II. History
- Unintentional Weight Loss
- Persistent cough
III. Exam
- Initially perform every 6 months for 5 years
- Later, perform exam yearly
- Observe for recurrent or new cancers
- Clinical Breast Exam
- Breast or chest wall changes
- Lymphadenopathy
- Pelvic exam
- Ovarian Cancer
- Endometrial Cancer (esp. if on Tamoxifen)
- Rectal exam for rectal cancers
- Stool Occult Blood for Colon Cancer
- Clinical Breast Exam
- Observe for other complications
- Lymphedema
- Premature Ovarian Failure
- Osteoporosis
- Major Depression
- Cognitive decline
IV. Labs: No longer routinely recommended
- Lab/XRay surveillance not indicated if asymptomatic
- Do not reliably identify metastases
- Does not improve survival
- Prior protocol
- Complete Blood Count every 6 months for 3 years
- Chemistry Panel every 6 months for first 3 years
- Start annual Liver Function Tests after 5 years
V. Imaging
- Mammogram: Yearly
VI. Complications: Primary and Secondary Cancer Risks
- Primary Breast Cancer recurrence
- Second primary Breast Cancer in either Breast
- Ovarian Cancer increased risk (especially associated with BRCA)
- Colorectal Cancer increased risk
- Other cancers related to treatment
- Endometrial Cancer increased risk (if treated with Tamoxifen)
- Leukemia (related to Chemotherapy)
- Lymphagiosarcoma (Stewart-Treves Syndrome)
- See Lymphedema (as well as description below)
- Metastatic and other complications
- Spinal cord compression
- Syndrome Inappropriate ADH Secretion (SIADH)
- Venous Thromboembolism
- Disseminated Intravascular Coagulation (DIC)
- Paraneoplastic Polymyositis
- Pericardial Effusion and Cardiac Tamponade
VII. Complications: Non-Cancer adverse effects related to treatment
- Surgical adverse effects
- Wound Infections or other local complications (e.g. seroma)
- Axillary Nerve Injury
- Upper extremity Lymphedema
- Lymphagiosarcoma (Stewart-Treves Syndrome)
- Upper extremity soft tissue malignancy complicating chronic upper extremity edema
- Presents as arm blue-purple Macule or Papule (or as bulla or Cellulitis)
- See Lymphedema
-
Chemotherapy effects
- Heart Failure
- Pulmonary toxicity
- Leukemia (see above)
- Tumor Lysis Syndrome (acute reaction to tumor debulking by Chemotherapy or radiation)
- Antiestrogen (e.g. Tamoxifen) effects
- Sexual Dysfunction
- Hot Flashes
- Endometrial Cancer risk (see above)
- Aromatase inhibitor (e.g. Arimidex) effects
- Increased Fracture risk
- Arthralgias
- Radiation Therapy
VIII. Protocol
- History and physical exam is performed 6 months for 5 years; then performed annually
- Monitoring
- Mammogram annually (see above)
- Self Breast Exam: Monthly is no longer recommended
- Pelvic Examination: Yearly
- Colonoscopy per routine screening guidelines
- Monitoring studies not recommended
- Routine lab tests are not recommended
- Routine Tumor Marker labs are not recommended
- Routine Chest X-Rays are not recommended
- Routine bone scan are not recommended
IX. Management: Breast Cancer Survivors (assorted topics)
- New Breast Masses
- Evaluate with Ultrasound
- Mammogram may be unreliable after reconstruction
-
Lymphedema (10-25%)
- See Lymphedema
- Compression with gloves or sleeves
- Physical therapy
-
Vasomotor Symptoms of Menopause
- Vaginal Estrogen is probably safe
- Osteoporosis (due to Chemotherapy)
X. References
- Shelby (2015) Crit Dec Emerg Med 29(6): 2-8
- Burstein (2000) N Engl J Med 343:10-1087 [PubMed]
- Sunga (2005) Am Fam Physician 71:699-714 [PubMed]
- Wilbur (2014) Am Fam Physician 91(1):29-36 [PubMed]