So you are breast cancer-free. Now what?
After all the nausea and vomiting, hair loss, weight gain, weakness and fatigue, the cancer is no longer detectable in your body. But it does not stop there.
Breast cancer – like any other cancer – has a chance of recurring, even if you're currently in remission. It is, therefore, important to have the correct follow-up procedure to guard against recurrence.
A good follow-up regime
Many breast tumours are harmless but there are four main types of malignant tumours that require specific clinical courses and procedures.
“A ‘one size fits all’ approach to the follow-up care of breast cancer is not acceptable anymore,” according to Professor Justus Apffelstaedt, Head of the Breast Clinic at Tygerberg Hospital and Associate professor of Surgery at the University of Stellenbosch.
“Customised follow-up protocols that are adapted to the specific cancer types are essential for early detection of a recurrence.
“Therefore, to detect recurrence early and to maintain your quality of life, it is important to adhere to a good follow-up regime.”
The four main tumour types
Prof Apffelstaedt distinguishes between these four types of tumours:
1. HER2 type: Human Epidermal growth factor Receptor 2 (HER2) is an excessive number of HER 2 receptors or copies of the HER2 gene. The HER2 gene makes a protein that is found on the cancer cell causing the tumour growth. The patient should undergo a clinical examination every four months for the first five years, after which an annual check-up is required.
2. Luminal A type is the most common type, affecting over four in 10 women with breast cancer. Luminal A type is exclusively dependant on oestrogen and can recur after long intervals. The patient should undergo a clinical examination every six months for the first two years. Thereafter, it can be done annually.
3. Luminal B type is dependent on oestrogen and sensitive to chemotherapy, and about one in five cancers are Luminal B types. The patient should continue clinical examinations every four months for the first three years and then every six months for the next two years. After the five years, the patient will need a check-up once a year.
4. Triple Negative type: Here the three most common types of receptors known to fuel breast cancer growth, namely oestrogen, progesterone, and HER2 are not present in the tumour. These cancers typically respond well to chemotherapy. The patient should undergo a clinical examination every four months for the first three years and one every six months for the following two years. After five years, the patient will need a check-up once a year.
“There is no scientific evidence that any follow-up regime is superior to another and that the detection of recurrence in asymptomatic patients by way of intensive – and expensive – imaging tests prolongs survival,” said Prof Apffelstaedt. “On the contrary, early treatment of asymptomatic recurrence will decrease quality of life of the patient due to the knowledge that she has recurrence and side effects of the treatment.”
Prof Apffelstaedt explains that there is value in doing any of the other frequently ordered imaging tests such as chest X-rays, ultrasounds of the abdomen, bone scans or any blood tests for "cancer markers" in asymptomatic patients.
It is therefore important to find a balance between scientific medical evidence; the fear of recurrence and confirmation that patients are cancer free; affordability of healthcare; and constraints of healthcare providers to provide care during follow-up procedures.
“Patients should only undergo diagnostic procedures if they develop symptoms”, said Prof Apffelstaedt.
“Not adhering to regular follow-ups by a service with a specific interest means that symptoms may be missed and patients are for prolonged periods experiencing disabling symptoms before undergoing appropriate diagnostics and treatment.”
Quality of life
A recent research project at the Breast Clinic at Tygerberg Hospital found that the vast majority of patients – over 80% – treated by Prof Apffelstaedt and his team were “alive and well after more than seven years after their initial treatment”.
This achievement came at the cost of extended treatment, said Prof Apffelstaedt.
"The majority of breast cancer patients now receive treatment to prevent recurrence for a minimum of five years and up to 10 years,” said Prof Apffelstaedt.
This exposes breast cancer patients to the side effects of the treatment.
“Therefore, while most oncologists focus on the diagnosis of recurrence, we have shifted our focus to the management of side effects of such prolonged therapy and much more importantly to the quality of life.”