Diagnostic testing is not indicated for this patient at this time. She had stage I breast cancer treated 3 years ago and has no worrisome symptoms and no abnormal findings on physical examination. In asymptomatic patients with a history of early breast cancer, routine imaging studies (excluding annual mammography) or blood tests, including tumor marker studies, are not beneficial. These tests have a 10% to 50% false-positive rate, leading to unnecessary studies and procedures. Two randomized trials showed no survival benefit from intensive screening with routine blood and imaging tests compared with clinical evaluation alone in asymptomatic patients. One of the trials showed a decreased quality of life in the group undergoing more intensive screening.

Patients with cancer in one breast are at higher risk for contralateral breast cancer (absolute risk 0.5% to 1.0% per year), although this risk is decreased by use of antiestrogen therapy. All women with a diagnosis of breast cancer should have annual mammograms. Breast MRI is only indicated for patients with BRCA1/2 mutations or other familial breast cancer syndromes or those with a very strong family history of breast cancer. None of these high-risk situations is present in this patient.

Except for patients with familial cancer syndromes, breast cancer survivors have no increased risks for other cancers except those related to certain treatments. Patients receiving adjuvant chemotherapy with cyclophosphamide and anthracyclines have a 0.5% risk of developing myelodysplasia and acute leukemia. Tamoxifen is associated with a 1/1000 per year risk of endometrial cancer in women over 55 years of age and a smaller risk of uterine sarcoma in this age group. These risks are low, however, and routine screening blood tests and imaging studies are not recommended in asymptomatic patients.

In addition to cancer surveillance, survivor issues that should be addressed at follow-up visits include menopausal symptoms (selective serotonin reuptake inhibitors that do not interfere with tamoxifen activation or gabapentin may be helpful), sexual dysfunction including dyspareunia due to vaginal dryness (lubricants and cautious use of very low-dose vaginal estrogen are options), arthralgia from antiestrogen therapy, cognitive dysfunction, depression, fatigue, weight gain, decreased bone density, cardiovascular disease due to radiation or chemotherapy, and thrombosis in patients taking tamoxifen.