Ask the Doctor: What Should Follow-Up Treatment Include?

Q: I finished breast cancer treatment two years ago. What should my follow-up care include? How should I be checked for metastasis?

Daniel Budman, M.D., professor of medicine at New York University, and associate director of medical oncology at North Shore University Hospital in New York, says that there are no good guidelines about how often patients should see their doctors after treatment for breast cancer ends. Budman is a member of the Board of Governors of The Cancer and Leukemia Group B, a National Cancer Institutesponsored network of more than 3,000 oncology specialists nationwide, who collaborate on developing new strategies for the early detection and prevention of cancer.

Most doctors follow national protocols, he says. They see their patients three to four times a year for the first several years, then less often after time goes on. They do more physical exams in the beginning and some do screening blood work too. If abnormalities are noted, then further testing is done.

“Most doctors insist on imaging studies such as mammography and, in certain instances, breast MRI as well,” he says. “While mammography and sonography (ultrasound) are the standard tools used for imaging studies and are used both to screen women without cancer and after having breast cancer, MRIs may be recommended for individuals who have a strong family history for breast cancer.”

They also may be recommended for individuals known to have a predisposing genetic abnormality, such as a BRCA mutation, or have had a prior breast cancer not identified by mammography or sonography. These imaging studies allow specialists the possibility to visually glimpse the formation of a lump, once it gets to a certain size—even if it is too small to feel.

For follow up after treatment of a breast cancer, if the patient has bone pain, or has abnormal bone enzyme levels in her blood, then a bone scan or a CAT scan may be recommended as well. But bone scans and CAT scans are not useful for routine screening in the totally asymptomatic patient, he says.

“Unfortunately,” Budman adds, “these are all crude tests. The tumor needs to grow to a size that can be seen on these imaging tests, which implies that the lump may have millions of cancer cells.”

There has been considerable change during the last 10 years from standard scanning and determination of tumor markers in the blood in asymptomatic individuals to finally realizing that these tests yield a very low chance of early detection. “It is now recognized that there are tremendous limitations on our ability to pick up cancer early—whether it be by scans, blood work, examinations or any way you want to look at it.”

The standard guidelines about how often patients should see their physicians were arbitrarily set, Budman points out, “because there is no great way to check for metastasis at this time.”

As disturbing as these comments are, Budman reports a tremendous change in our understanding of breast cancer in recent years. He says that we now know there are at least five distinct subtypes of breast tumors that arise from different cell types.

“These different types of breast cancer behave differently biologically. Some respond better to hormone therapy, some respond to chemotherapy; some progress slowly, others rapidly. What this means is that the way we are following patients today is probably not the way we will be following patients in the future. Over the next three to four years, we are going to see an explosion of knowledge in this field. Now we have to go back and rethink how we are treating and following up with people.

“This is an evolution, because the more we learn about subtypes, the more we are going to be able to target our therapy better and make it more specific—depending upon that subtype,” he says. “We don’t have a good handle on it yet, but it’s coming.”

We are literally on the threshold of a new era in treating breast cancer. The introduction of exciting new DNA and protein tools is opening the door not just to highly targeted therapies to treat breast cancer more effectively—but maybe to detect breast cancer in its earliest stages, even before it is a lump that can be felt.

Budman explains that The National Cancer Institute has some studies suggesting that by looking at the protein patterns in blood, they may be able to pick up ovarian cancer early. There are similar early studies looking at breast fluid. He predicts that if the experimental research tools they are using for ovarian cancer are dependable in a clinical setting, then we are going to see these tools used with other cancers as well — including breast cancer.

“We’ve never had the potential ability to understand these diseases before,” Budman says.

“This is changing so fast, it’s fascinating,” he continues. “Finally, something is happening.”

This article is from Lifeline.

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