Breast Cancer Monitoring

1. See Also
   1. Cancer Survivor Care
2. History
   1. Unintentional Weight Loss
   2. Persistent cough
3. Exam
   1. Initially perform every 3-6 months for 3 years, then 6-12 months for 2 years and then annually
   2. Observe for recurrent or new cancers
      1. Clinical Breast Exam
         1. Breast or chest wall changes
         2. Lymphadenopathy
      2. Pelvic exam
         1. Ovarian Cancer
         2. Endometrial Cancer (esp. if on Tamoxifen)
      3. Rectal exam for rectal cancers
      4. Stool Occult Blood for Colon Cancer
   3. Observe for other complications
      1. Lymphedema
      2. Premature Ovarian Failure
      3. Osteoporosis
      4. Major Depression
      5. Cognitive decline
4. Labs: No longer routinely recommended
   1. Lab/XRay surveillance not indicated if asymptomatic
      1. Do not reliably identify metastases
      2. Does not improve survival
   2. Prior protocol
      1. Complete Blood Count every 6 months for 3 years
      2. Chemistry Panel every 6 months for first 3 years
      3. Start annual Liver Function Tests after 5 years
5. Labs: Hereditary Breast Cancer
   1. Indications for testing
      1. Breast Cancer onset before age 50 years old
      2. Triple negative Breast Cancer (Estrogen, Progesterone, epidermal growth factor)
      3. Strong Family History of Breast or Ovarian Cancer
   2. Resources
      1. USPTF
         1. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing
6. Imaging
   1. Mammogram: Yearly
      1. Obtain of both Breasts or the remaining Breast
   2. MRI Indications (performed annually for those at high recurrence risk)
      1. Calculated lifetime risk >20%
      2. Strong FHx of Breast or Ovarian Cancer
      3. Personal history of Hodgkin Disease
   3. Echocardiogram indications (at 6-12 months after Breast Cancer treatment)
      1. High dose anthracycline Chemotherapy
         1. Or low dose anthracycline when combined with Cardiac Risks or radiation
      2. Trastuzumab
7. Complications: Primary and Secondary Cancer Risks
   1. Primary Breast Cancer recurrence
   2. Second primary Breast Cancer in either Breast
   3. Ovarian Cancer increased risk (especially associated with BRCA)
   4. Colorectal Cancer increased risk
   5. Other cancers related to treatment
      1. Endometrial Cancer increased risk (if treated with Tamoxifen)
      2. Leukemia (related to Chemotherapy)
      3. Lymphagiosarcoma (Stewart-Treves Syndrome)
         1. See Lymphedema (as well as description below)
   6. Metastatic and other complications
      1. Spinal Cord Compression
      2. Syndrome Inappropriate ADH Secretion (SIADH)
      3. Venous Thromboembolism
      4. Disseminated Intravascular Coagulation (DIC)
      5. Paraneoplastic Polymyositis
      6. Pericardial Effusion and Cardiac Tamponade
8. Complications: Non-Cancer adverse effects related to treatment
   1. Surgical adverse effects
      1. Wound Infections or other local complications (e.g. seroma)
      2. Axillary Nerve Injury
      3. Upper extremity Lymphedema
      4. Lymphagiosarcoma (Stewart-Treves Syndrome)
         1. Upper extremity soft tissue malignancy complicating chronic upper extremity edema
         2. Presents as arm blue-purple Macule or Papule (or as bulla or Cellulitis)
         3. See Lymphedema
   2. Chemotherapy effects
      1. Heart Failure (e.g. Doxorubicin, Trastuzumab)
      2. Pulmonary toxicity
      3. Leukemia (see above)
      4. Tumor Lysis Syndrome (acute reaction to tumor debulking by Chemotherapy or radiation)
      5. Cognitive Impairment (esp. verbal memory, psychomotor function)
         1. Consider cognitive rehabilitation
   3. Antiestrogen (e.g. Tamoxifen) effects
      1. Sexual Dysfunction
      2. Hot Flashes
      3. Endometrial Cancer risk (see above)
   4. Aromatase inhibitor (e.g. Arimidex) effects
      1. Increased Fracture risk (see Osteoporosis below)
      2. Arthralgias
   5. Radiation Therapy
      1. See Radiation Therapy
9. Protocol
   1. History and physical exam
      1. Every 3-6 months for 3 years, then
      2. Every 6-12 months for 2 years, then
      3. Annually
   2. Monitoring
      1. Mammogram annually (see above)
      2. Self Breast Exam: Monthly is no longer recommended
      3. Pelvic Examination: Yearly
      4. Colonoscopy per routine screening guidelines
   3. Monitoring studies not recommended
      1. Routine lab tests are not recommended
      2. Routine Tumor Marker labs are not recommended
      3. Routine Chest X-Rays are not recommended
      4. Routine bone scan are not recommended
10. Management: Breast Cancer Survivors (assorted topics)
    1. New Breast Masses
       1. Evaluate with Ultrasound
       2. Mammogram may be unreliable after reconstruction
    2. Lymphedema (10-25%)
       1. See Lymphedema
       2. Higher risk with Radiotherapy, Obesity, advanced cancer at diagnosis, axillary node dissection (41% at 10 years)
       3. Onset is often delayed months or years, and may be complicated by Cellulitis or lymphangitis
       4. Refer to Lymphedema specialist for complex decongestive therapy
       5. Compression with gloves or sleeves
       6. Physical therapy
    3. Vasomotor Symptoms of Menopause
       1. See Hot Flushes
       2. See Vaginal Dryness
       3. Vaginal Estrogen is probably safe, however unclear absorption
    4. Osteoporosis (esp. if premenopausal, also provoked by Chemotherapy)
       1. See Osteoporosis Management
          1. Consider Bisphosphonates
          2. Avoid Teriparatide (Forteo) due to cancer risk
       2. DEXA Scan Indications (at baseline and up to every 2 years)
          1. Chemotherapy-induced premature Menopause
          2. Premenopausal and treated with Tamoxifen or GnRH agonist
          3. Treated with aromatase inhibitor
             1. Consider Zoledronic acid (reclast) for 3-5 years or denosumab (prolia) for 24 months
    5. Chronic Pain
       1. See Chronic Pain Management
       2. Post-Mastectomy Pain Syndrome (20-50% Incidence)
          1. Burning, stinging, phantom Breast or axilla, chest or Shoulder Pain for >3 months
          2. Increased risk with Radiation Therapy, pre-existing pain syndromes (e.g. Headache, back pain), younger age
          3. Also increased with comorbid depression, anxiety, sleep disorders
          4. Consider Tricyclic Antidepressants (e.g. Amitriptyline), Duloxetine (Cymbalta)
    6. Mood Disorder
       1. Anxiety or Major Depression in 50% of Breast Cancer Survivors in first year
       2. Score lower on global functioning than general population, even 1 year out
11. References
    1. Shelby (2015) Crit Dec Emerg Med 29(6): 2-8
    2. Burstein (2000) N Engl J Med 343:10-1087 [PubMed]
    3. Sunga (2005) Am Fam Physician 71:699-714 [PubMed]
    4. Wilbur (2014) Am Fam Physician 91(1):29-36 [PubMed]
    5. Zoberi (2019) Am Fam Physician 99(6):370-5 [PubMed]