Follow Up after Treatment for Early Breast Cancer

Regular follow up is strongly recommended after treatment for breast cancer, to check whether the breast cancer has come back, to monitor side effects of treatment and to provide practical and emotional support, and usually alternates between the breast surgeon, medical oncologist and perhaps also radiation oncologist. The recommended frequency and duration of follow up varies across the world and while the National Institute for Clinical Excellence (NICE) in England, advocates follow up for only 2-3 years, in many other countries, including Australia, it is normal practice for patients to undergo specialist follow up for 5 years.

The purpose of follow up is to help maintain good health after treatment, which includes coping with side effects of treatment, advice on exercise and diet, reducing the risk of recurrence and detecting local recurrence. Cancer Australia in 2010 defined the aims and objectives of follow up as: to detect and treat local recurrence, to deal with adverse effects of treatment, to provide psychological support, to screen for new primary breast cancer, review and update family history, observe outcomes of therapy and review treatment including the potential for new therapies.

Follow Up after Treatment for Early Breast Cancer

A diagnosis of breast cancer marks the beginning of a journey full of emotional, psychological, physical and practical challenges. While breast cancer is a major event for all who are diagnosed, it also brings with it the chance for growth. As hard as treatment can be, many breast cancer survivors have told us that the experience led them to make important changes in their lives. Having cancer and treatment often makes people think about their health in different ways. Some people decide they want to live a healthier lifestyle than they did before getting cancer. Many people look for ways to reduce the chance of their cancer coming back and preventing a new cancer developing. It’s a great time to make some changes and commit to staying healthy. This includes: having a healthy diet, maintaining a healthy weight, stopping smoking and increasing physical activity. These simple measures may assist in preventing secondary, recurrent or a new primary breast cancer and they may also reduce many of the physical and emotional effects of cancer treatment.

The end of treatment can be both stressful and exciting. You’ll be relieved to finish treatment, yet it’s hard not to worry about cancer coming back. This is very common among people who have had cancer. Many women look forward to finishing their breast cancer treatment and getting on with life. However, for some women, the end of treatment can be a confusing or worrying time. Some people feel nervous or upset at the thought of no longer seeing members of their health care team regularly. Others feel worried about what the future holds.

In the past, routine surgical follow up visits had the main aim of detecting recurrent or new primary breast cancer, however more recently the concept of comprehensive ‘survivorship’ care has evolved, and various models have been proposed to deliver this more complex care in an effective, streamlined, organized and efficient manner.

Follow Up after Treatment for Early Breast Cancer

Rapid expansion in the follow up workload has occurred through a combination of the ageing of the population, leading to increasing numbers in the cancer prone age groups, and improving outcomes of treatment, massively expanding the pool of survivors. The incidence of breast cancer in Australia is increasing: in 2010, the number of new cases of breast cancer diagnosed in women increased to 14,181, from 5,303 in 1982. In 2014, about 15,270 Australian women are expected to be diagnosed with breast cancer. Early diagnosis and improved treatment outcomes have increased breast cancer survival rates, which has in turn led to increasing numbers of women undergoing follow up after completion of primary treatment. Between 1982–1987 and 2006–2010, the five-year survival from breast cancer increased from 72% to 89%. The ten year survival is now 83% and the current twenty year survival rate is greater than the five year survival rate was 30 years ago!

The escalating workload involved in providing follow up for the increasing numbers of breast cancer survivors is becoming rapidly unsustainable for breast surgeons, who also need to provide surgical care for women newly diagnosed or with a recurrence. The component of breast cancer follow up provided by the breast surgeon has traditionally focused primarily on the detection of local recurrence or a new primary breast cancer, with a combination of clinical examination and annual breast imaging. With modern treatment, the risk of local recurrence after breast conserving surgery or mastectomy is very low, and after the first two years, evidence suggests that review by a specialist breast surgeon is probably unwarranted, based on the number of local recurrences detected by routine follow up.

While the risk of local recurrence after breast conserving surgery falls over time, the development of new cancers in the treated breast increases, so that the overall incidence of breast events, is relatively constant at 0.5-1% each year, for the first 10 years, and probably for the rest of the patient’s life. Patients with cancer in one breast also have an increased risk of developing a cancer in the other breast- the incidence is 0.3-0.4% per year. If recurrences in the treated breast and axilla are combined with new cancers in either breast, the annual incidence of treatable locoregional disease is constant at 1-1.5% for the first 10 years, and 70% of these events occur after the first three years.

Follow Up after Treatment for Early Breast Cancer

Recently, since the concept of comprehensive ‘survivorship’ care has evolved, various models have been proposed to deliver this more complex care in an effective, streamlined, organized and efficient manner. Alternative models of follow up that have been studied include ‘shared care” programmes with increased involvement of general practitioners, and those utilising breast physicians (doctors, usually general practitioners, with a special interest in breast disease) and breast care nurses. An Australian study, published in 2014 in the British Journal of Cancer, looking at what sort of follow up services Australian breast cancer survivors would prefer, found that beyond the first two years from diagnosis, in the absence of a specialist led follow up, women would prefer to have their routine breast cancer follow up by a breast physician, in the dedicated local breast cancer centre.

Follow up in the treating breast cancer centre by a breast physician, allows surveillance to continue to be actively overseen by the operating breast surgeon, which not only provides continuity, but may also be an advantage compared to discharge to a general practitioner, in the circumstance for example of a significant change in clinical practice, such as the indications for screening breast MRI or an alteration in eligibility criteria for genetic testing. Routine annual breast imaging continues to be undertaken at the same imaging facility, which facilitates easier comparison with previous imaging, reducing unnecessary recalls. Long term assessment of the cosmetic outcome of oncoplastic and reconstructive procedures is important, and continued follow up at the treating breast cancer centre also allows for ongoing annual clinical photography.

Follow Up after Treatment for Early Breast Cancer

Our New Surgical Breast Cancer Follow Up Programme – “Survive and Thrive”

The number of recalls for routine follow up at the Epworth Breast Service each month continues to grow, making scheduling of appointments and coordinating of breast imaging increasingly difficult, and there is currently so little flexibility in the schedule, which is booked to absolute capacity, that if a patient unavoidably needs to reschedule an appointment, there is often a six week wait, and for patients who request an urgent interval appointment between routine visits, there is very limited capacity to offer this in a timely fashion.

To address these problems, in light of the recent local research, and as a result of informal discussions with patients over the last 18 months, we are restructuring our surgical follow up regimen to include a ‘breast physician” for the delivery of the routine follow up in years 3, 4 and 5 after diagnosis. The appointment process will remain the same, with patients receiving a recall letter by mail, and breast imaging will be conducted in the same manner, with imaging reports electronically transmitted to the breast surgeon as well as the breast physician. The breast physician will correspond with the general practitioner and all other treating specialists following the clinical consultation in the same manner as previously, and if there are any clinical or imaging concerns, will arrange for prompt review by the breast surgeon. Patients will continue to see their other treating specialists eg medical oncologist/radiation oncologist as previously.

As Australian guidelines support discharge from specialist follow up at 5 years and because of the large numbers of “survivors”, this has been our standard routine practice to date in the majority of cases. Many of our patients have however expressed a strong preference to continue with their ongoing follow up after 5 years (annual clinical breast examination and breast imaging) here at the Epworth Breast Service. Some of our patients from remote areas do not have suitable local imaging facilities, some from small country communities prefer not to see their local male GPs for breast examination and many of our patients live locally, and as such it is actually more convenient for them to continue their surveillance here at Epworth Richmond. The introduction of a breast physician to the team will allow us to offer ongoing follow up after 5 years to these patients if requested.

New Surgical Breast Cancer Follow Up Programme

Years

Follow Up Appointments

Doctor

1 & 2

6 months, 12 months, 2 years

Breast Surgeon

3-5

Annual – 3, 4 and 5 years

Breast Physician

6+

Annual

Breast Physician or GP

Follow Up after Treatment for Early Breast Cancer

New Surgical Breast Cancer Follow Up Programme

Follow Up after Treatment for Early Breast Cancer

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