tone of the source recommendation.
Surveillance tests and imaging in asymptomatic patients (Recommendation)
In patients who have been treated for breast cancer and who are not experiencing symptoms, do not perform intensive testing (full blood count, biochemistry or tumour markers) or intensive imaging (chest x-ray, PET, CT or radionuclide bone scans), as part of standard follow-up.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was adapted by using language consistent with the 2017 Cancer Australia Statement – Influencing best practice in breast cancer: Practice 12, and to reflect the fact that all clinicians, not just GPs, can be responsible for patient follow-up.
Population cancer screening programs (Recommendation)
All patients who have received treatment for breast cancer should be encouraged to participate in other cancer screening programs as for the general population.
How this guidance was developed
This recommendation was adopted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was accepted with minor stylistic changes but with no changes to the meaning or tone of the source recommendation.
Surveillance after mastectomy and breast reconstruction (Recommendation)
In patients who have undergone a mastectomy and breast reconstruction, surveillance should consist of regular clinical examination of the chest wall and reconstructed breast at every routine follow-up visit.
How this guidance was developed
This recommendation was adapted from the CCO 2016 guidelines (Canada). The source recommendation was based on a systematic review of the evidence conducted to 13 May 2014 and was not graded by the source guideline authors. The source recommendation was adapted by making it gender neutral, by adding more specificity, and by removing the phrase ‘as per the regular breast cancer follow-up regimen’.
Surveillance during follow-up – Patients at increased risk of cardiac dysfunction (Recommendation)
In asymptomatic patients considered to be at increased risk of cardiac dysfunction, perform cardiac imaging (preferably an echocardiogram, or a cardiac MRI or a gated heart pool scan) between 6-12 months and at 24 months after completion of cancer-directed therapy.
How this guidance was developed
This recommendation was adapted from the ASCO 2017 guideline on cardiac dysfunction in adult cancers (US). The source recommendation is based on a systematic review of the evidence conducted to February 2016 and was graded ‘moderate’ (using ASCO methods). ‘Gated heart pool scan’ is the relevant terminology used in Australia (rather than multi-gated acquisition (MUGA) scan). The inclusion of ‘and at 24 months’ reflects the more recent ESMO 2020 guidelines on the management of cardiac disease throughout oncological treatment, in which the source recommendation, based on an evidence review to June 2018, was graded ‘B’ (using ESMO guidelines methodology adapted from the Infectious Diseases Society of America-United States Public Health Service Grading System).
The ESMO 2020 guidelines also recommend that ‘For patients with a history of mediastinal chest radiotherapy, evaluation for ischaemic heart disease, as well as valvular disease, is recommended, even if asymptomatic, starting at 5 years post-treatment and then at least every 3-5 years thereafter’ ('A').
Referral of patients with breast symptoms or suspicious masses during follow-up (Practice Point)
Patients who have undergone treatment for breast cancer and are found to have breast symptoms, signs, or imaging results suggestive of a breast cancer recurrence during follow-up should be rapidly referred to a specialist for further assessment.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process. The practice point was informed by the evidence-based recommendation in the Alberta Breast Reconstruction Working Group 2014 guidelines (Canada) for patients who have undergone a mastectomy and breast reconstruction. ‘Specialist’ was preferred to encompass breast physicians as well as surgeons. ‘Rapidly’ was added to reflect rapid re-access for patients in a shared care arrangement, as per the Optimal care pathway for patients with breast cancer.
Follow-up imaging
Imaging after breast-conserving surgery – Routine surveillance (Recommendation)
Patients who have undergone breast-conserving surgery should be referred for annual mammography of both breasts. Patients who have undergone a unilateral mastectomy should be referred for annual mammography on the intact breast. Patients may choose to return to BreastScreen for routine annual mammographic surveillance after 5 years. Consider the addition of ultrasound to mammography for follow-up, when indicated on clinical or radiological grounds.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was adapted by making it gender neutral, and to reflect the fact that all clinicians, not just GPs, can be responsible for referring patients for mammography. The use of ultrasound (when there is an unexplained symptom requiring further investigation) was added. A recent systematic review of breast imaging surveillance across guidelines published Jan 2007-Jan 2017 (Swinnen et al. 2018) is noted.
The recently released ASCO 2020 guideline on the management of male breast cancer is noted. This guideline, based on a systematic review of the evidence to 20 September 2019, indicates that ‘Ipsilateral annual mammogram should be offered to men with a history of breast cancer treated with lumpectomy, if technically feasible, regardless of genetic predisposition’ (Type: formal consensus; evidence quality: low; strength of recommendation: strong) and that ‘Contralateral annual mammography should be offered to men with a history of breast cancer and a genetic predisposing mutation’ (Type: formal consensus; evidence quality: low; Strength of recommendation: moderate).
Imaging after breast-conserving surgery – Young patients with high-risk gene mutation (Practice Point)
In patients less than 50 years of age who are carriers of high-risk gene mutations (e.g. BRCA1/2) and who have not undergone risk-reducing mastectomy, consider the use of annual magnetic resonance imaging (MRI) of both breasts during follow-up.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process. It is informed by a recent systematic review of breast imaging surveillance across guidelines published Jan 2007-Jan 2017 (Swinnen et al 2018) suggesting use of MRI if women carry additional risk factors indicating a lifetime recurrence risk of >20%.
Imaging after breast-conserving surgery – Investigation of new symptoms (Recommendation)
In patients who have undergone breast-conserving surgery or a mastectomy and breast reconstruction, diagnostic imaging (mammography, ultrasound, or magnetic resonance imaging) is useful in the evaluation of new symptoms (e.g. lumps, skin changes).
How this guidance was developed
This recommendation was adopted from the CCO 2016 guidelines (Canada) for patients who have undergone a mastectomy and breast reconstruction, and is informed by recent evidence in patients who have undergone breast-conserving surgery. The source recommendation was based on a systematic review to 13 May 2014 and was not graded by the source guideline authors. The source recommendation was accepted with minor rearrangement of the wording, with no changes to the meaning or tone of the source recommendation.
Imaging after breast reconstruction – Routine surveillance (Recommendation)
In patients who have undergone a mastectomy and breast reconstruction and who are asymptomatic, routine imaging of the reconstructed breast is not recommended.
How this guidance was developed
This recommendation was adapted from the CCO 2016 guidelines (Canada). The source recommendation was based on a systematic review of the evidence conducted to 13 May 2014 and was not graded by the source guideline authors. The source recommendation was adapted by replacing ‘surveillance mammography’ with ‘routine imaging’, and by making it more directive by changing ‘there is insufficient evidence’ to ‘is not recommended’. It is also informed by a recent systematic review of breast imaging surveillance across guidelines published Jan 2007-Jan 2017 (Swinnen et al 2018) which indicated that none of the included guidelines recommended routine ipsilateral imaging follow-up after mastectomy surgery, with or without reconstruction.
Imaging after breast reconstruction – Investigation of new symptoms (Recommendation)
In patients who have undergone a mastectomy and breast reconstruction, diagnostic imaging (mammography, ultrasound, or magnetic resonance imaging) is useful in the evaluation of new symptoms (e.g. lumps, skin changes).
How this guidance was developed
This recommendation was adapted from the CCO 2016 guidelines (Canada). The source recommendation was based on a systematic review of the evidence conducted to 13 May 2014 and was not graded by the source guideline authors. The source recommendation was adapted by making the recommendation gender neutral and more directive by replacing 'may be helpful' with 'is useful'.
