Dr. MJ Bazos MD, Patient Handout
Follow-up care after Breast Cancer Treatment

My treatment for breast cancer is almost finished. Will I need further medical care?

Everyone who has had treatment for breast cancer should continue to visit the doctor regularly for the following reasons:

• To receive ongoing support. Your first visit after treatment will give you an opportunity to discuss problems, deal with any side effects of treatment and help you to find emotional or social support if you need it. You will also work out a schedule with your doctors for long-term care.

• To establish your current health status. About 4 to 6 months after treatment, when inflammation in your breast has settled down, you can expect to have mammography and a physical examination. This will show where you stand after treatment and serves as a “baseline” for comparison if changes occur at any time in the future. If you do not already practise breast self-examination, you may want to learn this technique now.

• To detect problems early. Cancer can return in the same breast, or a new one can start in the other breast. If this occurs, regular physical examination and mammography will help detect it at an early stage.

Who will be responsible for my follow-up care?

On your early visits, you will usually see the specialist(s) who have supervised your treatment: the surgeon, the medical oncologist or the radiation oncologist. At first, some or all of them may wish to see you. Later, with your participation and agreement, responsibility may be transferred to one of them or to your family doctor. The important thing is that the members of your medical team coordinate your care. They should keep you fully informed, and you should know exactly what follow-up arrangements have been made and who is responsible for carrying them out.

How often should I visit the doctor?

Canadian treatment centres often recommend visits every 6 months for 2 to 5 years after surgery. However, no one schedule has been proved best for everyone, and the timing should be adjusted to your own needs. You may wish to make additional visits if you need further advice or support, or if a new problem comes up. It is recommended that yearly visits continue for life.

What will happen on my followup visits?

Every visit should include an updating of your medical history and a physical examination. Yearly visits should also include mammography.

• Medical history. Your doctor will want to know about any side effects of treatment such as swelling or tenderness in your breasts, stiffness in your shoulder or swelling in your arm since your last visit. If you’re taking tamoxifen as part of your treatment and haven’t had a

hysterectomy, you should tell your doctor if any vaginal bleeding (even slight spotting) has occurred. This is because the risk of endometrial cancer (cancer in the lining of the uterus) is slightly higher for women taking tamoxifen.

• Physical examination. The main purpose of this examination is to look for recurrence of cancer and for new cancers in either breast. Your doctor will examine both breasts, the lymph nodes in the armpit and collarbone areas, the chest wall and the abdomen. Your arm will also be examined for “lymphedema” (swelling of the arm due to a build-up of lymphatic fluid, which can occur after removal of armpit lymph nodes) or any infection associated with it.

Shouldn’t I have regular tests to make sure the cancer hasn’t come back somewhere else?

No. The only regular test you need is mammography. Regular mammography is recommended to detect any return of cancer in the same breast or any new cancer in the opposite breast. The chance of a cure is better when these cancers are found early. If cancer does spread to other parts of the body, life expectancy is the same whether it is detected early or not. So routine use of other tests — such as bone and liver scanning, chest x-rays, blood tests and tests for tumour markers — is unnecessary and not recommended.

What if I get new symptoms or feel something is wrong between
visits?

After treatment for breast cancer, many women will experience pain or other unpleasant symptoms. If these problems come and go, or disappear within a week or so, they are very unlikely to be related to cancer. However, sometimes a problem does not go away. If you have any new, persistent symptoms, you should report them immediately, without waiting for your next regular appointment. Such symptoms may include the following:

• new, persistent pain,
• persistent coughing,
• discovery of a lump in either breast,
• unusual changes at the site of your surgery or in the scar itself,
• a persistent tired feeling,
• loss of appetite,
• tingling or numbness in the arm or hand,

• swelling of the arm (even slight swelling can signal lymphedema, which can be painful and is often easier to treat if recognized early) or

• any new symptom that is unusual, severe or persistent.

I would like to find someone to talk over these issues with, between visits to my doctor.

Support of this sort can be valuable in addition to any comfort it may give.

I’ve had breast cancer treatment, and now I’m having pain. Does this mean the cancer has come back?

The cause of the pain will have to be investigated because the pain may be from some other source that has nothing to do with breast cancer or its treatment. Or it may be a result of the surgery, radiotherapy or chemotherapy you have had. A third possibility is that the cancer has returned.

What types of pain may come from surgery?

One cause of pain is the “postmastectomy syndrome.” This occurs because removal of a lump can damage nerves in the area. This problem is more common after a total mastectomy (removal of the whole breast) but can also follow a lumpectomy (removal of just the cancer), especially if you’ve also had lymph nodes removed in the armpit area. Usually, this type of pain is not severe and will gradually improve. Swelling of the arm (lymphedema) is another condition that can cause discomfort and pain. Removal of lymph nodes from the armpit during surgery can damage the channels which drain lymph from the arm. This leads to swelling and can be painful, especially if the arm becomes infected.

Could my pain be related to anticancer drugs?

Some drugs may cause painful conditions, including bladder inflammation (cystitis), numbness and tingling (peripheral neuropathy), mouth ulcers (mucositis) and aching joints. Taking drugs intravenously may also cause painful inflammation of the veins (phlebitis).

What about pain caused by cancer?

One type of pain is called “brachial plexopathy.” A burning or stabbing pain is felt in the arm, shoulder or hand when these areas are touched, or they may feel “different” — either numb or very sensitive. There may also be weakness in the arm, especially if the pain has been going on for a long time. This pain usually means that cancer has come back in the lymph nodes behind the collarbone. Rarely, this kind of pain may be just a side effect of radiotherapy or surgery. Careful investigation is necessary to rule out cancer, although your doctor may be able to provide some reassurance by pinpointing which nerves are involved. This is because cancer usually attacks some nerve branches and not others. Pain due to cancer is often centred around the shoulder and seems to spread to the elbow, the forearm and the fourth and fifth fingers. Persistent pain in the bones is often a signal that the cancer has recurred and is spreading. If you have lasting pain at any time, you should consult your doctor immediately. Although the bones are the most common site in which cancer returns (metastasizes), pain can also occur from cancer spreading to the nerves and other organs.

Should medication get rid of all my pain?

If the pain is caused by cancer, anticancer treatment such as radiotherapy or chemotherapy may give you the relief you need. Otherwise, anti-pain medications can usually provide good pain control.

The medication should be chosen in such a way that the pain is controlled rapidly and completely.