Who Needs Closer Follow-Up After Breast Cancer?

Completing primary breast cancer treatment does not put every patient on the same follow-up schedule. A patient with residual disease after neoadjuvant chemotherapy may need closer oncology surveillance than someone with lower-risk disease years after treatment. ASCO’s updated guideline brings those differences into a risk-based framework for posttreatment care.¹

In an interview with Pharmacy Times, Danielle Roman, PharmD, BCOP, FHOPA, manager for clinical pharmacy services at Allegheny Health Network in Pittsburgh, Pennsylvania, described the update as a departure from a familiar approach.

“It really is categorizing patients based on their risk, and then establishing follow-up based on the risk of that particular patient,” Roman said. For pharmacists, understanding that framework can help explain why patients receive different follow-up plans and clarify when questions should return to the oncology team.

Match Follow-Up to the Patient

The guideline organizes surveillance into low-, intermediate-, and high-intensity approaches. Higher-risk circumstances include locally advanced disease and residual disease after neoadjuvant chemotherapy. Regular clinical assessment and mammography remain central to follow-up.¹

The recommendations also reflect an evidence gap. The guideline’s systematic review identified one randomized trial informing surveillance mammography, but no randomized trials comparing follow-up approaches according to relapse risk. The panel therefore used a formal consensus process to develop risk-based recommendations.¹

Examples in the high-intensity category include patients with triple-negative or HER2-positive disease who have residual disease after neoadjuvant chemotherapy and are within five years of diagnosis. Patients receiving endocrine therapy with a CDK4/6 inhibitor also fall within this category. Recommended clinical follow-up is generally every 3 to 6 months with the oncology team.²

Ongoing endocrine therapy alone is among the circumstances included in intermediate-intensity surveillance, with clinical follow-up every 6 to 12 months.² These distinctions make the current medication regimen relevant when pharmacists help patients understand their care plan.

Less Frequent Mammography Requires Careful Selection

Roman noted that the update challenges routine practices, including annual mammography for every survivor indefinitely. That flexibility applies to selected patients. For those aged 50 years or older with low-risk features who remain recurrence-free 3 years after diagnosis, surveillance mammography can be offered every 1 to 2 years. This is not a general recommendation to extend intervals for all survivors.²

The Mammo-50 randomized trial enrolled women aged 50 or older at diagnosis who were recurrence-free three years after curative surgery. Less frequent mammography meant every 2 years after breast-conserving surgery or every three years after mastectomy. Five-year breast cancer–specific survival was approximately 98.3% with less frequent surveillance versus 98.1% with annual surveillance, meeting the trial’s noninferiority criterion.³

Those eligibility criteria matter when discussing the findings. Patients should follow their individualized surveillance plan rather than independently postpone an examination.

Follow-Up Can Extend Beyond Oncology

“From a pharmacy perspective, I think one of the biggest things is just awareness that this guideline exists, so that we can help to educate patients and the health care team on appropriate follow-up and surveillance methods for patients,” Roman said.

Selected lower-risk patients can receive annual follow-up through survivorship services or other qualified clinicians, including primary care providers. In-person and virtual visits are options.² Roman highlighted the potential value of telehealth for eligible patients in rural settings.

Her comments point to a practical pharmacy role: helping patients understand who coordinates follow-up and directing surveillance questions to that clinician. A transition away from frequent oncology appointments should come with a clear explanation of how ongoing care will work.

ctDNA Remains a Research Question

Roman also highlighted growing patient interest in circulating tumor DNA (ctDNA). “We still don’t have prospective randomized clinical trials supporting use of ctDNA in this setting.”

Detecting recurrence risk does not establish that acting on a test result improves outcomes. ESMO’s precision medicine recommendations distinguish the prognostic value of molecular residual disease detection from evidence supporting treatment decisions based on those results.⁴

The prospective c-TRAK TN trial illustrates the challenge. Among patients allocated to intervention after ctDNA detection, approximately 72% already had metastases on staging scans. Only 5 began pembrolizumab (Keytruda; Merck), and none achieved sustained ctDNA clearance.⁵ The findings inform further research but do not establish a routine surveillance strategy.

For pharmacists answering patient questions, the distinction is consequential: ctDNA is being studied, while its clinical utility for routine posttreatment breast cancer surveillance remains unproven.^2,5

REFERENCES

1. Nahleh Z, Alfano CM, Somerfield MR, et al. Breast Cancer Follow-Up and Surveillance After Primary Treatment: ASCO Guideline Update. J Clin Oncol. 2026;44(30):2953-2971. doi:10.1200/JCO-26-01700

2. ASCO breast cancer guidelines. Cleveland Clinic. October 2, 2026. Accessed October 19, 2026. https://consultqd.clevelandclinic.org/asco-breast-cancer-guidelines

3. Dunn JA, Donnelly P, Elbeltagi N, et al. Annual versus less frequent mammographic surveillance in people with breast cancer aged 50 years and older in the UK (Mammo-50): a multicentre, randomised, phase 3, non-inferiority trial. Lancet. 2025;405(10476):396-407. doi:10.1016/S0140-6736(24)02715-6

4. Pascual J, Attard G, Bidard FC, et al. ESMO recommendations on the use of circulating tumour DNA assays for patients with cancer: a report from the ESMO Precision Medicine Working Group. Ann Oncol. 2022;33(8):750-768. doi:10.1016/j.annonc.2022.05.520

5. Turner NC, Swift C, Jenkins B, et al. Results of the c-TRAK TN trial: a clinical trial utilising ctDNA mutation tracking to detect molecular residual disease and trigger intervention in patients with moderate- and high-risk early-stage triple-negative breast cancer. Ann Oncol. 2023;34(2):200-211. doi:10.1016/j.annonc.2022.11.005