At a certain point in time after a patient with resected early-stage breast cancer has completed their adjuvant therapy (either chemotherapy and/or radiation therapy) at the cancer centre, they can be safely transitioned back to the care of their primary health care provider (PHCP) for ongoing routine breast cancer surveillance.
The goals of follow-up care for patients with early-stage breast cancer are to detect recurrent or new breast cancer, to monitor for and manage side effects of any adjuvant therapy (chemotherapy, endocrine therapy, biologic therapy, and/or radiation therapy) and to provide ongoing patient support, including patient education, reassurance, and psychosocial support.
To meet these surveillance goals, an evidence-based strategy for follow-up should be included in the patient's overall care plan. Most patients do not require follow-up at the tertiary cancer centres for ongoing routine breast cancer surveillance. Compared to follow-up at the tertiary cancer centre, it is known that follow-up care provided by PHCP is equivalent in terms of long term breast cancer outcomes (recurrence/survival and quality of life). 1 Moreover, patient satisfaction may be higher for some with follow-up care provided in general practice compared to hospital outpatient departments 2 and there are no significant increases in the workload of PHCPs. 3 Assuming that a shared approach is appropriate for the follow-up care of patients who were treated for early-stage breast cancer, the purpose of this guideline is to provide evidence-based strategies for the care of patients who have been discharged to their PHCP. As such, this guideline should enable physicians to provide follow-up care to their patients and ensure that essential elements are communicated to the patient in a practical format. o There is no evidence to support the use of BSE as a cancer screening method, and therefore it's not recommended for the average-risk population. For more information, please refer to Alberta's Breast Cancer Screening Guideline. (Level of Evidence: I 4 V 5,6 Strength of Recommendation: C) - Clinical Examination o History and physical examination of the breast(s), chest wall +/-reconstructed breast, and supraclavicular and axillary nodes. Also consider assessing arms for lymphedema, especially if axillary nodal dissection or regional nodal irradiation. (Level of Evidence: II 1, 7, 8 V 7,8 Strength of Recommendation: A)  Frequency: every 6 months for 2 years, then annually. - Imaging Tests (for patients with breast tissue or who have undergone breast conserving surgery)
- Mammography: post-treatment mammogram of intact breast(s) 1 year after diagnostic mammogram (or 6+ months post-definitive radiotherapy), then annually; performed at an accredited mammography centre. Mammography of an entirely reconstructed breast (autologous or implant) is not recommended as there is no significant residual natural breast tissue to image. Routine breast cancer screening with breast MRI is not indicated.
(Level of Evidence: V 9, 10 Strength of Recommendation: C) Supplemental breast ultrasound can be added to mammography in the setting of extremely dense breast tissue (American College of Radiology category D) and/or at the discretion of the reading radiologist. (Level of Evidence 11,12 Strength of Recommendation: C) Women at higher risk of breast cancer may benefit from tomosynthesis in addition to regular digital mammography during screening, however, it is not recommended for use on its own. (Level of Evidence:V 5,12  - Patients should be counselled on symptoms of potential recurrence and when to report them (i.e., new lumps, bone pain, chest pain, persistent headaches, dyspnea, or abdominal pain). - Table 1 describes signs and symptoms that may suggest recurrence. Patients presenting with any of these symptoms should undergo the appropriate investigations.
- If at any time the physician has concerns regarding possible local, regional, or metastatic recurrence this should be investigated as clinically indicated. - For referral back to the Cancer Centre, please contact the appointment booking office at the Cancer Centre to arrange to see the patient. - Should the physician have any specific or more pressing concerns, one of the oncologists in radiation oncology or medical oncology can be available to discuss the patient's case. To find an oncologist: o Specialist Link (Calgary/Southern Alberta) o ConnectMD (Edmonton/Northern Alberta) - For any emergent concerns, patients should be directed to the nearest emergency department for immediate evaluation and intervention. o The Oncologic Emergencies Guideline will outline common emergent concerns.

# Potential complications from cancer treatment.
General considerations for all patients:
- Long-term follow-up care is important for patients after breast cancer therapy, for cancer surveillance, medication adherence, side effect management, and general patient support. - For any patient with a history of previous breast cancer, the use of exogenous estrogens (such as oral contraceptives or hormone replacement therapy) is generally contraindicated. (Level of Evidence V, Strength of Recommendation: D)

# Endocrine therapy (Level of Evidence V, Strength of Recommendation, B):
- Intended treatment duration and/or endocrine therapy treatment plan will be outlined by the oncology team. - Initial prescription will be written and dispensed at the cancer centre.
- Further prescription will be obtained through the patient's PHCP. Prescription for endocrine therapy can be faxed to and dispensed by the cancer centre pharmacy (free of charge to the patient) for medications to either be picked up or mailed to the patient. - Adherence to adjuvant endocrine therapy should be routinely assessed and encouraged on each follow-up visit. - The oncology team may request re-referral to cancer centre after 2-5 years for discussion of potential switch in endocrine therapy (i.e., tamoxifen to an aromatase inhibitor) and/or for discussion of extended endocrine therapy (beyond 5 years). The request for re-referral will be indicated in the note from oncologist or delegate at the time of transition.
- Common side effects of tamoxifen include hot flashes and vaginal discharge.
- Patients receiving tamoxifen are at a slightly increased risk of more serious adverse events such as deep vein thrombosis, stroke, endometrial cancer, and cataracts. - Investigations and referrals should be performed as per signs and symptoms. For example, women with abnormal vaginal bleeding should have a pelvic ultrasound and be referred to gynecology. Concurrent use of CYP2D6 inhibitors can disrupt tamoxifen metabolism. Strong CYP2D6 inhibitors to be aware of include bupropion (Wellbutrin), fluoxetine (Prozac), paroxetine (Paxil), and quinidine (Quinidex). (Level of Evidence: V  Strength of Recommendation, C) Aromatase Inhibitors (AIs).
- Common side effects of AIs (i.e., anastrozole, letrozole, exemestane) include arthralgias, myalgias, dyspareunia, vulvovaginal atrophy, and hot flashes.
- Some postmenopausal patients will have had zoledronic acid IV q6 monthly x 2-5 years prior to discharge or be on clodronate as part of their treatment plan (to help reduce risk of recurrence to bone and improve overall survival above and beyond other treatments). (Level of Evidence:II 22 Strength of Recommendation, B) - Intended bisphosphonate treatment plan will be outlined by the oncology team.
- While zoledronic acid would have been administered at the cancer center, clodronate is an outside prescription that is filled in the community pharmacies.

# Peripheral Neuropathy:
- Certain types of chemotherapy may cause peripheral neuropathy. Visit the Chemotherapy Induced Peripheral Neuropathy guideline for more information on screening, assessing, and managing peripheral neuropathy.
- Lymphedema of the arm is a possible complication of breast cancer treatment. It occurs more frequently with mastectomy, axillary lymph node dissection, and radiation therapy. - Physicians should counsel survivors on how to prevent/reduce the risk of lymphedema, including weight loss for those who are overweight or obese. (Level of Evidence V 8 Strength of Recommendation, B) - The Alberta Lymphedema Association recommends Combined Decongestive Therapy (CDT) as best practice for the treatment of lymphedema 23. CDT consist of manual lymph drainage, compression therapy, education, exercise, and skin care. (Level of Evidence V 23,24 Strength of Recommendation: B):
- Manual lymph drainage: A specialized type of massage. The use of massage helps to move lymph fluid out of the affected limb to functioning lymph nodes for drainage. 24 Compression therapy: a technique that uses garments, bandages, or gradient pumps to compress the affected limb and move lymph fluid towards the torso. 24 Compression therapy may be combined with manual lymphatic drainage and/or physical therapy. - Exercise: To promote lymphatic flow. Use of muscle contractions of the affected limb to facilitate the drainage of lymph fluid; strenuous exercises should typically be avoided. 24 - Skin care: to prevent infection.
- There is no current evidence to support the use of medical therapies such as diuretics. (Level of Evidence:V 25 Strength of Recommendation: C) - Referral should be considered to lymphedema management services.
- For primary lymphedema, refer to the Calgary Ambulatory Lymphedema Service in Calgary and the CRIS Lymphedema Clinic in Edmonton. - For secondary lymphedema caused by cancer and/or cancer treatment, refer to Rehabilitation Oncology.

# Cardiac Dysfunction:
- Cardiac dysfunction is an increasingly rare complication but can still occur in some patients undergoing adjuvant treatment (e.g., anthracycline-based chemotherapy or trastuzumab or leftsided breast/chest wall adjuvant radiation therapy).

# Development and Revision History
This guideline was reviewed and endorsed by the Alberta Provincial Breast Tumour Team. Members include surgical oncologists, radiation oncologists, medical oncologists, nurses, pathologists, and pharmacists. Evidence was selected and reviewed by a working group comprised of members from the Alberta Tumour Teams, external participants identified by the Working Group Lead, and a methodologist from the Guideline Resource Unit. A detailed description of the methodology followed during the guideline development process can be found in the Guideline Resource Unit Handbook. This guideline was first developed in 2011 and updated in 2015 and 2021.

# Levels of Evidence