Baseline staging tests after a new diagnosis of breast cancer: further evidence of their limited indications

Diagnostic yield of contrast-enhanced abdominal staging CT in patients with initially diagnosed breast cancer

PURPOSE

To estimate the diagnostic yield (DY) of abdominal staging CT for detecting breast cancer liver metastasis (BCLM) in patients with initially diagnosed breast cancer and to determine the indications for abdominal staging CT.

METHODS

Patients with newly diagnosed breast cancer who underwent abdominal CT as an initial staging work-up between January 2019 and December 2020 were retrospectively analyzed. DY was calculated and analyzed according to patient age, type of treatments, histologic type, histologic grade, lymphovascular invasion, Ki-67 status, hormone receptor status, subtype, and the American Joint Committee on Cancer anatomical staging.

RESULTS

A total of 2056 patients (mean age, 51 ± 11 years) were included. The DY of abdominal staging CT for detecting BCLM was 1.1 % (22 of 2056). DY was significantly higher in stage III than in stage I or II cancers (3.9 % [18 of 467] vs. 0 % [0 of 412] or 0.4 % [4 of 1158], respectively, p < .001), and in human epidermal growth factor receptor-2 (HER2)-enriched cancers than in luminal or triple negative cancers (2.9 % [16 of 560] vs. 0.4 % [4 of 1090] or 0.5 % [2 of 406], respectively, p < .001).

CONCLUSIONS

The DY of abdominal staging CT for detecting BCLM was low among all patients with initially diagnosed breast cancer. However, although abdominal staging CT for detecting BCLM is probably unnecessary in all patients, it can be clinically useful in patients with stage III or human epidermal growth factor receptor-2-enriched breast cancers.

Utility of positron emission tomography for determination of axillary metastasis of breast cancer

Objectives

The involvement of axillary lymph nodes plays a key role in breast cancer staging. Positron emission tomography is a promising modality for detecting axillary lymph node metastasis. In addition, nomograms are used to predict the status of axillary lymph nodes. In this study, the role of positron emission tomography in determining axillary metastasis and its correlation with the nomogram was evaluated.

Material and Methods

The axillary maximum standard uptake value (SUVmax) values of the patients in the preoperative period, the features in the perioperative and postoperative specimen and Memorial Sloan Kettering Cancer Center nomogram data were evaluated.

Results

As axillary SUVmax detected by Positron emission tomography in the preoperative period increased, so did the likelihood of lymph node involvement. Axillary SUVmax value were compared with Memorial Sloan Kettering Cancer Center nomogram data but no correlation was found. Age, lymph node number, histopathology results, mass diameter, presence or absence of lymphovascular invasion and/or perineural invasion, tumor type, estrogen receptor status, Ki67 and Cerb-B2 statuses were not correlated. However, axillary SUVmax was inversely correlated with grade and progesterone receptor status.

Conclusion

Results from positron emission tomography of axillary lymph nodes in breasts cancer patients showed that SUVmax was only inversely related to cancer grade and progesterone receptor status while not correlating with other accepted parameters for tumor assessment. Thus there is insufficient reliability for the use of axillary SUVmax alone for accurate assessment of tumor characteristics at present.

The Effect of PACS in Breast Tumor Diagnosis Based on Numerical Analysis

The incidence and mortality rates are increasing year by year, and the incidence of the disease is gradually becoming younger. The purpose of this study was to investigate the clinical diagnostic value of PACS in breast tumor patients. Methods. 20 patients with breast tumor diagnosed by PACS were selected for the study, and the diagnosis was confirmed by pathological puncture or surgery. Results. The detection rates of breast tumor by MRI and CT were 94.44% and 96.67%, the sensitivities were 18.82% breast tumor and 96.67%, and the specificities were 53.84% and 54.54%, with no statistically significant difference ( $P>0.05$ ). There was no statistically significant difference in the detection rate of invasive lobular carcinoma (LDC) and PACS ( $P>0.05$ ). Conclusion. PACS has a greater detection rate for breast tumor and offers some diagnostic usefulness in diagnosing malignant breast tumor. The detection rate of breast tumors can be increased by selecting the most appropriate diagnostic tool for the patient’s current circumstances.

Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These NCCN Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.

Locally advanced breast cancer

Locally advanced breast cancer (LABC) is defined here as inoperable breast adenocarcinoma without distant metastases. Patients with LABC require a multidisciplinary approach. Given the risk of distant metastasis, staging exams are necessary. The incidence of LABC (stages IIIB and IIIC) has decreased in recent years. LABC has rarely been investigated separately: patients with LABC have participated both in clinical trials of palliative and of neoadjuvant therapy. Most trials did not analyze responses and long-term outcomes independently; thus, the treatment of patients with LABC is extrapolated from studies of patients with less or more advanced disease. Pathologic confirmation and molecular profiling are essential for the choice of neoadjuvant chemotherapy. Preoperative endocrine therapy may be considered in certain clinical situations; the addition of a CDK4/6 inhibitor is being investigated. HER2 positive LABCs are targeted with anti-HER2 agents combined with chemotherapy. PD-1 and PD-L1 antibodies in ‘triple-negative’ LABC are promising. Excellent responses to neoadjuvant therapy enable conservative surgery in many patients; however, inflammatory breast cancer may still indicate mastectomy. Postoperative radiotherapy is usually indicated. Target volumes include breast/chest wall, axillary, supraclavicular and internal mammary nodal basins. Preoperative radiation therapy can be useful in patients without response to systemic therapies. Palliative surgery for poor responders after neoadjuvant systemic and radiation therapy can be considered. Multidisciplinary teams can optimize local control and prevent relapses. However, modest improvement in survival was achieved between 2000 and 2014 underscoring the unmet need in patients with LABC who will benefit from specific research efforts in this disease entity.

Performance, clinical utility, and cost-effectiveness of selective use of staging investigations in early breast cancers

BACKGROUND

International guidelines do not recommend routine staging of EBCs. However, most clinicians still perform staging investigations (SI) selectively for several reasons. We examined our practice of selective use of SI to determine its performance, clinical utility, and cost-effectiveness.

METHODS

We performed this retrospective study on patients who had treatment for AJCC stage I or stage II breast cancer through Eastern health Breast and cancer centre, Melbourne, for 50 months from January 2012.

RESULT

Our practice of selective use resulted in SI in 41% of all EBCs (95% CI 37-46%). Overall yield was 3% (95% CI 0.4-5.4%) with a false positive rate of 22% (95% CI 1628%) and a false-negative rate of 45% (95% CI 11-79%). The sensitivity of SI is 55% (95% CI 21-89%) with a negative predictive value of 97% (95% CI 94.8-99.9%). None of the treatment components was found to be significantly changed based on findings on SI. There was no significant difference in all-cause mortality or new distant recurrence in the staged and non-staged groups. Identification of six new metastases cost at least 422 021 AUD. The approximate cost to stage one EBC is 2069 AUD. 'Number needed to scan' to detect one new metastasis is 34 at the expense of 70337AUD.

CONCLUSION

Selective use of SI results in better yield. However, the clinical utility of these results is not significant. It is debatable if this level of expenditure is cost-effective. Our results point to a need for change in practice.

Discordance in clinical versus pathological staging in breast cancer: Are we undermining the significance of accurate preoperative staging in the present era?

BACKGROUND

The present era of individualized treatment for breast cancer is influenced by the initial disease status including the anatomical extent, grade, and receptor status. An accurate preoperative staging is the basis of treatment planning and prognostication. Our study aims to determine the discordance between the preoperative clinical and the postoperative pathological stages of breast cancer patients.

METHODOLOGY

The medical records of all non-metastatic breast cancer patients from January 2017 to December 2018 who underwent upfront surgery were reviewed. They were staged as per the eighth AJCC and the concordance between the clinical (c) and pathological T (tumor), N (nodal), and final AJCC stage was studied. A Chi-square test was used to determine factors that significantly correlate with disease discordance.

RESULTS

A total of 307 breast cancer patients were analyzed. Among these, 43.3% were hormone receptor-positive, 30.6% were Her2 positive and 26% were triple-negative. Overall stage discordance was seen in 48.5% (n = 149) patients (upstaging in 22.1%, downstaging in 26.4%). The discordance rate was 48.9% for T stage (cT versus pT) and 57.4% for N stage (cN versus pN). Among patients with clinically node-negative disease, 53.4% were found to have positive nodes on histopathology, while 27.2% had vice versa. Overall, the factors associated with upstaging were ER-positive, Her2 positive and triple-negative status (all p < 0.05), while none of the factors showed significant association with downstaging.

CONCLUSIONS

About half of breast cancer patients had discordance between clinical and pathological staging with higher discordance in the nodal stage. This changes the disease prognosis, and may also affect the offered surgical treatment and radiotherapy. Thus highlighting the need for a precise pre-operative staging. Also, this information will aid clinicians in discussions with patients, keeping in mind the likelihood of change in disease staging and management.

Clinicopathologic Features Predictive of Distant Metastasis in Patients Diagnosed With Invasive Breast Cancer

PURPOSE

National Comprehensive Cancer Network and European Society for Medical Oncology guidelines suggest screening for distant metastasis (M1) in symptomatic patients or those with locally advanced breast cancer. These guidelines are based on studies that often used pathologic staging for analysis. Physician variability in screening for M1 has also resulted in overuse of diagnostic tests. We sought to identify clinicopathologic features at diagnosis that could guide testing for metastatic disease.

METHODS

Patients diagnosed with invasive breast cancer between January 2014 and December 2015 were identified from our institutional database. Demographic and clinical variables were collected, including receptor profiles and clinical TNM staging. Rates of upstaging for each clinical stage and rates of concordance of pathologic and clinical staging were analyzed. Univariate analysis and multivariate regression analysis (P < .05) identified predictors of upstaging to stage IV disease.

RESULTS

A total of 370 patients met the inclusion criteria. Seventy patients (18.9%) had metastatic disease at diagnosis. The rate of upstaging for stages I, IIA, IIB, and III were 0%, 5.6%, 18.8%, and 36.6%, respectively. Advancing clinical stage, tumor size, and nodal status resulted in a significantly higher rate (P < .001) of upstaging to M1 disease. Age and hormone receptor status were not associated with upstaging to stage IV disease. Clinical stages I-III were concordant with pathologic staging in 65(42.8%) of 152 patients (kappa’s index, 0.197; P < .000).

CONCLUSION

Advancing clinical stage, tumor size, and nodal status at diagnosis were predictive of upstaging to M1 disease in patients with breast cancer. Distant metastatic workup should be considered in patients with clinical stage IIB disease or higher.

Epidemiology of De Novo Metastatic Breast Cancer

Most cases of metastatic breast cancer (MBC) arise as a recurrence of a previously treated early breast cancer. Distinct from recurrent MBC is de novo MBC (dnMBC), which describes patients who present with distant sites of disease at initial diagnosis and is reviewed here. dnMBC represents approximately 3% to 6% of new breast cancer diagnoses in high-income countries. This incidence has not declined despite decades of widespread use of population-based mammography screening. Overrepresentation of both biologically aggressive tumors and patients negatively impacted by social determinants of health are characteristics of dnMBC. Survival has generally been superior for patients with dnMBC compared with those with recurrent MBC, although it is similar to that for patients with recurrent MBC with long disease-free intervals. Subgroups of patients with dnMBC who experience prolonged survival include those with human epidermal growth factor receptor-2-positive disease or hormone receptor-positive bone-only disease. Opportunities to decrease dnMBC presentation may include novel screening modalities suited for biologically aggressive breast tumors and improved access to health care. Recognizing that there will remain some women diagnosed with dnMBC, refining our ability to identify those likely to be long-term survivors could allow for appropriate escalation or de-escalation of care. Finally, evaluation of tumor genomics in robust sample sizes has the potential to advance our knowledge of the biology of dnMBC as an entity distinct from recurrent MBC.

Risk and prognostic factors of breast cancer with liver metastases

Background

Liver metastasis is a significant adverse predictor of overall survival (OS) among breast cancer patients. The purpose of this study was to determine the risk and prognostic factors of breast cancer with liver metastases (BCLM).

Methods

Data on 311,573 breast cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database and 1728 BCLM patients from Fudan University Shanghai Cancer Center (FUSCC) were included. Logistic regression was used to identify risk factors for liver metastasis. Cox proportional hazards regression model was adopted to determine independent prognostic factors in BCLM patients.

Results

Young age, invasive ductal carcinoma, higher pathological grade, and subtype of triple-negative and human epidermal growth factor receptor 2 positive (HER2+) were risk factors for developing liver metastasis. The median OS after liver metastasis was 20.0 months in the SEER database and 27.3 months in the FUSCC dataset. Molecular subtypes also played a critical role in the survival of BCLM patients. We observed that hormone receptor-positive (HR+)/HER2+ patients had the longest median OS (38.0 for SEER vs. 34.0 months for FUSCC), whereas triple-negative breast cancer had the shortest OS (9.0 vs. 15.6 months) in both SEER and FUSCC. According to the results from the FUSCC, the subtype of HR+/HER2+ (hazard ratio (HR) = 2.62; 95% confidence interval (CI) = 1.88–3.66; P < 0.001) and HR−/HER2+ (HR = 3.43; 95% CI = 2.28–5.15; P < 0.001) were associated with a significantly increased death risk in comparison with HR+/HER2- patients if these patients did not receive HER2-targeted therapy. For those who underwent HER2-targeted therapy, however, HR+/HER2+ subtype reduced death risk compared with HR+/HER2- subtype (HR = 0.74; 95% CI = 0.58–0.95; P < 0.001).

Conclusions

Breast cancer patients at a high risk for developing liver metastasis deserve more attention during the follow-up. BCLM patients with HR+/HER2+ subtype displayed the longest median survival than HR+/HER2- and triple-negative patients due to the introduction of HER2-targeted therapy and therefore it should be recommended for HER2+ BCLM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07968-5.

The use of 18F-FDG positron emission tomography to detect mediastinal lymph nodes in metastatic breast cancer

BACKGROUND

To assess the predictive value of 18F-fluorodeoxyglucose positron-emission tomography (FDG-PET/CT) in detecting mediastinal lymph node metastasis with histopathologic verification in breast cancer (BC) patients.

MATERIALS AND METHODS

Between February 2012 and October 2019, 37 BC patients who underwent histopathological verification for FDG-PET positive mediastinal lymph nodes were retrospectively analyzed. Nine patients (24%) were screened before beginning treatment, while 27 (76%) were screened at the time of disease progression, an average of 39 months after completion of initial treatment.

RESULTS

The histopathologic diagnosis revealed lymph node metastasis from BC in 15 patients (40%) and benign disease in 22 patients (60%). The standardized uptake value (SUVmax) of mediastinal lymph nodes was significantly higher in patients with lymph node metastasis compared to those with benign histology (9.0 ± 3.5 vs. 5.9 ± 2.4; P = 0.007). The cut-off value of SUVmax after the ROC curve analysis for pathological lymph node metastasis was 6.4. Two of the 15 patients with mediastinal SUVmax ≤ 6.4 and 13 of the 22 patients with SUVmax > 6.4 had lymph node metastasis. Age and pathological findings were prognostic factors for overall survival in univariate analysis. The treatment decision was changed in 19 patients (51%) after mediastinoscopic evaluation of the entire cohort.

CONCLUSIONS

This is the first study to support the need for pathologic confirmation of a positive PET/CT result following evaluation of mediastinal lymph nodes for staging BC, either at initial diagnosis or at the time of progression. Treatment decisions were consequently altered for nearly half of the patients.

Diagnostic workup of early-stage breast cancer: can we choose more wisely?

INTRODUCTION

Current international guidelines, including the Choosing Wisely Initiative, recommends against the routine use of systemic imaging studies or tumor markers in early-stage breast cancer. Accumulating data suggests that adherence to these guidelines is low. We aimed to investigate the execution of unnecessary diagnostic tests among Israeli breast cancer patients and identify factors associated with their performance.

METHODS

A retrospective analysis was conducted involving a database of early breast cancer patients treated at Tel Aviv Sourasky Medical Center. A survey was distributed among Israeli surgeons and oncologists specializing in breast cancer treatment.

RESULTS

The study included early breast cancer patients (n = 178), who have no indication for completing systemic evaluation. Nearly half of the patients (76, 42%) were referred to 128 unjustified diagnostic studies, with the most common referral comprising a PET-CT (n = 39 30.5%). As expected, none of the tests led to any change in either disease staging or alteration in clinical management. Variables associated with systemic evaluation included younger age (61.8% for < 50 years vs 38.9% for > 50 years, p = 0.02), diagnosis by palpable mass compared to screening mammography (26.9% vs 52.9% p = 0.043, respectively) and higher tumor grade (33.7% vs 52.2% p = 0.02, respectively). In concordance with the findings of the database, the physicians' survey revealed low adherence to guidelines and a role of the treating physicians' subjective feelings. Doctors were more likely to recommend unnecessary studies when presented with a clinical case as an image, than to an informative question.

CONCLUSIONS

Our data indicate a high rate of non-adherence to guidelines, physicians recommending extensive systemic evaluation for women with early breast cancer. These deviations from the guidelines are associated with subjective factors, some of them being physician-dependent. Initiatives aimed at improving adherence to guidelines, and specifically to guidelines recommending "doing less" should therefore include not just knowledge-based education but also encourage conversation about what is appropriate and necessary.

Neoadjuvant Endocrine Therapy in Breast Cancer: Current Knowledge and Future Perspectives

In locally advanced (LA) breast cancer (BC), neoadjuvant treatments have led to major achievements, which hold particular relevance in HER2-positive and triple-negative BC. Conversely, their role in hormone receptor positive (HR+), hormone epidermal growth factor 2 negative (HER2-) BC is still under debate, mainly due to the generally low rates of pathological complete response (pCR) and lower accuracy of pCR as predictors of long-term outcomes in this patient subset. While administration of neoadjuvant chemotherapy (NCT) in LA, HR+, HER2- BC patients is widely used in clinical practice, neoadjuvant endocrine therapy (NET) still retains an unfulfilled potential in the management of these subgroups, particularly in elderly and unfit patients. In addition, NET has gained a central role as a platform to test new drugs and predictive biomarkers in previously untreated patients. We herein present historical data regarding Tamoxifen and/or Aromatase Inhibitors and a debate on recent evidence regarding agents such as CDK4/6 and PI3K/mTOR inhibitors in the neoadjuvant setting. We also discuss key issues concerning the optimal treatment length, appropriate comparisons with NCT efficacy and use of NET in premenopausal patients.

Baseline staging imaging for distant metastasis in women with stages I, II, and III breast cancer

Background

In Ontario, there is no clearly defined standard of care for staging for distant metastasis in women with newly diagnosed and biopsy-confirmed breast cancer whose clinical presentation is suggestive of early-stage disease. This guideline addresses baseline imaging investigations for women with newly diagnosed primary breast cancer who are otherwise asymptomatic for distant metastasis.

Methods

The medline and embase databases were systematically searched for evidence from January 2000 to April 2019, and the best available evidence was used to draft recommendations relevant to the use of baseline imaging investigation in women with newly diagnosed primary breast cancer who are otherwise asymptomatic. Final approval of this practice guideline was obtained from both the Staging in Early Stage Breast Cancer Advisory Committee and the Report Approval Panel of the Program in Evidence-Based Care.

Recommendations

These recommendations apply to all women with newly diagnosed primary breast cancer (originating in the breast) who have no symptoms of distant metastasis Staging tests using conventional anatomic imaging [chest radiography, liver ultrasonography, chest-abdomen-pelvis computed tomography (ct)] or metabolic imaging modalities [integrated positron-emission tomography (pet)/ct, integrated pet/magnetic resonance imaging (mri), bone scintigraphy] should not be routinely ordered for women newly diagnosed with clinical stage i or stage ii breast cancer who have no symptoms of distant metastasis, regardless of biomarker status. In women newly diagnosed with stage iii breast cancer, baseline staging tests using either anatomic imaging (chest radiography, liver ultrasonography, chest-abdomen-pelvis ct) or metabolic imaging modalities (pet/ct, pet/mri, bone scintigraphy) should be considered regardless of whether the patient is symptomatic for distant metastasis and regardless of biomarker profile.

Unwarranted imaging for distant metastases in patients with newly diagnosed ductal carcinoma in situ and stage I and II breast cancer

Background

In 2012, the American Society of Clinical Oncology (ASCO) released a Choosing Wisely Top Five list that included a recommendation against ordering advanced imaging tests to screen for metastases among asymptomatic patients with early breast cancer. Our provincial breast cancer staging guideline was subsequently updated. We report on the use of unwarranted bone scanning (BS), computed tomography (CT), nonbreast magnetic resonance imaging (MRI) and positron emission tomography (PET) among women diagnosed with stage 0–II breast cancer in Alberta in 2011–2015.

Methods

The cohort was retrospectively ascertained from the Alberta Cancer Registry. We used additional provincial data sources to obtain information about diagnostic imaging tests completed from biopsy to surgical date plus 4 months. The reason for each BS, CT, MRI and PET was abstracted. We calculated the frequency of advanced imaging tests completed for routine metastatic screening.

Results

Of 10 142 patients included, 2887 (28.5%) had at least 1 advanced imaging test completed for routine metastatic screening. Of these 2887 patients, 438 (15.2%) had a follow-up BS, CT, MRI or PET, and 28 patients (1.0%) had a nonbreast imageguided biopsy. Use of routine advanced imaging tests did not change clearly over time.

Conclusion

Our results demonstrate persistent use of advanced imaging tests for routine metastatic screening among patients with stage 0–II breast cancer despite the release of the ASCO Choosing Wisely recommendations and the update of our provincial breast cancer staging guideline. Investigation of strategies for guideline translation to improve upon value-based care of patients with early breast cancer is warranted.

Adherence to guidelines for baseline staging in newly diagnosed localized breast cancer

RATIONALE, AIMS, AND OBJECTIVES

Different health agencies in Canada including Cancer Care Ontario (CCO) have developed guidelines for the baseline staging of newly diagnosed breast cancer patients but adherence to them is unknown. We sought to investigate adherence to CCO staging guidelines in a single cancer center in addition to the factors that influence this adherence.

METHOD

A retrospective chart review was conducted on 212 newly diagnosed breast cancer patients between 2015 and 2017. Baseline patient demographic and disease characteristics as well as radiologic staging studies and subsequent treatments were recorded. The group of patients in whom the guidelines were observed was compared to the group of patients in whom the guidelines were not followed.

RESULTS

Staging guidelines were not followed in 46.7% of the patients in the cohort (99 of 212 patients). In most cases, deviations from the guidelines consisted of performing more than the recommended baseline screening, most commonly in the form of a computerized tomography (CT) scan or a bone scan and chest x-ray (CXR)/ ultrasound (US) of the liver. Less commonly, a recommended staging evaluation was omitted or the suggested timing of the staging procedure (i.e., pre-operatively versus post-operatively) was not followed. Higher stage and grade of the disease and subsequent chemotherapy administration were associated with higher guideline non-adherence.

CONCLUSIONS

Low adherence to staging guidelines for newly diagnosed breast cancer according to CCO is shown in a community cancer center. Incorporation of arising prognostic factors to staging procedure determination may increase acceptance and adherence to guidelines in the future.

Regulation of Immunity in Breast Cancer

Breast cancer affects millions of women worldwide, leading to many deaths and significant economic burden. Although there are numerous treatment options available, the huge potentials of immunotherapy in the management of localized and metastatic breast cancer is currently being explored. However, there are significant gaps in understanding the complex interactions between the immune system and breast cancer. The immune system can be pro-tumorigenic and anti-tumorigenic depending on the cells involved and the conditions of the tumor microenvironment. In this review, we discuss current knowledge of breast cancer, including treatment options. We also give a brief overview of the immune system and comprehensively highlight the roles of different cells of the immune system in breast tumorigenesis, including recent research discoveries. Lastly, we discuss some immunotherapeutic strategies for the management of breast cancer.

A critical review of the chest CT scans performed to detect asymptomatic synchronous metastasis in new and recurrent breast cancers

Background

Chest computed tomography (CTC) has now replaced chest X-ray (CXR) as the first choice of investigation to stage breast cancers in most centers in Australia. Routine staging is not recommended in early breast cancers (EBCs). This recommendation is based largely on the use of conventional tests like CXR as staging investigations (SIs). We looked at our experience with CTC in detecting asymptomatic synchronous distant metastasis (ASM) in new and recurrent breast cancers (RBCs).

Materials and methods

Breast cancer patients from Eastern Health Breast Unit during the period from January 2012 to March 2016 were included in the study. Cases were grouped into early, advanced, and recurrent breast cancers, and outcome of CTC was assessed in each group. Relative risk of potential risk factors (tumor size, axillary nodal status, presence of lymphovascular invasion and estrogen, and HER2 receptor status) with a positive result in CTC was determined.

Results

Fourteen ASMs were detected from 335 CTCs giving an overall yield of 4% (95% CI 1.89–6.47). The overall false-positive rate was 10% due to 35 indeterminate findings that were found not to be metastases after further tests or observation. Even with selective use, CTCs have a low yield of 2% (95% CI − 0.19–4.19) in EBCs. Advanced breast cancers have a 9% incidence of ASMs. None of the clinically isolated locoregionally recurrent diseases were associated with detectable distant metastasis in CTC. The most common cause of indeterminate findings was small pulmonary nodules.

Conclusion

Even with selective use, CTC has a very low yield in EBCs. Advanced breast cancers can benefit from CTC in their initial evaluation due to the higher yield. Locoregional RBCs were not usually associated with detectable metastasis on CTC. The usefulness of CTC in all stages of breast cancer is further reduced by its high rate of false-positive results.

What is the Utility of Routine Complete Blood Count, Liver Function Tests, and Chest X-ray in the Evaluation of Patients with Clinically Node-Negative Breast Cancer?

National Comprehensive Cancer Network guidelines suggest a selective workup of early-stage breast cancer with complete blood count (CBC) and liver function tests (LFTs) and no longer recommend chest X-ray (CXR) to screen for occult metastasis. We evaluated the utility of routine preoperative screening tests in patients with clinically node-negative (cN0) breast cancer. We identified 1611 patients with cN0 breast cancer treated at our institution between October 1998 and December 2015; 94.4 per cent of the patients underwent at least one preoperative screening test: 90.8 per cent CBC, 89.4 per cent LFTs, and 63.6 per cent CXR. Thirty-six per cent of CBCs, 13.1 per cent of LFTs, and 6.7 per cent of CXRs were abnormal. Abnormalities led to 17 CTscans, and one found an occult metastasis. Eleven patients (0.7%) were diagnosed with metastatic disease post-operatively, but only half had abnormal preoperative screening tests. Positive predictive values of preoperative CBC, LFTs, and CXR for occult metastasis are 1.3 per cent, 1.1 per cent, and 1.5 per cent, respectively. Preoperative screening in cN0 breast cancer is of low yield. Even when abnormalities are found, metastasis is present in less than 1 per cent of patients, and a normal study does not rule out metastasis. Routine preoperative determination is not warranted, and staging studies should be limited to patients with signs or symptoms.

Updates in the Evaluation and Management of Breast Cancer

Breast cancer is the most commonly diagnosed cancer worldwide. More than 200,000 new cases of invasive breast cancer are diagnosed annually in the United States; approximately 40,000 patients die of the disease. The etiology of most breast cancer cases is unknown, although multiple factors predisposing to the disease have been identified. Apart from increasing age and female sex, these other factors account for only a minority of breast cancer diagnoses. This article provides an overview of the management of noninvasive and invasive breast cancer, which is often complex and varies according to patient factors, disease stage, and breast cancer subtype. Although much progress has been made, continued research endeavors are ongoing; enrollment of eligible patients in prospective clinical trials is an essential way to improve patient outcomes.

Radiotherapy in Italy after Conservative Treatment of Early Breast Cancer. A Survey by the Italian Society of Radiation Oncology (AIRO)

Aims and Background

The aim of surveys on clinical practice is to stimulate discussion and optimize practice. In this paper the current Italian radiotherapy practice after breast-conserving surgery for early breast cancer is described and adherence to national and international guidelines is assessed. Furthermore, results are compared with an earlier survey in northern Italy and international reports.

Study Design

A multiple-choice questionnaire sent to all 138 Italian radiation oncology centers.

Results

48% of centers responded. Most performed breast-conserving surgery when tumor size was ≤3 cm. All centers routinely performed axillary dissection; 45 carried out sentinel node biopsy followed by axillary dissection when the sentinel node was positive. Most centers re-excised when resection margins were positive. The median interval between surgery and radiotherapy, when chemotherapy was not administered, was 60 days. Adjuvant chemotherapy was preferably administered before radiotherapy. Regional lymph nodes were never irradiated in 10 centers; in all others irradiation depended on the number of positive lymph nodes and/or involvement of axillary fat and/or tumor location in medial quadrants. All centers used standard fractionation; hypofractionated schemes were available in 6. Most centers used 4–6 MV photons. In 59 centers the boost dose of 10 Gy could be increased if margins were not negative. All centers ensured patient setup reproducibility. Treatment planning was computerized in 59 centers. The irradiation dose was prescribed at the ICRU point in 56 centers and portal films were made in 54 centers. Intraoperative radiotherapy was used in 4 centers: for partial breast irradiation in 1 and for boost administration in 3 centers.

Conclusions

Although the quality of radiotherapy delivery has improved in Italy in recent years, approaches that do not conform to international standards persist.

ACR Appropriateness Criteria® Stage I Breast Cancer: Initial Workup and Surveillance for Local Recurrence and Distant Metastases in Asymptomatic Women

Women and health care professionals generally prefer intensive follow-up after a diagnosis of breast cancer. However, there are no survival differences between women who obtain intensive surveillance with imaging and laboratory studies compared with women who only undergo testing because of the development of symptoms or findings on clinical examinations. American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines state that annual mammography is the only imaging examination that should be performed to detect a localized breast recurrence in asymptomatic patients; more imaging may be needed if the patient has locoregional symptoms (eg, palpable abnormality). Women with other risk factors that increase their lifetime risk for breast cancer may warrant evaluation with breast MRI. Furthermore, the quality of life is similar for women who undergo intensive surveillance compared with those who do not. There is little justification for imaging to detect or rule out metastasis in asymptomatic women with newly diagnosed stage I breast cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Variation in the use of advanced imaging at the time of breast cancer diagnosis in a statewide registry

BACKGROUND

Although national guidelines do not recommend extent of disease imaging for patients with newly diagnosed early stage breast cancer given that the harm outweighs the benefits, high rates of testing have been documented. The 2012 Choosing Wisely guidelines specifically addressed this issue. We examined the change over time in imaging use across a statewide collaborative, as well as the reasons for performing imaging and the impact on cost of care.

METHODS

Clinicopathologic data and use of advanced imaging tests (positron emission tomography, computed tomography, and bone scan) were abstracted from the medical records of patients treated at 25 participating sites in the Michigan Breast Oncology Quality Initiative (MiBOQI). For patients diagnosed in 2014 and 2015, reasons for testing were abstracted from the medical record.

RESULTS

Of the 34,078 patients diagnosed with stage 0-II breast cancer between 2008 and 2015 in MiBOQI, 6853 (20.1%) underwent testing with at least 1 imaging modality in the 90 days after diagnosis. There was considerable variability in rates of testing across the 25 sites for all stages of disease. Between 2008 and 2015, testing decreased over time for patients with stage 0-IIA disease (all P < .001) and remained stable for stage IIB disease (P = .10). This decrease in testing over time resulted in a cost savings, especially for patients with stage I disease.

CONCLUSION

Use of advanced imaging at the time of diagnosis decreased over time in a large statewide collaborative. Additional interventions are warranted to further reduce rates of unnecessary imaging to improve quality of care for patients with breast cancer. Cancer 2017;123:2975-83. © 2017 American Cancer Society.

ACR Appropriateness Criteria® Stage I Breast Carcinoma

Stage I breast carcinoma is classified when an invasive breast carcinoma is ≤2 cm in diameter (T1), with no regional (axillary) lymph node metastases (N0) and no distant metastases (M0). The most common sites for metastases from breast cancer are the skeleton, lung, liver, and brain. In general, women and health care professionals prefer intensive screening and surveillance after a diagnosis of breast cancer. Screening protocols include conventional imaging such as chest radiography, bone scan, ultrasound of the liver, and MRI of brain. It is uncertain whether PET/CT will serve as a replacement for current imaging technologies. However, there are no survival or quality-of-life differences for women who undergo intensive screening and surveillance after a diagnosis of stage I breast carcinoma compared with those who do not. The ACR Appropriateness Criteria^® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Use and Yield of Baseline Imaging and Laboratory Testing in Stage II Breast Cancer

BACKGROUND

Despite guideline recommendations, baseline laboratory testing and advanced imaging are widely ordered in clinical practice to stage asymptomatic patients with clinical stage II breast cancer (BC).

MATERIALS AND METHODS

A retrospective study at two academic centers in Boston, Massachusetts, between 2006 and 2007 explored the use, results, and implications of laboratory tests, tumor markers, and imaging in patients with clinical stage II BC.

RESULTS

Among 411 patients, 233 (57%) had liver function testing, 134 (33%) had tumor marker tests, and 237 (58%) had computed tomography (CT) as part of their initial diagnostic workup. Median age was 52 (range, 23-90 years). On multivariable analysis, young age, more advanced stage, and tumor subtype (human epidermal growth receptor-positive [HER2+] and triple-negative breast cancer [TNBC]) were significantly associated with baseline CT. The rate of detection of true metastatic disease with use of baseline staging imaging was 2.1% (95% confidence interval, 0.7%-5%). It was 2.2% (3 of 135) for estrogen receptor/progesterone receptor-positive disease, 1.9% (1 of 54) for HER2+ disease, and 2.1% (1 of 48) for TNBC. At 5 years of follow-up, 46 of 406 patients were diagnosed with metastatic breast cancer. Thirty-four of 46 (73.9%) who developed recurrent disease had imaging at their initial diagnosis, and of these, five had abnormalities on their initial imaging that was correlated with where they developed metastatic disease.

CONCLUSION

In this cohort of women with stage II BC, staging imaging at diagnosis had a low yield in detecting distant metastases (2.1%). The detection rate was not higher with HER2+ disease or TNBC, despite the trend that patients with these subtypes were more likely to undergo imaging.

IMPLICATIONS FOR PRACTICE

Despite guideline recommendations, asymptomatic patients with stage II breast cancer (BC) often undergo staging imaging with computed tomography, bone scanning, or positron emission tomography. Physicians have often reported that they order imaging despite recommendations because they believe that younger patients or patients with more aggressive BC phenotypes, such as human epidermal receptor 2-positive BC or triple-negative BC, benefit from staging imaging. In this cohort of women younger than those in prior studies, the yield of detecting distant metastatic disease in patients with clinical stage II BC was very low and the detection rate was not higher in the presence of HER2-positive or triple-negative BC.

Clinical significance of noncalcified lung nodules in patients with breast cancer

Patients with breast cancer are increasingly likely to have chest computed tomography (CT) performed. In many cases, small lung nodules will be detected, raising concern for metastases and causing considerable patient anxiety. The majority of these nodules, however, are benign, though the specific probability of malignancy is uncertain in any given case. Therefore, we analyzed the results of chest CT scans of a large number of patients with breast cancer, to determine characteristics and clinical significance of noncalcified lung nodules. 3313 patients were investigated, and 4889 CT scans from 1325 patients were retrospectively reviewed. Among the 1325 patients, 812 (59 %) had at least one noncalcified lung nodule, of which 330 (41 %) had malignant nodules, 197 (24 %) had large (≥10 mm) nodules, and 586 (72 %) had multiple nodules. Large nodules were more often malignant than benign (P < 0.001). In patients with multiple large nodules, the rate of malignancy rate was 83 %, and most of these were metastases. In the case of very small (2-4 mm) nodules, the malignancy rates for solitary and multiple nodules were 8 and 20 %, respectively. Lung metastases were more likely with breast cancer cell grade 3 (22 %) than grade 1-2 (10 %) (P < 0.001) and when patients were clinical stage 2-3 (14 %) than stage 0-1 (7.9 %) (P = 0.03). Lung metastases are highly likely in patients with multiple nodules greater than 10 mm. Higher cancer cell grades and clinical stage are also related to an increased likelihood of lung metastases. The great majority of small lung nodules in breast cancer patients are benign.

Complete blood counts, liver function tests, and chest x-rays as routine screening in early-stage breast cancer: value added or just cost?

Current National Comprehensive Cancer Network guidelines for breast cancer staging include pre-treatment complete blood count (CBC) and liver function tests (LFT) to screen for occult metastatic disease. To date, the relevance of these tests in detecting metastatic disease in asymptomatic women with early-stage breast cancer (Stage I/II) has not been demonstrated. Although chest x-rays are no longer recommended in the NCCN guidelines, many centers continue to include this imaging as part of their screening process. We aim to determine the clinical and financial impact of these labs and x-rays in the evaluation of early-stage breast cancer patients. A single institution IRB-approved retrospective chart review was conducted of patients with biopsy-proven invasive breast cancer treated from January 1, 2005–December 31, 2009. We collected patient demographics, clinical and pathologic staging, chest x-ray, CBC, and LFT results at the time of referral. Patients were stratified according to radiographic stage at the time of diagnosis. We obtained Medicare reimbursement fees for cost analysis. From 2005 to 2009, 1609 patients with biopsy-proven invasive breast cancer were treated at our institution. Of the 1082 patients with radiographic stage I/II disease, 27.3 % of patients had abnormal CBCs. No additional testing was performed to evaluate these abnormalities. In the early-stage population, 24.7 % of patients had elevated LFTs, resulting in 84 additional imaging studies. No metastatic disease was detected. The cost of CBC, LFTs and chest x-rays was $110.20 per patient, totaling $106,410.99. Additional tests prompted by abnormal results cost $58,143.30 over the five-year period. We found that pre-treatment CBCs, LFTs, and chest x-rays did not improve detection of occult metastatic disease but resulted in additional financial costs. Avoiding routine ordering of these tests would save the US healthcare system $25.7 million annually.

Imaging in the evaluation and follow-up of early and advanced breast cancer: When, why, and how often?

Imaging in the evaluation and follow-up of patients with early or advanced breast cancer is an important aspect of cancer care. The role of imaging in breast cancer depends on the goal and should only be performed to guide clinical decisions. Imaging is valuable if a finding will change the course of treatment and improve outcomes, whether this is disease-free survival, overall survival or quality-of-life. In the last decade, imaging is often overused in oncology and contributes to rising healthcare costs. In this context, we review the data that supports the appropriate use of imaging for breast cancer patients. We will discuss: 1) the optimal use of staging imaging in both early (Stage 0-II) and locally advanced (Stage III) breast cancer, 2) the role of surveillance imaging to detect recurrent disease in Stage 0-III breast cancer and 3) how patients with metastatic breast cancer should be followed with advanced imaging.

Distant metastasis detected by routine staging in breast cancer patients participating in the national German screening programme: consequences for clinical practice

PURPOSE

To determine frequency of routine radiological staging of breast cancer patients diagnosed in a German Breast Cancer Screening Center from 2007 to 2014, the incidence and consequences of distant metastases detected and the resulting implications for clinical routine.

METHODS

Records of 896 patients with primary breast cancer diagnosed in the Screening Centre and treated in five participating hospitals were analyzed retrospectively. Evaluation included frequency and type of staging procedures and results with respect to distant metastasis and their consequences on clinical management.

RESULTS

894/896 Patients (99.8 %) received staging for distant metastases by bone scintigraphy, chest X-ray and liver sonography and/or CT/MRT diagnostics. Distant metastasis was suggested In 6/894 patients but excluded in 3 by further diagnostics or clinical course. Thus, 3 (0.3 %) were clinically verified to have metastatic disease in bone (n = 2; both pT2) or in bone and lung (n = 1; cT4, cN3).

CONCLUSION

Due to the low incidence of verified metastatic disease, the high false positive rate of staging procedures and the unfavorable cost/benefit ratio routine radiological staging should be completely omitted in asymptomatic breast cancer patients diagnosed in a breast cancer screening programme.

Role of bone scan in addition to CT in patients with breast cancer selected for systemic staging

Background

The majority of women with breast cancer present with localized disease. The optimal strategy for identifying patients with metastatic disease at diagnosis remains unclear. The aim of this study was to evaluate the additional diagnostic yield from isotope bone scanning when added to CT staging of the thorax, abdomen and pelvis (CT-TAP) in patients with newly diagnosed breast cancer.

Methods

All patients diagnosed with breast cancer who underwent staging CT-TAP and bone scan between 2011 and 2013 were identified from a prospective database of a tertiary referral breast cancer centre that provides a symptomatic and population-based screening breast service. Criteria for staging included: biopsy-proven axillary nodal metastases; planned neoadjuvant chemotherapy or mastectomy; locally advanced or inflammatory breast cancer and symptoms suggestive of metastases.

Results

A total of 631 patients underwent staging by CT-TAP and bone scan. Of these, 69 patients (10·9 per cent) had distant metastasis at presentation, with disease confined to a single organ in 49 patients (71 per cent) and 20 (29 per cent) having metastatic deposits in multiple organs. Bone metastasis was the most common site; 39 of 49 patients had bone metastasis alone and 12 had a single isolated metastatic deposit. All but two of these were to the axial skeleton. No preoperative histological factors identified a cohort of patients at risk of metastatic disease. Omission of the bone scan in systemic staging would have resulted in a false-negative rate of 0·8 per cent.

Conclusion

For patients diagnosed with breast cancer, CT-TAP is a satisfactory stand-alone investigation for systemic staging.

Incidental radiologic findings at breast cancer diagnosis and likelihood of disease recurrence

Despite guidelines recommending against its routine use, perioperative imaging for distant metastases is frequently performed in newly diagnosed breast cancer patients, uncovering incidental findings of uncertain significance. We assessed the clinical significance of incidental findings by determining if their presence is associated with disease recurrence. A retrospective review of staging imaging was performed in patients with stage II or III invasive breast cancer diagnosed during 2008-2009 at a large academic medical center. Data related to perioperative imaging and disease recurrence were abstracted from the medical record. Kaplan-Meier curves and Cox proportional hazards models were used to assess the association between incidental findings and time to disease recurrence. A total of 169 of 340 patients (49.7 %) underwent staging evaluation for distant metastases (CT chest, abdomen, pelvis, bone scan, and/or PET-CT). Of these, 146 (86.4 %) had at least one suspicious or indeterminate finding. Follow-up studies were performed in 73 (43.2 %) patients. Nineteen patients were diagnosed with metastatic disease at diagnosis, 18 of whom had stage III disease. In patients without metastatic disease at diagnosis, 32 later developed recurrence. Non-calcified pulmonary nodules were associated with shorter time to disease recurrence (hazard ratio 2.51, 95 % CI 1.13-5.57, p = 0.02). Imaging for distant metastases frequently reveals indeterminate findings, most of which are not associated with disease recurrence. The association between pulmonary nodules and recurrence warrants validation in an independent cohort. Overall, these findings support current guidelines recommending against routine extent of disease evaluation in patients with newly diagnosed stage II breast cancer.

Skeletal metastases from breast cancer: pathogenesis of bone tropism and treatment strategy

Breast cancer (BC) is the most common female cancer worldwide with approximately 10 % of new cases metastatic at diagnosis and 20-50 % of patients with early BC who will eventually develop metastatic disease. Bone is the most frequent site of colonisation and the development of skeletal metastases depends on a complex multistep process, from dissemination and survival of malignant cells into circulation to the actual homing and metastases formation inside bone. Disseminated tumor cells (DTCs) can be detected in bone marrow in approximately 30 % of BC patients, likely reflecting the presence of minimal residual disease that would eventually account for subsequent metastatic disease. Patients with bone marrow DTCs have poorer overall survival compared with patients without them. Although bone-only metastatic disease seems to have a rather indolent behavior compared to visceral disease, bone metastases can cause severe and debilitating effects, including pain, spinal cord compression, hypercalcemia and pathologic fractures. Delivering an appropriate treatment is therefore paramount and ideally it should require interdisciplinary care. Multiple options are currently available, from bisphosphonates to new drugs targeting RANK ligand and radiotherapy. In this review we describe the mechanisms underlying bone colonization and provide an update on existing systemic and locoregional treatments for bone metastases.

SEOM clinical guidelines in early-stage breast cancer 2015

Breast cancer is a major public health problem. Despite remarkable advances in early diagnosis and treatment, one in three women may have metastases since diagnosis. Better understanding of prognostic and predictive factors allows us to select the most appropriate adjuvant therapy in each patient. In these guidelines, we summarize current evidence for the medical management of early-stage breast cancer.

Variation in metastatic workup for patients with invasive breast cancer

BACKGROUND

Despite guidelines, surgeons vary in the metastatic workup they order for their breast cancer patients.

METHODS

Surgeons were surveyed as to their practices in ordering staging studies for their breast cancer patients using a Web-based survey. Nonparametric analyses were performed to determine factors associated with guideline adherence.

RESULTS

Two hundred fifty-three surgeons responded to the survey; 55.8% had practices with ≥50% breast patients; 7.3% of respondents stated they always did a metastatic workup before surgery, 8.6% never did; only 52.4% ordered a metastatic workup only in patients with clinical stage III disease. Surgeons who had ≥50% breast-related practices were more likely to follow these guidelines (P = .031). Only 17% stated that a computed tomography chest/abdomen and bone scan was their "usual" metastatic workup.

CONCLUSIONS

Nearly 40% of surgeons perform metastatic workup when they are not indicated, and few adhere to National Comprehensive Cancer Network guidelines in terms of the tests ordered.

Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study

BACKGROUND

Practice guidelines recommend that imaging to detect metastatic disease not be performed in the majority of patients with early-stage breast cancer who are asymptomatic. We aimed to determine whether practice patterns in Ontario conform with these recommendations.

METHODS

We used provincial registry data to identify a population-based cohort of Ontario women in whom early-stage, operable breast cancer was diagnosed between 2007 and 2012. We then determined whether imaging of the skeleton, thorax, and abdomen or pelvis had been performed within 3 months of tissue diagnosis. We calculated rates of confirmatory imaging of the same body site.

RESULTS

Of 26,547 patients with early-stage disease, 22,811 (85.9%) had at least one imaging test, and a total of 83,249 imaging tests were performed (mean of 3.7 imaging tests per patient imaged). Among patients with pathologic stage I and II disease, imaging was performed in 79.6% (10,921/13,724) and 92.7% (11,882/12,823) of cases, respectively. Of all imaging tests, 19,784 (23.8%) were classified as confirmatory investigations. Imaging was more likely for patients who were younger, had greater comorbidity, had tumours of higher grade or stage or had undergone preoperative breast ultrasonography, mastectomy or surgery in the community setting.

INTERPRETATION

Despite recommendations from multiple international guidelines, most Ontario women with early-stage breast cancer underwent imaging to detect distant metastases. Inappropriate imaging in asymptomatic patients with early-stage disease is costly and may lead to harm. The use of population datasets will allow investigators to evaluate whether or not strategies to implement practice guidelines lead to meaningful and sustained change in physician practice.

Use of imaging for staging of early-stage breast cancer in two integrated health care systems: adherence with a choosing wisely recommendation

PURPOSE

Advanced imaging is commonly used for staging of early-stage breast cancer, despite recommendations against this practice. The objective of this study was to evaluate and compare use of imaging for staging of breast cancer in two integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was routine or used for diagnostic purposes.

METHODS

We identified patients with stages 0 to IIB breast cancer diagnosed between 2010 and 2012. Using KP and IH electronic health records, we identified use of computed tomography, positron emission tomography, or bone scintigraphy 30 days before diagnosis to 30 days postsurgery. We performed chart abstraction on a random sample of patients who received a presurgical imaging test to identify indication.

RESULTS

For the sample of 10,010 patients, mean age at diagnosis was 60 years (range, 22 to 99 years); with 21% stage 0, 47% stage I, and 32% stage II. Overall, 15% of patients (n = 1,480) received at least one imaging test during the staging window, 15% at KP and 14% at IH (P = .5). Eight percent of patients received imaging before surgery, and 7% postsurgery. We found significant intraregional variation in imaging use. Chart abstraction (n = 129, 16% of patients who received presurgical imaging) revealed that 48% of presurgical imaging was diagnostic.

CONCLUSION

Use of imaging for staging of low-risk breast cancer was similar in both systems, and slightly lower than has been reported in the literature. Approximately half of imaging tests were ordered in response to a sign or symptom.

Staging studies have limited utility for newly diagnosed stage I-II breast cancer

BACKGROUND

For stage I-II breast cancer, routine radiologic staging in the absence of symptoms suggesting distant metastasis is not recommended. This study aims to determine the yield of these studies at a National Comprehensive Cancer Network member institution.

METHODS

Patients presenting with clinical stage I-II breast cancer between 1998 and 2012 were identified in a prospective database. Charts were reviewed to document staging studies (computed tomography, bone scan, and positron emission tomography) performed within 6 mo of diagnosis. Results and additional diagnostic procedures were recorded. Appropriate statistical tests were used for the analysis.

RESULTS

A total of 3291 patients were included (2044 stage I and 1247 stage II). Eight hundred eighty-two patients (27%) received computed tomography, bone scan, or positron emission tomography within 6 mo of diagnosis. Three hundred twelve patients were stage I (15% of the stage I cohort) and 570 patients were stage II (46% of the stage II cohort). Patients receiving staging studies were more often younger and had estrogen receptor/progesterone receptor-negative or HER2/neu-positive tumors. Of the 882 patients, 194 (22%) required additional imaging and/or biopsies to further evaluate abnormalities. Only 11 of those (5%) were confirmed to have metastasis (1.2% of the imaged patients, 0.3% of the total cohort). Of these, 1 was stage I at presentation and 10 were stage II.

CONCLUSIONS

Identification of distant metastasis among stage I-II patients was rare. Even among patients judged appropriate for staging, only 1.2% were diagnosed with metastatic disease. These findings suggest that even at a National Comprehensive Cancer Network member institution staging studies are overused and lead to additional testing in over 20% of patients.

Imaging for metastatic disease in patients with newly diagnosed breast cancer: are doctor's perceptions in keeping with the guidelines?

RATIONALE, AIMS AND OBJECTIVES

Despite multiple guidelines advocating against routine radiological evaluation for metastases in women with early stage breast cancer, imaging is still frequently overused. The objective of this study was to assess doctor's views on imaging guidelines, and an attempt to establish why personal and local clinical practice patterns regarding imaging may differ from current guidelines.

METHODS

Canadian doctors who treat breast cancer were invited by email to complete an online survey developed by members of the research team.

RESULTS

Responses were received from 173 physicians (26% response rate). Most (82%) indicated awareness of at least one published imaging guideline. Sixty per cent indicated that they had read the recommendations of the 2012 American Society of Clinical Oncology 'Top 5' list for choosing wisely in oncology imaging and, of those, 81% agreed with it. However, most indicated that this recommendation has not influenced them to order less imaging. Over 95% of doctors identified suspicious history, physical examination findings and inflammatory breast cancer as important factors for performing imaging. The majority did not feel that patient demand, fear of litigation or ease of access to imaging influenced their ordering for imaging.

CONCLUSIONS

The majority of breast cancer doctors are aware of and generally agree that guidelines pertaining to staging imaging for early breast cancer are reflective of evidence. Despite this, adherence is variable and factors such as local practice patterns and disease biology may play a role. Alternative strategies, beyond simply publishing recommendations, are therefore required if there is to be a sustained change in doctor behaviour.

Are Physicians Choosing Wisely When Imaging for Distant Metastases in Women With Operable Breast Cancer?

PURPOSE

In 2012, the American Society of Clinical Oncology (ASCO) published its inaugural Top Five recommendations for "choosing wisely" in oncology. One recommendation was to avoid imaging for metastatic disease in asymptomatic patients with early-stage breast cancer. We assessed whether local practice is in keeping with provincial practice guidelines and whether publication of the ASCO recommendations had any significant impact on this.

METHODS

A retrospective review of staging imaging for distant metastases was performed in patients with primary operable (early-stage) breast cancer seen at a large Canadian academic cancer center.

RESULTS

A total of 200 patient medical records were reviewed: 100 patients from 2011 (pre-ASCO Top Five), and 100 after September 2012 (post-ASCO Top Five). Baseline patient and tumor characteristics were similar in both groups. Overall, 169 patients (84.5%) underwent at least one imaging test (mean, 3.6 tests per imaged patient); 154 patients (77.0%) underwent imaging that was not in keeping with the spirit of the local guideline recommendations. The frequency of imaging did not change after publication of the ASCO recommendations. Furthermore, imaging to clarify indeterminate initial imaging was required in 51 (30.2%) of 169 patients. None of the confirmatory imaging results ultimately revealed metastatic disease.

CONCLUSION

Despite the presence of local imaging guidelines, patients with early-stage breast cancer still undergo imaging for distant metastases. There was no reduction in imaging after publication of the ASCO Top Five recommendations. Broader knowledge translation strategies beyond publication are needed if recommendations are to be implemented into routine clinical practice.