Frequency and duration of follow-up. It is logical for surveillance to follow the hazard of relapse, which is highest after 2–3 years and low after 5 years. Therefore, a clinical examination every 3–4 months for the first 2–3 years and then every 6 months up to 5 years is appropriate, with yearly follow-up thereafter (specific recommendations vary between countries). For this approach to work, however, it is vital that the patient should be well informed and present promptly should symptoms develop.
It should be remembered that regular and intensive follow-up does not improve the success rates for treatment of a recurrence. However, it may serve other purposes. The patient’s perceived need for follow-up may mean that visiting her doctor regularly for reassurance (even if it is sometimes proven false) will improve her personal well-being. Physicians may also gain more job satisfaction by regularly seeing so many patients doing well rather than seeing only those patients who have had a recurrence. As neither of these possible benefits has been tested in randomized trials, it would be prudent to explain to the patient that regular follow-up, though offered, is not necessarily of proven value.
From a different perspective, because our understanding of breast cancer is continually changing, it may be important to follow up patients for a long time, not only to continue treatment such as extended adjuvant hormone therapy (see Chapter 5), but to assess and treat the long-term side effects of therapy such as osteoporosis and cognitive dysfunction, and the late side effects of radiotherapy.
Mammography. The role of mammography in follow-up is somewhat controversial. Clinicians and patients alike need to be reassured that the risk of local relapse within the retained breast is similar to the risk of a contralateral breast cancer, which is about 4% over 10 years. The relative risk of dying from a contralateral breast cancer depends on the recurrence risk associated with the original tumor. It may be extremely small when compared with the risk of death from the original disease. For this reason, a policy of annual or biennial mammography, for example, might be a reasonable compromise. Nevertheless, it is usually difficult to justify a contralateral prophylactic mastectomy in a woman with sporadic breast cancer.
Magnetic resonance imaging is often used in the follow-up period for patients whose cancer was initially mammographically occult or for whom the risk of a relapse or new cancer is considered high. In such cases, a good policy would be yearly MRI and yearly mammograms but spaced 6 months apart (e.g. a mammogram every March and MRI every September).
Patients undergoing surgery for primary breast cancer require rehabilitation to address the physical and psychological consequences of surgery.
Physiotherapy. Although the incidence of severe arm and shoulder disorders after mastectomy has largely declined with the reduction in radical procedures, minor nerve damage may still occur, and physiotherapy should be started as soon as possible after surgery.
A range of exercises can be used to improve arm and shoulder mobility. The patient should be able to brush the back of her hair and fasten zips at the back of her clothing by the time she returns home, and exercises should be continued after discharge from hospital. Physiotherapy can also reduce the risk of lymphedema after full axillary clearance. Elastic bandaging may also be useful, and the affected arm should be elevated whenever possible, particularly at night, and protected from knocks.
Breast prostheses are an important aspect of physical rehabilitation after mastectomy, and can also strongly influence psychological rehabilitation. A light, temporary prosthesis can be used for the first few weeks until the wound has healed. A suitable permanent prosthesis can then be selected from the wide range available, according to the required size, shape and adherence to the chest wall. Many hospitals have a nurse or physiotherapist trained in the use of breast prostheses.
Psychological rehabilitation. Breast cancer imposes considerable psychological stress and trauma. The initial diagnosis and preparation for surgery can produce a period of emotional turmoil in which rapid mood swings are accompanied by immense disruption to the woman’s lifestyle. By contrast, the patient may be euphoric during the immediate postoperative period, possibly due to relief of uncertainty and anticipation of a return to normal life. However, this initial reaction is transient; many women experience a period of shock and denial followed by anxiety about 2–3 months after surgery. Most women eventually develop coping skills, enabling them to live a normal lifestyle. Some women have persistent psychological or sexual problems after surgery.4–6 This does not seem to be related to the type of operation; anxiety and depression appear to be as common in women undergoing breast-conserving surgery as in women undergoing mastectomy.
It is possible that while women undergoing conservative surgery are less concerned about the mutilating effect of surgery and perceived loss of femininity, they are more worried than mastectomy patients about the possibility of recurrence. Patients may also experience anxiety or depression in association with follow-up visits to the clinic, because of the fear that the cancer might recur. If recurrent disease is detected, the patient must again come to terms with the risk of death and the need for further treatment; major depression may occur in up to 50% of women with recurrent disease.
Psychological support is available from a number of sources:
Specialist nurse counselors can offer advice and emotional support throughout the processes of diagnosis and treatment, and can identify patients with psychological problems requiring treatment. It is important, however, that both the patient and the nurse recognize when such support is no longer needed; maintaining contact on a purely routine basis can foster a sense of being unwell in the patient, making her feel that she is unable to cope on her own. Volunteer groups, composed of women who have had breast cancer themselves, self-help groups and national cancer charities can also offer valuable help and advice to breast cancer patients and their families.