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Breast Cancer Monitoring
Aka: Breast Cancer Monitoring, Breast Cancer Survivor
- See Also
- Cancer Survivor Care
- History
- Unintentional Weight Loss
- Persistent cough
- Exam
- Initially perform every 3-6 months for 3 years, then 6-12 months for 2 years and then annually
- 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
- Observe for other complications
- Lymphedema
- Premature Ovarian Failure
- Osteoporosis
- Major Depression
- Cognitive decline
- 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
- Labs: Hereditary Breast Cancer
- Indications for testing
- Breast Cancer onset before age 50 years old
- Triple negative Breast Cancer (Estrogen, Progesterone, epidermal growth factor)
- Strong Family History of Breast or Ovarian Cancer
- Resources
- USPTF
- https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing
- Imaging
- Mammogram: Yearly
- Obtain of both Breasts or the remaining Breast
- MRI Indications (performed annually for those at high recurrence risk)
- Calculated lifetime risk >20%
- Strong FHx of Breast or Ovarian Cancer
- Personal history of Hodgkin Disease
- Echocardiogram indications (at 6-12 months after Breast Cancer treatment)
- High dose anthracycline Chemotherapy
- Or low dose anthracycline when combined with Cardiac Risks or radiation
- Trastuzumab
- 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
- 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 (e.g. Doxorubicin, Trastuzumab)
- Pulmonary toxicity
- Leukemia (see above)
- Tumor Lysis Syndrome (acute reaction to tumor debulking by Chemotherapy or radiation)
- Cognitive Impairment (esp. verbal memory, psychomotor function)
- Consider cognitive rehabilitation
- Antiestrogen (e.g. Tamoxifen) effects
- Sexual Dysfunction
- Hot Flashes
- Endometrial Cancer risk (see above)
- Aromatase inhibitor (e.g. Arimidex) effects
- Increased Fracture risk (see Osteoporosis below)
- Arthralgias
- Radiation Therapy
- See Radiation Therapy
- Protocol
- History and physical exam
- Every 3-6 months for 3 years, then
- Every 6-12 months for 2 years, then
- 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
- Management: Breast Cancer Survivors (assorted topics)
- New Breast Masses
- Evaluate with Ultrasound
- Mammogram may be unreliable after reconstruction
- Lymphedema (10-25%)
- See Lymphedema
- Higher risk with Radiotherapy, Obesity, advanced cancer at diagnosis, axillary node dissection (41% at 10 years)
- Onset is often delayed months or years, and may be complicated by Cellulitis or lymphangitis
- Refer to Lymphedema specialist for complex decongestive therapy
- Compression with gloves or sleeves
- Physical therapy
- Vasomotor Symptoms of Menopause
- See Hot Flushes
- See Vaginal Dryness
- Vaginal Estrogen is probably safe, however unclear absorption
- Osteoporosis (esp. if premenopausal, also provoked by Chemotherapy)
- See Osteoporosis Management
- Consider Bisphosphonates
- Avoid Teriparatide (Forteo) due to cancer risk
- DEXA Scan Indications (at baseline and up to every 2 years)
- Chemotherapy-induced premature Menopause
- Premenopausal and treated with Tamoxifen or GnRH agonist
- Treated with aromatase inhibitor
- Consider Zoledronic acid (reclast) for 3-5 years or denosumab (prolia) for 24 months
- Chronic Pain
- See Chronic Pain Management
- Post-Mastectomy Pain Syndrome (20-50% Incidence)
- Burning, stinging, phantom Breast or axilla, chest or Shoulder Pain for >3 months
- Increased risk with Radiation Therapy, pre-existing pain syndromes (e.g. Headache, back pain), younger age
- Also increased with comorbid depression, anxiety, sleep disorders
- Consider Tricyclic Antidepressants (e.g. Amitriptyline), Duloxetine (Cymbalta)
- Mood Disorder
- Anxiety or Major Depression in 50% of Breast Cancer Survivors in first year
- Score lower on global functioning than general population, even 1 year out
- 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]
- Zoberi (2019) Am Fam Physician 99(6):370-5 [PubMed]