Prevention & Screening

Diagnostic Work-up & Referral

Supporting Patients During Treatment

After Treatment Surveillance

Advanced Cancer, Palliative, End-of-Life

Supportive Care & Wellness Resources

Breast Cancer

Cancer Care Alberta

The evidence-based recommendations described below outline the standard follow-up procedures for breast cancer surveillance and are intended to assist you in providing optimal cancer follow-up care for your patient; these recommendations are not intended to be a substitute for clinical judgement.

Topics

Surveillance Activities & Timelines|Red Flags|Referrals for Recurrence|Complications & Late Effects of Treatment|Specific Concerns for Patients|General Support for Healthy Living

Quick Reference

Surveillance Activities & Timelines

Once a patient has been discharged from Cancer Care Alberta, their primary care provider is asked to organize the following surveillance activities:

  • Diagnostic mammography of intact breast(s) annually. First post-treatment mammogram should be 1 year after diagnostic mammogram (and at least 6 months after radiotherapy). Reconstructed breasts (autologous tissue or implants) or non-reconstructed chest wall post- mastectomy do not require any form of imaging surveillance. Supplemental breast ultrasound can be added to mammography in the setting of extremely dense breast tissue (American College of Radiology category D) and/or at the discretion of the reading radiologist.
  • Periodic clinical examination should specifically include examination of the breast(s)/chest wall, supraclavicular and axillary lymph nodes in addition to routine clinical examination. Clinical examinations should be performed every 6 months for 2 years then annually thereafter.
  • There is no evidence to support the use of breast self-examination (BSE) as a cancer screening method. To learn more about recognizable signs and symptoms of breast cancer, visit the Screening for Life website.

Red Flags

Signs and symptoms of breast cancer recurrence include the following:

 
Symptoms / Signs Actions / Investigations
New mass in breast or armpit, changes in the contour/shape/size of the breast, nipple retraction, or swelling of the breast or arm Mammography +/- ultrasound (+/- biopsy).
New suspicious rash, bleeding or nodule on nipple or chest wall, mastectomy scar changes Refer to surgeon for evaluation and biopsy.
New palpable lymphadenopathy Refer to surgeon or interventional radiology for biopsy.
New persistent bone pain Plain x-ray of affected site(s) and bone scan.
New persistent cough or dyspnea Chest x-ray and/or CT chest.
New hepatomegaly or RUQ abdominal pain or jaundice Ultrasound and/or CT scan of abdomen and liver enzymes.
New persistent headache or new concerning neurologic deficits CT/MRI of brain.
New onset seizures Seizure management (as required) and CT/MRI of brain.
Back pain with limb weakness, change in reflexes, change in sensation, or loss of bowel/bladder control MRI of spine.
Altered level of consciousness, nausea, vomiting, and/or pain with symptomatic hypercalcemia IV hydration and bisphosphonate therapy.
Unexpected constitutional symptoms (severe fatigue, unexplained weight loss) Workup for any identifiable or treatable causes of fatigue and weight loss (e.g. anemia, liver dysfunction, thyroid or cardiac dysfunction), imaging investigations according to local symptoms and laboratory abnormalities as appropriate (e.g. liver ultrasound/CT abdomen if abnormal liver enzymes).
 

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Referrals for Recurrence

Contact the treating oncologist to determine how to refer the patient back to the cancer centre. If the oncologist's contact information is not available, search “breast cancer” in the Alberta Referral Directory for the most up-to-date information and instructions for referral. Contact information can also be found in the Provincial Breast Health Referral Pathway.

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Complications & Late Effects of Treatment

Following treatment for breast cancer, your patient may present with some of the complications outlined below. Continue to monitor and address concerns related to cancer therapy.

 
Complication Treatment-Related Causes Actions
Fatigue
  • Radiation
  • Chemotherapy

Fatigue should start to improve within months of treatment completion. Persistent or recurrent fatigue warrants further work-up to rule out other potential causes. For more information refer to the Cancer-Related Fatigue Guideline.

Consider referral to Alberta Cancer Exercise Program.
Peripheral neuropathy
  • Taxane-chemotherapy
 Chemotherapy related peripheral neuropathy should improve over months. Painful paresthesias may respond to gabapentin or amitriptyline. If neuropathy is progressive/persistent, consider additional investigations and referral to neurology.
Lymphedema
  • Axillary dissection
  • Radiation
 Early symptoms include heaviness or discomfort close to lymph node removal site and may be present with/without overt swelling. Referral to local rehabilitation therapy services (e.g. physiotherapy) or tertiary lymphedema clinic can be made. Calgary Rehabilitation Oncology - Physiotherapy or Cross Cancer Institute Rehabilitation Oncology - Physiotherapy.
Cardiac dysfunction
  • Anthracycline-chemotherapy
  • Trastuzumab
 If patient is symptomatic or has clinical signs treat accordingly and evaluate further with ECG and MUGA or echocardiogram. Consider a referral to cardiology if significant abnormalities are noted.
Acute Leukemia / Myelodysplasia
  • Chemotherapy
 If your patient has concerning clinical symptoms, perform CBC + differential (with peripheral blood smear) and refer to hematology if significant persistent cytopenias or blast cells are noted.
Deep venous thrombosis (DVT) or pulmonary embolus (PE)
  • Tamoxifen
 Confirm with ultrasound of affected extremity (DVT) or CT for PE. Stop Tamoxifen and commence anticoagulation. Consult medical oncologist for direction.
Endometrial carcinoma
  • Tamoxifen
 Endometrial ultrasound, endometrial biopsy if abnormal vaginal bleeding. Stop Tamoxifen. Refer to gynecology and consult medical oncologist for direction. Routine surveillance ultrasounds in asymptomatic individuals are discouraged.
Osteopenia/ Osteoporosis
  • Aromatase inhibitors
 Bone density assessment (DEXA scan) and management as per OP guidelines.
 

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Specific Concerns for Breast Cancer Patients

Endocrine Therapy

  • The exact endocrine therapy regimen will be decided in consultation with your patient and communicated to your patient and yourself in a separate notation. If you and/or your patient have any questions in this regard, please contact your patient’s medical oncologist for additional clarification.
  • Once the patient is transferred from the cancer centre back to your care, you may write refill prescriptions for these medications to be dispensed through the cancer centre pharmacy or fax the prescription to the cancer centre for it to be mailed to the patient. Typically, endocrine therapy is prescribed for 5 years in total – however, selected patients may be offered extended duration of therapy beyond 5 years.
  • For patients with ER+ breast cancer who have been initiated on adjuvant endocrine therapy (e.g. either single agent or sequential agent – tamoxifen and/or aromatase inhibitor), encourage endocrine therapy adherence and assess for side effects and complications.
  • In patients with a previous history of invasive breast cancer and osteopenia/osteoporosis:
    • EVISTA® (raloxifene) should NOT be prescribed for management of osteopenia/osteoporosis.
    • In cases where osteopenia/osteoporosis treatment is indicated, consideration for an alternate bone targeted agent (e.g. bisphosphonate or RANK-ligand inhibitor) should be used instead.
  • Side effects of Tamoxifen and aromatase inhibitors (e.g., anastrozole, letrozole, exemestane) may occur in your patient.

More information about endocrine therapy, including side effects, is found in the Breast Cancer Transfer of Care Physician Letter.

Bisphosphonate Therapy

  • The exact bisphosphonate therapy regimen will be decided in consultation with your patient and communicated to your patient and yourself in a separate notation. If you and/or your patient have any questions in this regard, please contact your patient’s medical oncologist for additional clarification.
  • Some postmenopausal patients may be prescribed bisphosphonate therapy (clodronate 1600 mg po daily or zoledronic acid 4 mg IV every 6 months) for 2 to 5 years as part of their breast cancer treatment. 
  • Clodronate prescriptions need to be filled at a community pharmacy. Patients on adjuvant zoledronic acid will have appropriate lab monitoring and will be treated at the cancer centre. 
  • Given the small risk for osteonecrosis of the jaw, we counsel patients to inform their dentist of bisphosphonate therapy use prior to procedures and to see their dentist in the event of persistent mouth ulcer, or tooth or jaw pain. 

More information about bisphosphonate therapy is found in the Breast Cancer Transfer of Care Physician Letter.

Sexual Health

Information about Sexual Health concerns, such as menopause symptoms, self-image concerns and family planning, is found in the Breast Cancer Transfer of Care Physician Letter.

Genetic Counselling

Patients should be informed to report any changes in their family history to their physician.  All women from high-risk families should be offered a referral to genetic counselling. For more information, visit the Hereditary Cancer Clinic. 

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Note: The information on this page was adapted from the AHS Guideline Resource Unit's Follow-Up Care for Early-Stage Breast Cancer guideline, and the accompanying Breast Cancer Transfer of Care Physician Letter. Also available is the Breast Cancer Transfer of Care Patient Letter.