2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Clinical and Imaging Surveillance Following
Breast Cancer Diagnosis
By Chris I. Flowers, MBBS, Blaise P. Mooney, MD, and Jennifer S. Drukteinis, MD
Overview: Breast cancer is the most common malignancy
affecting women worldwide. Women have a1in8lifetime risk
of breast cancer. Breast conservation therapy (BCT) is the
most common method of definitive treatment. Patients who
previously have had to undergo mastectomy may be now
eligible for BCT or a multitude of options for reconstruction,
either immediate or delayed. Surveillance imaging after a
breast cancer diagnosis is important because there is an
increased risk of recurrence developing in patients, and early
detection has been shown to improve survival. There is
currently no consensus on a protocol for imaging the postoperative
breast. In patients who have undergone mastectomy,
LOCAL RECURRENCE, second ipsilateral breast cancer,
and contralateral breast cancer may develop in
women with a personal history of breast cancer. 1-3 Lumpectomy
followed by whole breast irradiation or BCT is the most
common treatment following a diagnosis of breast cancer.
BCT of clinical stage I and stage II breast cancer has become
a standard of care, with long-term studies showing no
significant difference (p � 0.001) in survival rates between
those treated with BCT as opposed to mastectomy. 4-10 Early
detection of local recurrence of breast cancer has been shown
to improve long-term survival (HR 2.44 [95% CI] if without
symptoms); therefore, it is important to optimize the use of
clinical and imaging tools for the patient with a history of
breast cancer to diagnose recurrence in its most early stages.
Locoregional recurrence occurs in approximately 5% of
patients at 5 years with a local failure rate of approximately
1% to 2.5% per year. In the immediate postoperative period,
suspicious findings likely represent residual disease, whereas
local recurrence typically occurs 3–7 years after BCT. 11,12
Many factors affect local, regional recurrence and distant
metastasis. These include age at diagnosis, primary tumor
subtype and size, presence of local or regional node disease,
surgical treatment, use and type of radiation therapy, and
use of adjuvant hormonal therapy and chemotherapy.
With the increasing number and variability of oncoplastic
procedures, there are many potential ways in which local
recurrence can appear and be detected on imaging. Mammographic
surveillance has shown utility in the detection
of recurrent disease, and in screening the contralateral
breast for early breast cancer. As a result, mammographic
follow-up has become the norm for women who have been
treated for breast cancer. There are, however, significant
variations in the way this has been implemented across the
United States and the world.
Most published data compare mammographic surveillance
and physical examination. This combination has been
the standard of care and is most frequently used in discussion
of follow-up protocols. In contrast, mammography of the
treated breast for recurrence is seldom performed routinely
for patients who have had a mastectomy and breast reconstruction,
with physical examination being the primary tool
to detect recurrence. MRI has been shown to be a valuable
tool in evaluating the reconstructed breast following mastectomy.
MRI may also have an increasing role in the
detection of recurrence has mostly been via clinical symptoms
and physical exam, often at a later stage. New imaging
modalities, such as magnetic resonance imaging (MRI), ultrasound
(US), and positron emission mammography (PEM) are
changing the way we image the postsurgical breast. MRI,
coupled with physical exam and mammography, approaches
100% sensitivity and high specificity for the identification of
recurrent disease. We present a review of major academic
institutions’ imaging protocols and discuss the advantages
of including MRI in traditional mammographic and clinical
exams.
treatment of patients who have undergone BCT or women
with an originally mammographically occult primary breast
cancer.
When discussing the follow-up examination of a patient
previously treated for breast cancer, we must remember that
the ultimate goal of imaging following a breast cancer
diagnosis is to detect recurrence or new primary cancer
before it is clinically detectable.
Surveillance of the contralateral breast is essentially a
type of screening exam, except that it is targeted to a
high-risk group. As a planned medical intervention, this
is often referred to as surveillance. However, in a patient
with breast conservation, the contralateral breast is being
screened.
There is very little data available to make specific guidelines
about surveillance of the patient previously treated for
breast cancer. Therefore, a review of the limited literature
and surveillance protocols at a few selected academic centers
will be presented.
Effectiveness of Mammography
Mammography has been proven to be efficacious as a
screening modality in detecting breast cancer recurrence,
with various papers showing a 50% detection rate of recurrent
tumors by mammography and the rest by physical
examination. 13-15 Depending on the type of prior surgery,
there may be confounding and distracting features both on
physical examination and on imaging, and the number of
false-positive examinations may be higher than those for the
general population.
Recurrent tumors detected by surveillance mammography
are in general smaller and less invasive than those found
during clinical examination, as demonstrated by Lu and
colleagues. 16 This systematic review compared isolated locoregional
recurrence or contralateral cancers on survival.
The authors demonstrated better overall survival for mam-
From the H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, and
University of South Florida, Tampa, FL.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Chris Flowers, MBBS, H. Lee Moffitt Cancer Center and
Research Institute, 12902 Magnolia Dr., Tampa, FL 33612; email: chris.flowers@
moffitt.org.
© 2012 by American Society of Clinical Oncology.
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