Follow-up after treatment for breast cancer. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer.

OBJECTIVE: To assist patients and their physicians in arriving at the most effective follow-up strategy after treatment for breast cancer.

OUTCOMES: Survival, metastasis-free survival, local recurrence, quality of life.

EVIDENCE: Evidence was based on a literature review using MEDLINE for the years 1991 to 1996, references cited in reviews and consensus conference proceedings.

RECOMMENDATIONS: All patients who have completed their primary treatment for breast cancer should have regular follow-up surveillance. The frequency of follow-up visits should be adjusted according to individual patient's needs. The following issues and schedule should be considered: (a) The need to discuss and manage early side effects of therapy, plan a follow-up program and provide general support. (This visit is usually scheduled 4 to 6 weeks after therapy.) (b) The need to establish a post-treatment baseline, detect early recurrences and teach breast self-examination. (This visit is usually 4 to 6 months after therapy.) (c) The need for regular physical and mammographic examination to detect potentially curable disease. (These examinations should be at approximately 1-year intervals indefinitely thereafter.) (d) The need to provide support and counselling may require additional visits for some women, particularly for the first few years. (e) If metastases develop, the frequency of visits must be determined by the symptoms, course of disease and need for further treatment. All visits should include a medical history. For women who are taking tamoxifen, it is important to ask about vaginal bleeding. Physical examination should include both breasts, regional lymph nodes, chest wall and abdomen. The arms should be examined for lymphedema. Annual visits should include mammographic examination. Routine laboratory and radiographic investigations should not be carried out for the purpose of detecting distant metastases. Patients should be encouraged to report new, persistent symptoms promptly, without waiting for the next scheduled appointment. Breast self-examination should be taught to those women who wish to carry it out. Psychosocial support should be encouraged and facilitated. Participation in clinical trials should be facilitated and encouraged. The responsibility for follow-up care should be formally allocated to a single physician, with the patient participating as much as possible. The patients should always be fully informed of these arrangements. Communication between all members of the therapeutic team must be ensured to avoid duplication of visits and tests.

VALIDATION: Successive reviews and revisions of this document were carried out by a writing committee, expert primary reviewers, secondary reviewers from across Canada, and by the Steering Committee. This final version reflects a substantial consensus of all individuals involved. This guideline has been reviewed and approved by the Canadian Association of Radiation Oncologists.