Rethinking clinical follow-up for breast cancer survivorship care: A narrative literature review.

e13797 Background: Breast cancer recurrence rates are declining with improvements in therapies. Earlier detection is facilitated by improvements in radiographic techniques, yet guidelines for clinical breast exam (CBE) remain the same. Current guidelines recommend follow-up visits with specialists every three to twelve months for the first five years after diagnosis then annually. More frequent follow-up visits provide unknown benefit while exacerbating financial toxicity for survivors and may delay care for new patients awaiting access to specialists. We sought to review and understand the evidence behind current recommendations to understand the utility of clinical surveillance for patients with low-risk breast cancer. Methods: We searched English-language PubMed sources, including randomized controlled trials (RCTs), retrospective cohort studies, systematic reviews, meta-analyses, cross-sectional studies, and guidelines. We focused on breast cancer surveillance after treatment, recurrence, follow-up schedules, costs of care, delays in treatment, and patient experience. The findings were synthesized thematically. Results: A review of the literature reveals mammography and breast self-exam are the primary methods of detection of local breast cancer recurrence. Of those detected by CBE, fewer than 1% were curable. Over half of local recurrences were identified outside of routine follow-up visits. Literature cites risk of local recurrence being 1% or less for most subtypes of breast cancer after three event-free years. Fewer than 10% of national follow-up guidelines are based on data from RCTs. Our review further reveals that 14% of survivors experience financial concerns and documents visit frequency exceeding guidelines. Many survivors report follow-up visits with multiple providers at a cadence that exceeds current guideline recommendations, regardless of treatment modality received. Comparing visits with specialists vs. primary care providers, both are rated as high-quality with no significant difference in health-related quality of life. Delays in time to surgery, radiation and/or systemic chemotherapy are associated with decreased survival. Conclusions: This literature review demonstrates limited benefit from frequent clinical surveillance and CBE. Clinical visits add expense to patients who are reporting increasing treatment-related financial toxicity. Although there is little level 1 evidence with which to redesign guidelines, this aggregate review of literature suggests modifications to current guidelines can decrease cost of care and potentially increase access for newly diagnosed patients without compromising patient satisfaction or outcomes. RCTs are needed in order to inform such modifications. Health systems must also work to improve coordination of care for in order to reduce redundancy in survivor follow-up care.