With increasing incidence and rising survival there is a growing population of breast cancer survivors in Australia. Cancer Australia guidelines recommend a minimum follow-up incorporating seven visits over the first five years, based on level IV evidence, making this a substantial consumer of medical resources. Accepted components include regular histories, examination and annual mammography. We have assessed the value of these individual elements of follow-up through a review of relapse detection mechanisms.
We examined the method of detection and mode of recurrence for 241 women (12.5%) relapsing from an initial observed population of 1942 patients with estrogen receptor positive early breast cancer. Data was obtained from a multidisciplinary breast service database with further information accrued from medical records and death certification.
Relapses included 44 local, 20 regional, 51 contralateral (likely new primary), and 168 distant events. 147 (60%) patients recurred within five years, 75 (31%) between five and 10 years and 21 (9%) after 10 years. Mode of recurrence detection was available on 195 cases and included 21 (11%) detected in routine clinics, 113 (58%) by patient self-detection and early presentation, and 45 (23%) by routine mammography. 64%, 88% and 0% of such cases involved metastatic disease at first relapse. Eight clinic-detected events involved symptom investigation and 13 were locoregional recurrences found on examination, with five of the latter surviving. Initial treatment was endocrine in 55%, chemotherapeutical in 36% and radiotherapeutical in 7%. 2% of patients received best supportive care alone. In seven of the 195 cases relapse detection at an advanced stage potentially limited therapy.
Overall only one in 10 recurrences were detected by routine follow-up processes, the majority of relapses being diagnosed following self-presentation with symptoms or through mammography. For the purposes of relapse detection, systems of routine mammographic surveillance and patient-driven symptom investigation should take precedence over routine clinic visits.