Skip to content
How It Works
Explore
Ask a Question Resources Pricing
Who It's For
Patients
Decode results, prep for appointments, weigh options.
Caregivers & advocates
Carry the research load for someone you love.
Providers & clinicians
Resources for patients in your practice.
Log In Ask a Question
PubMed This is a summary of 20 peer-reviewed journal articles Updated
Medical Oncology · Estrogen Receptor-Positive Breast Cancer

Survivorship, Monitoring, & Managing Side Effects

At a Glance

After treatment for ER-positive breast cancer, follow-up usually includes exams and yearly mammograms rather than routine scans in people without symptoms. Survivors may need help with hormone therapy side effects, bone health, and deciding whether treatment should continue beyond five years.

The transition from active treatment (like surgery and radiation) to long-term survivorship is a major milestone. For ER-positive (ER+) breast cancer, this phase is often described as a marathon rather than a sprint. Because this type of cancer has a persistent risk of returning 10, 15, or even 20 years later, survivorship focuses on three pillars: careful monitoring, managing the side effects of long-term hormone therapy, and deciding how long that therapy should last [1][2].

Your Surveillance Schedule

One of the most common surprises for survivors is that “more testing” is not necessarily better. Once you finish initial treatment, the goal of surveillance is to find a recurrence in the breast early, while avoiding unnecessary “false alarms” from body scans [3].

  • What IS recommended: A physical exam by your doctor every 6–12 months for the first five years, then annually [3]. You should also have an annual mammogram of the treated breast and opposite breast (or the remaining breast if you had a unilateral mastectomy) [3].
  • What IS NOT recommended: Standard guidelines (ASCO and NCCN) recommend against routine blood tests (like “tumor markers”), PET scans, CT scans, or bone scans for patients who do not have symptoms [3]. Research shows these scans do not help patients live longer and often lead to invasive biopsies for “spots” that turn out to be harmless [3].

When to call your doctor: Patients should contact their clinical team promptly about concerning new or persistent symptoms—such as a new lump, unexplained bone pain, or a persistent cough. Seek emergency care immediately for sudden neurologic deficits, severe shortness of breath, sudden chest pain, or a swollen, painful leg [2].

Managing Endocrine Side Effects

Taking a daily pill for 5 to 10 years can be challenging if the side effects impact your daily life. Fortunately, there are evidence-based ways to manage the most common issues:

Joint Pain (Arthralgia)

Aromatase inhibitors (AIs) can cause stiffness and pain, often worst in the morning.

  • Exercise: This is the most effective treatment. A 12-month program of aerobic exercise and strength training has been shown to significantly improve pain and function [4].
  • Acupuncture: Several trials have found that real acupuncture can reduce joint pain more effectively than “sham” (placebo) acupuncture [5][6].
  • Switching Drugs: If the pain is severe, your doctor may suggest switching to a different AI or to tamoxifen. Many patients find that their body reacts differently to different brands or types of hormone therapy [7][8].

Hot Flashes and Vaginal Symptoms

Systemic menopausal hormone therapy is generally avoided in ER-positive survivors. Non-hormonal options exist for hot flashes, including certain antidepressants (like venlafaxine or duloxetine); however, be sure to discuss drug interactions with your oncologist, especially strong CYP2D6-inhibiting antidepressants if you are taking tamoxifen [9]. For severe genitourinary symptoms, selected low-dose local vaginal treatments may sometimes be considered with oncology input when nonhormonal measures fail [10].

Bone Health

Aromatase inhibitors can thin your bones (osteopenia or osteoporosis). Your team will monitor this with a DEXA scan [11].

  • Bone-Protecting Drugs: Bisphosphonates (like zoledronic acid) may provide an adjuvant anticancer benefit for selected postmenopausal patients, whereas denosumab is mainly used for fracture prevention and requires a planned transition when stopped so you do not experience rebound bone loss [12][13].
  • An Added Benefit: For postmenopausal women, taking an adjuvant bisphosphonate may also lower the risk of the cancer spreading to the bones [14][15].

Deciding on ‘Extended’ Therapy: 5 Years or 10?

The standard length of endocrine therapy used to be 5 years. However, because of the long-term risk of ER+ cancer, many patients now consider staying on treatment for 7 or 10 years [16]. Two tools help you and your doctor make this decision:

  1. CTS5 Calculator: Uses your age, tumor size, grade, and nodal status, and is most applicable to selected patients disease-free after five years of endocrine therapy, estimating your risk of the cancer returning between years 5 and 10 [17][18].
  2. Breast Cancer Index (BCI): This is a specialized genomic test performed on your original tumor tissue. BCI can help predict possible benefit from extended endocrine therapy in selected patients [19][3].

If your BCI result is “Low Benefit,” you may be able to stop at 5 years, but this result does not by itself mean it is universally safe to stop [19][20]. This decision should always be a conversation that balances your personal clinical risk with your daily quality of life.

Common questions in this guide

How often should I have follow-up visits and mammograms after ER-positive breast cancer?
A physical exam is generally recommended every 6–12 months during the first five years and then once a year. An annual mammogram is recommended for the treated and opposite breast, or for the remaining breast after a unilateral mastectomy. Your oncology team may adjust this schedule for your circumstances.
Do I need routine CT scans, PET scans, or tumor-marker blood tests after treatment?
For people without symptoms, standard follow-up generally does not include routine tumor-marker blood tests, PET scans, CT scans, or bone scans. These tests can find harmless changes that lead to anxiety or invasive biopsies without improving survival. New or persistent symptoms may change what testing is appropriate.
What can help with joint pain caused by an aromatase inhibitor?
A program combining aerobic exercise and strength training can improve aromatase-inhibitor joint pain and function. Acupuncture may also help. If pain remains difficult, ask your oncologist whether changing to another aromatase inhibitor, switching to tamoxifen, or considering a medicine such as duloxetine is appropriate.
How is bone health monitored during aromatase inhibitor treatment?
A DEXA scan measures bone density and helps your care team monitor for osteopenia or osteoporosis. Selected postmenopausal patients may be offered a bisphosphonate such as zoledronic acid, which can also lower the risk of cancer spreading to bone. Denosumab is mainly used to prevent fractures and should be stopped only with a planned transition to reduce rebound bone loss.
Should I take endocrine therapy for five years or extend it to 10 years?
Some people with ER-positive breast cancer consider 7 or 10 years of endocrine therapy because recurrence can happen many years after treatment. The CTS5 calculator estimates late-recurrence risk using factors such as age, tumor size, grade, and lymph-node status, while the Breast Cancer Index may help predict benefit from extended therapy. These results support a shared decision with your doctor and do not by themselves determine whether it is safe to stop.
Which symptoms should prompt a call to my doctor after breast cancer treatment?
Contact your clinical team promptly about a new lump, unexplained bone pain, or a cough that does not go away. Seek emergency care for sudden neurologic changes, severe shortness of breath, sudden chest pain, or a leg that is swollen and painful. These symptoms do not prove recurrence, but they should be assessed.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Based on my specific diagnosis (tumor size, grade, and nodes), what is my score on the CTS5 calculator for late recurrence risk?
  2. 2.Am I a candidate for the Breast Cancer Index (BCI) test to see if I would actually benefit from taking endocrine therapy for 10 years instead of 5?
  3. 3.Since I am on an aromatase inhibitor, when should my next DEXA bone density scan be scheduled, and do I need a 'bone-protecting' medication like a bisphosphonate?
  4. 4.If my joint pain becomes difficult to manage with exercise, would you recommend switching to a different aromatase inhibitor or trying a medication like duloxetine?
  5. 5.Are there specific symptoms I should watch for that would trigger a scan, since we aren't doing 'routine' full-body imaging?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (20)
  1. 1

    20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 Years.

    Pan H, Gray R, Braybrooke J, et al.

    The New England journal of medicine 2017; (377(19)):1836-1846 doi:10.1056/NEJMoa1701830.

    PMID: 29117498
  2. 2

    Ongoing Symptoms and Concerns Experienced by Low-Risk Breast Cancer Survivors Following Active Treatment.

    Schumacher JR, Tucholka JL, Breuer CR, et al.

    Annals of surgical oncology 2025; (32(5)):3252-3259 doi:10.1245/s10434-025-16959-w.

    PMID: 39881007
  3. 3

    Biomarkers for Adjuvant Endocrine and Chemotherapy in Early-Stage Breast Cancer: ASCO Guideline Update.

    Andre F, Ismaila N, Allison KH, et al.

    Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2022; (40(16)):1816-1837 doi:10.1200/JCO.22.00069.

    PMID: 35439025
  4. 4

    Endocrine-related quality of life in a randomized trial of exercise on aromatase inhibitor-induced arthralgias in breast cancer survivors.

    Baglia ML, Lin IH, Cartmel B, et al.

    Cancer 2019; (125(13)):2262-2271 doi:10.1002/cncr.32051.

    PMID: 30840336
  5. 5

    Effect of Acupuncture vs Sham Acupuncture or Waitlist Control on Joint Pain Related to Aromatase Inhibitors Among Women With Early-Stage Breast Cancer: A Randomized Clinical Trial.

    Hershman DL, Unger JM, Greenlee H, et al.

    JAMA 2018; (320(2)):167-176 doi:10.1001/jama.2018.8907.

    PMID: 29998338
  6. 6

    Acupuncture and Vitamin D for the Management of Aromatase Inhibitor-Induced Arthralgia.

    Anand K, Niravath P

    Current oncology reports 2019; (21(6)):51 doi:10.1007/s11912-019-0795-1.

    PMID: 30997616
  7. 7

    Current and future advances in practice: aromatase inhibitor-induced arthralgia.

    Kim S, Chen N, Reid P

    Rheumatology advances in practice 2024; (8(2)):rkae024 doi:10.1093/rap/rkae024.

    PMID: 38601139
  8. 8

    Supportive care of women with breast cancer: key concerns and practical solutions.

    Zdenkowski N, Tesson S, Lombard J, et al.

    The Medical journal of Australia 2016; (205(10)):471-475 doi:10.5694/mja16.00947.

    PMID: 27852186
  9. 9

    Q-122 as a novel, non-hormonal, oral treatment for vasomotor symptoms in women taking tamoxifen or an aromatase inhibitor after breast cancer: a phase 2, randomised, double-blind, placebo-controlled trial.

    Vrselja A, Latifi A, Baber RJ, et al.

    Lancet (London, England) 2022; (400(10364)):1704-1711 doi:10.1016/S0140-6736(22)01977-8.

    PMID: 36366886
  10. 10

    Adverse Events and Perception of Benefit From Duloxetine for Treating Aromatase Inhibitor-Associated Arthralgias.

    Schnell PM, Lustberg MB, Henry NL

    JNCI cancer spectrum 2021; (5(2)) doi:10.1093/jncics/pkab018.

    PMID: 33842832
  11. 11

    Management of Aromatase Inhibitor-Associated Bone Loss (AIBL) in postmenopausal women with hormone sensitive breast cancer: Joint position statement of the IOF, CABS, ECTS, IEG, ESCEO IMS, and SIOG.

    Hadji P, Aapro MS, Body JJ, et al.

    Journal of bone oncology 2017; (7()):1-12 doi:10.1016/j.jbo.2017.03.001.

    PMID: 28413771
  12. 12

    Adjuvant denosumab in breast cancer (ABCSG-18): a multicentre, randomised, double-blind, placebo-controlled trial.

    Gnant M, Pfeiler G, Dubsky PC, et al.

    Lancet (London, England) 2015; (386(9992)):433-43.

    PMID: 26040499
  13. 13

    Bone modifying agents for bone loss in patients with aromatase inhibitor as adjuvant treatment for breast cancer; insights from a network meta-analysis.

    Miyashita H, Satoi S, Kuno T, et al.

    Breast cancer research and treatment 2020; (181(2)):279-289 doi:10.1007/s10549-020-05640-3.

    PMID: 32318956
  14. 14

    Adjuvant bisphosphonate treatment in early breast cancer: meta-analyses of individual patient data from randomised trials.

    Lancet (London, England) 2015; (386(10001)):1353-1361 doi:10.1016/S0140-6736(15)60908-4.

    PMID: 26211824
  15. 15

    Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Breast Cancer: ASCO-OH (CCO) Guideline Update.

    Eisen A, Somerfield MR, Accordino MK, et al.

    Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2022; (40(7)):787-800 doi:10.1200/JCO.21.02647.

    PMID: 35041467
  16. 16

    Pembrolizumab and chemotherapy in high-risk, early-stage, ER+/HER2- breast cancer: a randomized phase 3 trial.

    Cardoso F, O'Shaughnessy J, Liu Z, et al.

    Nature medicine 2025; (31(2)):442-448 doi:10.1038/s41591-024-03415-7.

    PMID: 39838117
  17. 17

    Integration of Clinical Variables for the Prediction of Late Distant Recurrence in Patients With Estrogen Receptor-Positive Breast Cancer Treated With 5 Years of Endocrine Therapy: CTS5.

    Dowsett M, Sestak I, Regan MM, et al.

    Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2018; (36(19)):1941-1948 doi:10.1200/JCO.2017.76.4258.

    PMID: 29676944
  18. 18

    Overestimation of Late Distant Recurrences in High-Risk Patients With ER-Positive Breast Cancer: Validity and Accuracy of the CTS5 Risk Score in the TEAM and IDEAL Trials.

    Noordhoek I, Blok EJ, Meershoek-Klein Kranenbarg E, et al.

    Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2020; (38(28)):3273-3281 doi:10.1200/JCO.19.02427.

    PMID: 32706636
  19. 19

    Breast Cancer Index and prediction of benefit from extended endocrine therapy in breast cancer patients treated in the Adjuvant Tamoxifen-To Offer More? (aTTom) trial.

    Bartlett JMS, Sgroi DC, Treuner K, et al.

    Annals of oncology : official journal of the European Society for Medical Oncology 2019; (30(11)):1776-1783 doi:10.1093/annonc/mdz289.

    PMID: 31504126
  20. 20

    Comparison of the Performance of 6 Prognostic Signatures for Estrogen Receptor-Positive Breast Cancer: A Secondary Analysis of a Randomized Clinical Trial.

    Sestak I, Buus R, Cuzick J, et al.

    JAMA oncology 2018; (4(4)):545-553 doi:10.1001/jamaoncol.2017.5524.

    PMID: 29450494

This page is for informational purposes only and does not constitute medical advice. Your oncology team should tailor surveillance, side-effect treatment, bone-health care, and endocrine-therapy duration to your situation.

Get notified when new evidence is published on estrogen-receptor positive breast cancer.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.