By Christine Harrell
Not all breast cancer patients carry the same risk of recurrence. Therefore, they do not all require the same type of post-treatment follow-up. In an effort to move away from a one-size-fits-all approach to follow-up care, the American Society of Clinical Oncology (ASCO) recently released updated guidelines establishing low-, intermediate-, and high-intensity surveillance strategies tailored to a patient’s individual risk of recurrence.
Zeina Nahleh, MD, FACP, Regional Vice Chief and Chair of the Department of Hematology-Oncology and Director of the Maroone Cancer Center at Cleveland Clinic in Florida, led the ASCO Expert Panel that published the new guidelines in the Journal of Clinical Oncology.
According to the update and in line with prior ASCO guidance, routine blood testing in patients with no clinical evidence of disease who are asymptomatic after treatment is not recommended due to a lack of evidence that testing for complete blood counts, tumor markers and chemistry panels improves outcomes.
Low-Intensity Surveillance
Patients with ductal carcinoma in situ who did not have or are off endocrine therapy, patients with stage I HR-positive breast cancer who are off endocrine therapy and any other systemic therapy after completion of treatment, and patients with triple negative (TNBC) or HER2-positive breast cancer at least five years from diagnosis may qualify for low-intensity surveillance.
Low-intensity surveillance recommendations include an in-person or virtual annual clinical visit managed by oncology survivorship clinics, oncology advanced practice providers, or other healthcare providers including gynecologists, or primary care physicians. Annual mammography is recommended for the first three years after treatment in patients who underwent breast-conserving surgery. Then, surveillance mammography can be offered every one to two years for patients 50 years and older with low-risk features and no recurrence three years after diagnosis.
Intermediate-Intensity Surveillance
Patients with stage I TNBC or HER2-positive breast cancer within the first five years from diagnosis, stage II or stage III TNBC with pathologic complete response after completion of neoadjuvant therapy, stage II or stage III HER2-positive breast cancer with pathologic complete response after completion of neoadjuvant therapy, and patients receiving ongoing endocrine therapy are among the patient populations included in intermediate-intensity surveillance.
Recommendations in this group include clinical follow-up every six to 12 months with oncology team or an oncology survivorship clinic for at least five years and up to 10 years after diagnosis, and annual mammography for patients treated with breast-conserving surgery or unilateral mastectomy. Following five years after diagnosis, patients can transition to management with a survivorship clinic with advanced practice providers or oncologists such as within routine primary care visits.
High-Intensity Surveillance
The high-intensity surveillance group includes higher-risk patients such as those with TNBC or HER2-positive breast cancer with residual disease after neoadjuvant chemotherapy and within five years of diagnosis, patients with TNBC or HER2-positive breast cancer continuing on active systemic therapy, patients with germline mutations, patients with inflammatory breast cancer and within 10 years of diagnosis and patients with hormone receptor-positive breast cancer on endocrine therapy plus CDK4/6 inhibitor therapy.
Recommendations for this group include clinical follow-up every three to six months for up to 10 years with the oncology team, annual mammography for patients who underwent breast-conserving surgery, and chest wall examinations every six months.
The updated guidelines do not recommend circulating tumor DNA testing as its utility in the clinical setting has not been proven. Supplemental imaging with MRI may be used in select patients as it may reduce interval cancers and should be utilized based on shared decision-making that considers patient and tumor characteristics (e.g., germ line mutation, invasive lobular cancer, heterogeneously or extremely dense breasts, etc.) and potential risk of incidental findings and false positive results. Other supplemental imaging options include contrast enhanced mammography or breast ultrasound. Routine imaging for distant metastases is not recommended in patients who have completed breast cancer treatment and are asymptomatic.
The updated guidelines emphasize collaboration and communication between the patient and healthcare team regarding all the above-mentioned recommendations as well as emotional support.
