Annals of Surgical Oncology

, Volume 5, Issue 6, pp 522–528 | Cite as

Evaluation of an intensive strategy for follow-up and surveillance of primary breast cancer

  • Emmanuella Joseph
  • Micheline Hyacinthe
  • Gary H. Lyman
  • Carl Busch
  • LaTara Demps
  • Douglas S. Reintgen
  • Charles E. Cox
Original Articles


Background: Controversies over the frequency and intensity of the follow-up care of breast cancer patients exist. Some physicians have adopted an intensive approach to follow-up care that consists of frequent laboratory tests and routine imaging studies, including chest radiographs, bone scans, and CT scans, whereas others have established a minimalist approach consisting of only history, physical examinations, and mammograms.

Objectives: Our objective was to evaluate the role of intensive follow-up on detection of breast cancer recurrence and to examine the impact of follow-up on overall survival.

Methods: During a 10-year period (1986–1996), 129 patients with recurrent disease were identified from a prospective database of 1898 breast cancer patients. The patients with recurrent disease were divided into minimalist or intensive groups according to method of detection.

Results: Twenty-seven of 126 (21%) patients were assigned to the intensive method of detection group (LFT, CEA, CA 15-3, chest radiograph, CT scan, and bone scan); 99 of 126 (79%) patients were assigned to the minimal detection group (history, physical examination, and mammography). Distant disease to the bone was the most common initial tumor recurrence, at 27%. History, physical examination, and mammography detected recurrent cancer in approximately the same amount of time as LFTs, tumor markers, CT scans, and chest radiographs (P=.960). When the recurrent patients were divided into intensive and minimalist groups and analyzed by time to detection of recurrence, there was no significant difference between the time to detection in those recurrences detected by intensive methods and those recurrences detected by minimalist methods (P=.95).

The independent variables age, tumor size, type of surgery, number of positive nodes, time to recurrence, method of detection, and site of recurrence (regional or distant) were subject to univariate and multivariate analysis by the Cox proportional hazards model. Only two variables had an impact on survival by multivariate analysis: early timing of the recurrence (P=.0011) and the site of the recurrence (P=.02). Timing was defined as early (⩽365 days from the time of diagnosis to recurrence) or late (⩾365 days from the time of diagnosis to recurrence). Early recurrence was the first variable found to be significant on stepwise forward regression analysis. The primary site of recurrence was significant at step two. The method of detection—intensive or minimal—did not significantly affect survival (P=.18).

Conclusions: There is no survival benefit to routine intensive follow-up regimens in detecting recurrent breast cancer. Expensive diagnostic tests such as bone scans, CT scans, and serial tumor markers are best used for detection of metastasis in symptomatic patients.

Key Words

Breast cancer Surveillance Guidelines Diagnostic test 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Horton J. Follow-up of breast cancer patients.Cancer 1984;53:790–7.PubMedGoogle Scholar
  2. 2.
    Simmon MS, Hoff M, Hussien, et al. An evaluation of clinical follow-up in women with early stage breast cancer among physicians members of ASCO.Breast Cancer Res Treat 1993;1:207–11.Google Scholar
  3. 3.
    Carlson R, Goldstein LJ, McCormick B. Breast cancer practice guidelines: panel presentation.National Comprehensive Cancer Network 1996.Google Scholar
  4. 4.
    Tannock IF, Belanger D. Use of physician directed questionnaire to define a consensus about management of breast cancer: implications for assessing costs and benefits of treatment.J Natl Cancer Inst Monograph 1992;11:137–42.Google Scholar
  5. 5.
    American Society Of Clinical Oncology. Recommended Breast Cancer Surveillance Guidelines.J Clin Oncol 1997;15:2149–56.Google Scholar
  6. 6.
    Schapira DV, Urban N. A minimalist policy for breast cancer surveillance.JAMA 1991;265:380–2.CrossRefPubMedGoogle Scholar
  7. 7.
    Shapira DW. Breast cancer surveillance—a cost-effective strategy.Breast Cancer Res Treat 1993;25:107–11.Google Scholar
  8. 8.
    Liberati A. The GIVIO trial on the impact of follow-up care on survival and quality of life in breast cancer patients.Ann Oncol 1995;6(Suppl 2):40–6.Google Scholar
  9. 9.
    The Givio Investigators. Impact of follow up testing on survival and health-related quality of life in breast cancer patients: a multicenter randomized controlled trial.JAMA 1995;271:1587–92.Google Scholar
  10. 10.
    Woolf SH. Practice guidelines, a new reality in medicine. II: Methods of developing guidelines.Arch Intern Med 1992;152:946–52.CrossRefPubMedGoogle Scholar
  11. 11.
    Love SM, McGuigan KA, Linnea C. The Revlon/UCLA Breast Center practice guidelines for the treatment of breast disease.Cancer J Sci Am 1996;2:S2–23.Google Scholar
  12. 12.
    Paradiso A, Nitti P, Freeza P, et al. A survey in Pulgia: the attitudes and opinions of specialists, general physicians and patients on follow-up practice.Ann Oncol 1995;6(suppl 2):S53–6.Google Scholar
  13. 13.
    Orel Greenstein S, Fowble BL, Solin LJ. Breast cancer recurrence after lumpectomy and radiation therapy for early stage disease: prognostic significance of detection method.Radiology 1993;188:189–94.Google Scholar
  14. 14.
    Crivelli D. Routine follow-up of patients after primary treatment for operable breast cancer.Ann Oncol 1995;6:769–76.Google Scholar
  15. 15.
    Rosselli Del Turco M, Palli D, Cariddi A, Ciatto S. The efficacy of intensive follow-up testing in breast cancer cases.Ann of Oncol 1995;6(suppl 2):S37–9.Google Scholar
  16. 16.
    Zwaaveling A, Albers GHR, Felthuis W. An evaluation of routine follow-up for detection of breast cancer.J Surg Oncol 1987;34:194–7.Google Scholar
  17. 17.
    Rosselli Del Turco M, Palli D, Cariddi A, et al. Intensive diagnostic follow-up after treatment of primary breast cancer: a randomized trial.JAMA 1994;271:1593–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Gion M, Barioli P, Mione R, et al. Tumor markers in cancer follow-up: a potentially useful parameter still awaiting definitive assessment.Ann Oncol 1995;6(suppl 2):S31–5.Google Scholar
  19. 19.
    Crippa F, Bombardieri E, Seregni E, et al. Single determination of CA 15.3 and bone scintigraphy in the diagnosis of skeletal metastasis of breast cancer.J Nucl Biol Med 1992;36:52–5.PubMedGoogle Scholar
  20. 20.
    Beard DB, Haskell CM. Carcinoembryonic antigen in breast cancer.Am J Med 1986 80:241–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Hannisdal E, Gundersen S, Kvaloy S, et al. Follow-up of breast cancer patients stage I-IIA baseline study.Eur J Cancer 1993;29A:992–7.PubMedGoogle Scholar
  22. 22.
    Waalkes TP, Enterline JP, Sharper JH, et al. Biological markers for breast carcinoma.Cancer 1984;53:644–51.PubMedGoogle Scholar
  23. 23.
    Khansur T, Haick A, Patel B, et al. Evaluation of bone scan as a screening work-up in primary and local-regional recurrence of breast cancer.Am J Clin Oncol 1987;10:167–70.PubMedGoogle Scholar
  24. 24.
    Kagan R, Steckel RJ. Routine imaging studies for the post treatment surveillance of breast and colorectal carcinoma.J Clin Oncol 1991;9:837–42.PubMedGoogle Scholar
  25. 25.
    Hietanen P. Chest radiography in the follow-up of breast cancer.Acta Radiol Oncol 1985;25:15–8.Google Scholar
  26. 26.
    Cox CE, Greenberg H, Fleisher D, et al. Natural history and clinical evaluation of the lumpectomy scar.Am Surg 1993;59:55–9.PubMedGoogle Scholar
  27. 27.
    Muller-Runkel R, Kalokhe UP. Scatter dose from tangential breast irradiation to the uninvolved breast.Radiology 1990;175:873–6.PubMedGoogle Scholar
  28. 28.
    Harms SE, Flamig DP, Hesley KL, Evans WP. MRI of the breast.Magn Reson Q 1992;1813:139–55.Google Scholar
  29. 29.
    Schnitt SJ, Connolly JL, Harris JR. Pathologic predictors of early local regional recurrence in Stage I and II breast cancer treated by primary radiation therapy.Cancer 1984;53:1049–57.PubMedGoogle Scholar
  30. 30.
    Rosen PP, Groshen S, Kinne DW. Survival and prognostic factors in node negative breast cancer: results of long-term follow-up studies.J Natl Cancer Inst Monograph 1992;11:159–62.Google Scholar
  31. 31.
    Tomiak E, Piccart M. Routine follow-up of patients after primary therapy for early breast cancer: changing concepts and challenges for the future.Ann Oncol 1993;4:199–204.PubMedGoogle Scholar
  32. 32.
    Grilli R, De Lena M, Paradiso A, Nitti P. A shared effort toward better quality of care. The Consensus Conference on Breast Cancer Follow-up.Ann Oncol 1995;6(suppl 2):S5–9.Google Scholar

Copyright information

© The Society of Surgical Oncology, Inc. 1998

Authors and Affiliations

  • Emmanuella Joseph
    • 1
  • Micheline Hyacinthe
    • 1
  • Gary H. Lyman
    • 1
  • Carl Busch
    • 1
  • LaTara Demps
    • 1
  • Douglas S. Reintgen
    • 1
  • Charles E. Cox
    • 1
  1. 1.From The Comprehensive Breast Cancer ProgramMoffitt Cancer Center, University Of South FloridaTampa

Personalised recommendations