Breast Cancer and Post-Surgical Screening: Advising Patients on Appropriate Imaging

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“Medical Journeys” is a set of clinical resources reviewed by doctors, meant for physicians and other healthcare professionals as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. “Medical Journeys” chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

After breast cancer surgery — lumpectomy or mastectomy — regular monitoring and screening are crucial to detect any potential recurrence or new developments. The specific screening and follow-up plans can vary depending on an individual’s medical history, the stage of the cancer, the type of surgery performed, and other factors.

The primary care provider (PCP) should have a good understanding of their patient’s individual risk factors for breast cancer recurrence. This includes tumor characteristics, lymph node involvement, hormone receptor status, and genetic factors — all knowledge that can help guide the frequency and type of screening.

Clinical Breast Examination

Regular clinical breast exams conducted by a healthcare professional can help detect any changes or abnormalities in the breast tissue, such as thickening or lumps.

A breast cancer survivor’s risk of recurrence should serve as the main pillar of surveillance, taking into consideration their functional status and preference. In general, patients at a higher risk for local recurrence should have appropriate screening.

According to survivorship care guidelines from the American Cancer Society (ACS) and the American Society of Clinical Oncology (ASCO), a detailed cancer-related history and breast physical examination should occur every 3 to 6 months for the first 3 years after primary breast cancer therapy, every 6-12 months for the next 2 years, and annually thereafter. Guidelines also call for surveillance imaging of ductal carcinoma in situ (DCIS) breast cancer every 6-12 months for 5 years and then annually. The National Comprehensive Cancer Network (NCCN) recommends that patients with DCIS have a physical exam every 6-12 months.

Patient Breast Self-Exam

Reviewing breast self-exam techniques may be helpful for people who have undergone a lumpectomy or partial mastectomy as this may increase the odds of early breast cancer detection.

Encouraging self-breast examinations and raising awareness about any unusual changes may empower people to play a more active role in their own healthcare. In some cases, this self-exam may be more effective at detecting breast cancer than those provided by healthcare professionals, such as post-treatment ductal carcinoma in situ, which was more likely to be found via self-exam or mammogram compared with clinical breast self-exam, according to a 2023 study in the Journal of the NCCN.

The ACS/ASCO guidelines recommend that primary healthcare providers educate and counsel all breast cancer patients about the signs and symptoms of local or regional recurrence.

Mammography Screening

If breast-conserving surgery has been performed – lumpectomy or partial mastectomy – the American College of Radiology (ACR) recommends a mammogram about 6 to 12 months after surgery and radiation therapy are completed, and then at least every year thereafter on both breasts.

The first mammogram after lumpectomy or partial mastectomy and radiation therapy will become the new standard against which future mammograms of the remaining breast tissue are compared.

People who have had a mastectomy (including simple mastectomy, modified radical mastectomy, and radical mastectomy) typically no longer need mammograms on that side. Unless both breasts were removed, yearly mammograms on the remaining breast are recommended, per the ACR Appropriateness Criteria.

The NCCN Clinical Practice Guidelines state that “annual mammography” is recommended after breast cancer treatment.

For people who have elected to have breast reconstruction performed after a mastectomy, routine mammograms are generally not performed, as there usually isn’t enough deep breast tissue left for cancer to return.

If breast cancer does return, it would most likely appear on the surface of the breast, where it can be felt during a routine physical exam. However, mammograms may be required if the breast was reconstructed after a lumpectomy, if the breast was reconstructed using the patient’s tissue, or if an implant has been placed in the healthy breast so that it matches the rebuilt breast.

Individuals with silicone implants should have an MRI exam or ultrasound to monitor the implants for potential rupture. The FDA recommends that this occur 5-6 years postoperatively, and then every 2-3 years.

The ACR Appropriateness Criteria detail eight imaging variants for post-surgical breast cancer. The variants define the “imaging at the beginning of the care episode for the medical condition.” One of the goals of these imaging variants is to help the PCP guide the patient to the optimal imaging exam, as these modalities may be “equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)” or “complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously in which each procedure provides unique clinical information to effectively manage the patient’s care).”

Additional Imaging Modality Screening

ACS/ASCO recommend that a patient who has undergone surgery for breast cancer should not be referred for routine screening with MRI of the breast unless they meet ACS guidelines for high-risk criteria for increased breast cancer surveillance. ACS guidelines highlight multiple criteria that may make a patient a candidate for annual MRI screening, including but not limited to the presence of a BRCA mutation, being a first-degree relative of a BRCA carrier (but untested), and radiation therapy to the chest between ages 10-30.

Per ACS, there is not enough evidence to recommend for or against MRI screening for patients who meet multiple criteria, such as having lobular carcinoma in situ or atypical lobular hyperplasia, having atypical ductal hyperplasia or heterogeneously or extremely dense breast tissue on mammography.

As for other imaging options, the ACR guidelines for post-mastectomy imaging found that there was no relevant literature to support the use of digital breast tomosynthesis or fluoro-2-deoxy-D-glucose (FDG)-PET breast screening. Breast ultrasound, according to the ACR, demonstrated insufficient evidence to support use of the modality solely for screening purposes in this group.

Laboratory Tests For Breast Cancer Screening

The ACS/ASCO guidelines recommend that PCPs not offer routine laboratory tests or imaging, except mammography if indicated, for the detection of disease recurrence in the absence of symptoms.

Postmenopausal women with breast cancer who are treated with aromatase inhibitors are advised to undergo baseline bone mineral density testing with a dual-energy x-ray absorptiometry scan repeated every 1-2 years, per NCCN.

Screening for Second Primary Cancers

ACS/ASCO recommend that primary healthcare providers screen for other cancers in breast cancer patients at average risk as they would for people in the general population, and that they provide an annual gynecologic assessment for postmenopausal women on selective estrogen receptor modulator therapies.

The NCCN calls for cardiotoxicity monitoring for patients who received left-sided radiation therapy, anthracyclines, or HER2-targeted therapy.

Patients should be asked periodically about changes in genetic history, as sometimes people who did not previously meet genetic testing criteria may now do so. Criteria include a change in family history of cancer, such as a relative with a new diagnosis, or, inclusion due to a change in guidelines.

Evolution of Care

Recommendations for breast cancer screening after breast cancer surgery will more than likely evolve on the basis of new research and individual patient characteristics as more people with breast cancer are living longer with the disease.

As such, PCPs and allied healthcare professionals need to stay updated on the latest breast cancer screening guidelines and collaborate closely to tailor their screening approach to each breast cancer patient’s unique situation.

Read previous installments in this series:

Part 1: Breast Cancer — The Basics of Diagnosis, Staging, and Treatment

Part 2: Breast Cancer: Making the Diagnosis With Breast Biopsy

Part 3: What to Know About Management of Early-Stage Breast Cancer

Part 4: New Treatment Options for Locally Advanced and Metastatic Breast Cancer

Part 5: Genetic Testing in Breast Cancer: Mutations, Multigene Panels, and More

Part 6: Case Study: Older Male With Rash, Chest Swelling, and Mysterious Skin Issues

Part 7: Breast Cancer Palliative Care and Metastatic Disease: Looking Beyond End of Life

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    Shalmali Pal is a medical editor and writer based in Tucson, Arizona. She serves as the weekend editor at MedPage Today, and contributes to the ASCO and IDSA Reading Rooms.

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