II. History

  1. Unintentional Weight Loss
  2. Persistent cough

III. Exam

  1. Initially perform every 6 months for 5 years
  2. Later, perform exam yearly
  3. Observe for recurrent or new cancers
    1. Clinical Breast Exam
      1. Breast or chest wall changes
      2. Lymphadenopathy
    2. Pelvic exam
      1. Ovarian Cancer
      2. Endometrial Cancer (esp. if on Tamoxifen)
    3. Rectal exam for rectal cancers
    4. Stool Occult Blood for Colon Cancer
  4. Observe for other complications
    1. Lymphedema
    2. Premature Ovarian Failure
    3. Osteoporosis
    4. Major Depression
    5. Cognitive decline

IV. Labs: No longer routinely recommended

  1. Lab/XRay surveillance not indicated if asymptomatic
    1. Do not reliably identify metastases
    2. Does not improve survival
  2. Prior protocol
    1. Complete Blood Count every 6 months for 3 years
    2. Chemistry Panel every 6 months for first 3 years
    3. Start annual Liver Function Tests after 5 years

V. Imaging

  1. Mammogram: Yearly

VI. Complications: Primary and Secondary Cancer Risks

  1. Primary Breast Cancer recurrence
  2. Second primary Breast Cancer in either Breast
  3. Ovarian Cancer increased risk (especially associated with BRCA)
  4. Colorectal Cancer increased risk
  5. Other cancers related to treatment
    1. Endometrial Cancer increased risk (if treated with Tamoxifen)
    2. Leukemia (related to Chemotherapy)
    3. Lymphagiosarcoma (Stewart-Treves Syndrome)
      1. See Lymphedema (as well as description below)
  6. Metastatic and other complications
    1. Spinal cord compression
    2. Syndrome Inappropriate ADH Secretion (SIADH)
    3. Venous Thromboembolism
    4. Disseminated Intravascular Coagulation (DIC)
    5. Paraneoplastic Polymyositis
    6. Pericardial Effusion and Cardiac Tamponade

VII. Complications: Non-Cancer adverse effects related to treatment

  1. Surgical adverse effects
    1. Wound Infections or other local complications (e.g. seroma)
    2. Axillary Nerve Injury
    3. Upper extremity Lymphedema
    4. Lymphagiosarcoma (Stewart-Treves Syndrome)
      1. Upper extremity soft tissue malignancy complicating chronic upper extremity edema
      2. Presents as arm blue-purple Macule or Papule (or as bulla or Cellulitis)
      3. See Lymphedema
  2. Chemotherapy effects
    1. Heart Failure
    2. Pulmonary toxicity
    3. Leukemia (see above)
    4. Tumor Lysis Syndrome (acute reaction to tumor debulking by Chemotherapy or radiation)
  3. Antiestrogen (e.g. Tamoxifen) effects
    1. Sexual Dysfunction
    2. Hot Flashes
    3. Endometrial Cancer risk (see above)
  4. Aromatase inhibitor (e.g. Arimidex) effects
    1. Increased Fracture risk
    2. Arthralgias
  5. Radiation Therapy
    1. See Radiation Therapy

VIII. Protocol

  1. History and physical exam is performed 6 months for 5 years; then performed annually
  2. Monitoring
    1. Mammogram annually (see above)
    2. Self Breast Exam: Monthly is no longer recommended
    3. Pelvic Examination: Yearly
    4. Colonoscopy per routine screening guidelines
  3. Monitoring studies not recommended
    1. Routine lab tests are not recommended
    2. Routine Tumor Marker labs are not recommended
    3. Routine Chest X-Rays are not recommended
    4. Routine bone scan are not recommended

IX. Management: Breast Cancer Survivors (assorted topics)

  1. New Breast Masses
    1. Evaluate with Ultrasound
    2. Mammogram may be unreliable after reconstruction
  2. Lymphedema (10-25%)
    1. See Lymphedema
    2. Compression with gloves or sleeves
    3. Physical therapy
  3. Vasomotor Symptoms of Menopause
    1. Vaginal Estrogen is probably safe
  4. Osteoporosis (due to Chemotherapy)
    1. See Osteoporosis Management

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