Early Detection of Breast Cancer Recurrences through Periodic follow-up - is it Useless?

Early Detection of Recurrences in the Follow-up of Primary Breast Cancer in an Asymptomatic or Symptomatic Phase

Aims and background

Periodic follow-up after primary treatment for breast cancer is a common procedure for the early detection of recurrent disease in the asymptomatic state. Anyway, there is no clinical evidence that treatment of metastases may improve the prognosis if applied in the asymptomatic state. The aim of the present study was to investigate the modality of detection of the first relapse in the asymptomatic vs the symptomatic state.

Methods

We retrospectively analyzed 717 breast cancer patients who had been consecutively referred to the Parma Oncology Division during the period 1986 to December 1988. Recurrences were detected in the course of periodic follow-up.

Results

A total of 211 of the 408 patients evaluated had a first relapse with a median follow-up of 94.7 months. Local and distant recurrences were 49% and 47%, respectively. Bone recurrences represented 24% of the total first recurrences, then chest wall recurrences in 23%, local regional nodes in 13%, lung in 7%, liver in 4%, and brain in 2%. The distribution of the studied patients according to recurrence site and asymptomatic or symptomatic state was different: 69% of asymptomatic patiens (110) had a local recurrence vs 31% of symptomatic patients (101). A difference in survival was recorded in favor of cases detected in the asymptomatic state (P <0.001).

Conclusions

The present study suggests that an early detection of local recurrence might have a favorable impact on the prognosis of patients followed after primary treatment for breast cancer. It should be considered that any difference in survival could also be explained by several “biases” and that breast cancer follow-up is still an area of investigation open to discussion in which many questions remain to be clarified.

Chest X-Ray Survey in Breast Cancer Follow-Up – A Contrary View

The authors report on 83 cases of introthoracic metastases (ITM) observed as isolated first recurrences in a ten-year experience of periodic chest x-ray (CXR) survey of primary breast cancer. In 44 of 83 cases ITM were detected on CXR in absence of subjective symptoms or clinical signs (A) whereas 39 ITM cases were detected as subjectively (S) symptomatic in the interval between two planned CXR controls. Diagnosis was anticipated by CXR survey as the disease-free interval was significantly shorter (30 vs. 43 months, p < 0.04) for A respect to S cases. Nevertheless such a diagnostic anticipation had no prognostic impact as the ten year survival from primary treatment did not differ (0.12 vs. 0.16, p = 0.6) between A and S cases. Multivariate analysis confirmed that no impact on survival from primary treatment is expected whether ITM are detected in an earlier (asymptomatic, preclinical) or in a more advanced (subjectively symptomatic) phase. CXR survey after primary treatment of breast cancer seems thus a very questionable policy.

The Role of a New Monoclonal Antibody Assay in the Detection of Recurrent Breast Cancer

The immunoradiometric assay “CA 15-3”, recently developed to measure a breast tumor-associated antigen, gave a mean serum value of 13.8 U/ml (S.D. 6.2) for this antigen in 156 non-cancer controls (36 biopsies for a benign breast lesion and 120 healthy controls).

Setting a cut-off value of 30 U/ml (specificity 99.3%), only 3 out of 58 primary breast cancer cases were positive. In metastatic breast cancer, 11 out of 33 cases with limited recurrence (33.3%) and 36 out of 56 cases with extensive recurrence (64.3%) gave abnormal values in this assay, above the cut-off point, with an overall sensitivity of 52.8%; the difference between the sensitivity values in the two groups of recurrent cases was statistically significant (P < 0.01).

According to the findings of the present study, CA 15-3 has no role in the detection of primary breast cancer, but its usefulness in disease monitoring can be hypothesized, as circulating levels of the antigen seem to be dependent on the tumor mass.

Resource savings in the single reading of plain radiographs by oncologist only in cancer patient follow-up: a randomized study

The aim of this study was to estimate the need for a radiologist's clinical report in the interpretation of plain radiographs in cancer patient follow-up. Consecutive new cancer patients receiving primary treatment were randomized between two arms with different diagnostic modes: a double-reading arm (an oncologist and then a radiologist independently interpreted plain radiographs) and a single-reading arm (radiographs interpreted by an oncologist only; if necessary a radiologist's clinical report was obtained on separate request). Altogether 869 eligible patients participated. No differences were found in the total number of plain radiographs between the two arms. The number of radiologists was 20 and there were 28 oncologists. A separate clinical report was requested from a radiologist in 44% of all plain radiographs in the single-reading arm. This saving of radiologists' work (56%) took place without detriment, as the indicators of earliness of diagnosis were the same in both arms. The role of the radiologist should be more in consultation than in routine interpretation during follow-up.

Impact on survival of early detection of isolated breast recurrences after the primary treatment for breast cancer: a meta-analysis

PURPOSE

The purpose was to establish the impact on survival of early detection of a local recurrence of breast cancer as compared to late detection.

DESIGN

A meta-analysis was carried out using Cochrane review manager software (RevMan version 4.2). Studies were included if women were treated for primary breast cancer without evidence of distant metastasis at primary diagnosis and if these concerned routine follow-up strategies focusing on the early detection of curable recurrences. Data regarding the risk for death were derived from each study. Multi level models were used to study heterogeneity by using MLWin.

RESULTS

Thirteen studies concerning 2,263 patients were included. Early detection of breast cancer recurrences during follow-up gave a significantly better survival as compared to late detected recurrences (HR: 1.68 (95% CI: 1.48-1.91)). Survival was better when the recurrence was found by mammography instead of physical examination or in patients without symptoms as compared to those with symptoms (HR: 2.44 (95% CI: 1.78-3.35); HR: 1.56 (95% CI: 1.36-1.79), respectively). If all breast cancer recurrences would be detected earlier, that 5-8 deaths (i.e. an absolute reduction in mortality of 17-28%) would be avoided by performing routine follow-up during a 10 year-period for 1,000 breast cancer patients.

CONCLUSION

These data support the hypothesis that detection of isolated loco-regional or contra-lateral breast cancer recurrences in patients without symptoms has beneficial impact on survival of breast cancer patients when compared to late symptomatic detection.

Routine follow-up examinations in breast cancer patients have minimal impact on life expectancy: a simulation study

BACKGROUND

Little is known about the effects of routine follow-up examinations on life expectancy in cancer patients. Lately, the benefits of follow-up examinations have been debated, which has given rise to less extensive, though still frequent, follow-up strategies. In this study, a simulation model was applied to evaluate the impact of different follow-up strategies on life expectancy in breast cancer patients.

MATERIALS AND METHODS

A five-state Markov chain model was developed, with which various follow-up strategies with regard to frequency and elaborateness were simulated. Calculations were based on a hypothetical population of breast cancer patients treated with curative intent. Medical aspects were studied, such as life expectancy and the proportion of patients who died from breast cancer. Social and psychological aspects and quality of life were not taken into account. Data from the literature were used to estimate the parameters needed for the model.

RESULTS

The gain in life expectancy with standard follow-up compared to no follow-up examination, was about 2 months in breast cancer patients aged 50 years treated with curative intent. The percentage of patients who died from breast cancer was 45.4% with standard follow-up, versus 45.8% without follow-up. In older women, the gain was even less. Sensitivity analyses showed that the effects on life expectancy were robust.

CONCLUSIONS

Our model showed that standard follow-up had minimal impact on the prognosis of breast cancer patients. It may be unnecessary to continue standard follow-up by medical specialists after the end of the surveillance period of the primary therapy, provided that the patients continue to have easy access to health care facilities in the case of symptoms or concern. However, future research is needed to study quality of life aspects of follow-up.

Mandibular pain as the leading clinical symptom for metastatic disease: nine cases and review of the literature

BACKGROUND

Metastases to the jaws are a rare phenomenon. Nevertheless, the appearance of non-specific symptoms such as toothache can signal the onset of neoplastic disease in some patients.

PATIENTS

In this article, we present details of a 74-year-old patient with a history of breast cancer to illustrate this point. Retrospectively, covering a time span of one year, we could identify nine patients (1.2%) with metastatic disease to the mandible out of a total of 763 patients referred to our Maxillofacial Surgery department with non-specific jaw pain.

RESULTS

Four patients were subsequently diagnosed as having breast cancer, two had lung cancer, one prostate cancer, one renal cell carcinoma and one adenocarcinoma of unknown primary site. Only three of these patients had documented tumor spread to bones before the onset of jaw pain. In the other patients, the dental symptoms were either the first sign of a generalized neoplastic disease, or indicated relapse of disease after long term disease free interval. However, further work up disclosed generalized tumor spread with additional organ- or bone-lesions in all patients, and the median survival was only six months (range 3.5(-)+22) from diagnosis.

CONCLUSION

Pain of uncertain origin in the jaws should alert clinicians to the potential of metastatic disease in patients with a history of cancer and a bone scintigraphy should be done to rule out metastatic involvement. Although metastatic lesions in this area usually herald generalized neoplastic spread according to our experience, prompt diagnosis nevertheless can lead to useful palliation and an enhanced quality of life.

Clinical value of CA 15-3, mucin-like carcinoma-associated antigen, tumor polypeptide antigen, and carcinoembryonic antigen in monitoring early breast cancer patients

A total of 209 postsurgical breast cancer patients were prospectively monitored with simultaneous serum level estimations of CA 15,3, mucin-like carcinoma-associated antigen (MCA), tumor polypeptide antigen (TPA), and carcinoembryonic antigen (CEA); 141 (67.5%) were free of recurrence and 68 (32.5%) developed metastases during the follow-up. The mean values of tested tumor markers differed significantly in those with progressive disease compared with those free of disease recurrence. The sensitivity of tumor markers were CA 15-3, 68.2%; CEA, 34.1%; MCA, 72.7%; and TPA, 72.7%. The combination of CA 15-3 with TPA or MCA with TPA showed a trend for improved sensitivity of both markers (p = 0.06), with no specific loss of specificity (p = 0.11). The addition of CEA to CA 15-3 or MCA does not provide additional information for clinical evaluation. Patients with elevated tumor marker determinations had significantly shorter survival than those with values within the normal range. Two serial, progressively increasing values of tumor markers during the follow-up strongly predict recurrence. This study indicates that the comeasurement of CA 15-3 with TPA or MCA with TPA is justifiable in monitoring breast cancer patients postoperatively.

Recommendations on follow-up of breast cancer patients following primary therapy

Follow-up of breast cancer patients who have completed their primary therapy has not been standardized. The literature is reviewed and it is proposed that "minimal" follow-up with history and physical examination is the most appropriate procedure. Data show that more expensive imaging studies be carried out only in patients who are symptomatic from their disease, otherwise such an intensive follow-up schedule is not cost effective.

Detection of breast cancer local recurrences

BACKGROUND

Early detection of locoregional recurrences of breast cancer is possible with a variety of diagnostic methods. A combination of palpation, sonography and aspiration cytology is probably as accurate and certainly simpler, faster and cheaper compared to other more complicated and costly tests (computerized tomography, magnetic resonance imaging, lymphoscintigraphy). Retrospective studies have estimated that periodic observation may anticipate the detection of local symptomatic recurrences of about 3 months time with respect to their symptomatic onset. After correcting for lead time, this anticipated diagnosis has a moderate to null effect on prognosis (survival from primary treatment) in retrospective studies. According to their natural history, most local recurrences are just a local presentation of diffuse metastatization and, except for a few subgroups (isolated recurrent nodules in the mastectomy scar, isolated axillary nodes), prolonged disease-free survival suggests the absence of associated progressing systemic disease.

CONCLUSIONS

Periodic control aimed at the early detection of these local recurrences might be recommended, although the prognostic impact (if any) of such a policy is probably limited, and extremely large controlled studies would be necessary to demonstrate impact at a significant level.

Evaluating primary care follow-up of breast cancer: methods and preliminary results of three studies

OBJECTIVE

To evaluate a primary care centred system of routine follow-up of women with breast cancer in remission. DESIGN, PATIENTS AND OUTCOME MEASURES: Three related studies are reported: 1) A randomized controlled trial (RCT) involving 296 women with breast cancer in remission (stage I, II, or III) all receiving routine follow-up at two district general hospitals in England. Women in the control group received follow-up in hospital clinics according to the usual practice. Women in the experimental group received follow-up from their own general practitioners (GP), and were referred back to hospital clinics if any breast cancer related problems developed. The main outcome of the trial was 'diagnostic delay': the time from the first presentation of signs or symptoms suggestive of recurrence to the time that recurrence was diagnosed. 2) A prospective descriptive study of a cohort of 141 women who were eligible for the trial, but who declined to participate. 3) A national survey of 376 specialists in breast cancer, and a survey of 226 general practitioners of the patients eligible for the RCT described above, to determine their views on follow-up of breast cancer in remission.

RESULTS

1) The randomized trial to evaluate primary care follow-up of breast cancer in remission has been successfully conducted and final results are pending. 2) Patients who were eligible but declined to participate in the trial were significantly older than participants (mean age 64.3 years compared with 60.7 years; difference 3.6 years; 95% confidence interval 0.53; 6.59). The two groups were similar in clinical characteristics and quality of life. 3) The majority of specialists and GPs preferred a system of routine follow-up which was primarily provided by their own professional group.

CONCLUSIONS

A general practice centred system of routine follow-up of women with breast cancer in remission is acceptable to both patients and general practitioners. Final results of a randomized trial evaluating quality of care and quality of life outcome measures are pending.

The efficacy of intensive follow-up testing in breast cancer cases

BACKGROUND

A preliminary inquiry into the follow-up practices of Italian breast cancer centers revealed a considerable diversity of policy. It is clear that accurate follow-up examinations supply important information about the development of metastases, but there is no clinical proof that they extend survival time. It is possible that the effects of early diagnosis are only negative, extending the period over which the patient is aware of her illness and leading to over-diagnosis, overtreatment and increased health-care costs.

PATIENTS AND METHODS

In a study involving the national oncological centers, patients were randomized into two groups: an intensive follow-up group (6 monthly chest X-rays and bone scans) and a control group (clinical examination only).

RESULTS

An excess of isolated bone and intrathoracic metastases were observed in the intensive follow-up group. The survival curves showed no difference between the two groups.

CONCLUSIONS

Six monthly X-rays and bone scans provide occasion for early diagnosis of intrathoracic and bone metastases without, however, influencing overall 5-year survival. Recourse to diagnostic tests only in the presence of symptoms appears to be the most appropriate follow-up procedure. However, other studies considering long term effects of early diagnosis and the effects of considering long term effects of early diagnosis and the effects of new diagnostic tests and/or treatment modalities are clearly needed.

Routine follow-up of patients after primary therapy for early breast cancer: changing concepts and challenges for the future

In an era of increasing financial constraints, physicians are being forced to critically re-evaluate various clinical practices that have not been shown to be cost-effective or associated with definitive patient benefit. Routine follow-up programs following primary therapy for early-stage breast cancer vary widely from centre to centre, and although the subject of numerous retrospective analyses, they have not been prospectively evaluated to date. This review paper presents arguments for changing the emphasis of follow-up visits and stresses the need for prospective clinical and cost-benefit evaluations of current follow-up practices.

Follow-up of breast cancer patients stage I-II: a baseline strategy

In 430 stage I-II breast cancer patients the cost-benefit of investigations during follow-up have been studied. Median follow-up time was 8 years and 128 patients had relapsed, 91 with metastatic disease. High costs of routine chest X-ray, limited skeletal X-ray and bone scan examinations were associated with low incidence of diagnosed relapses not suspected otherwise. In the eight blood analyses examined, increases of more than 10 mm/h in erythrocyte sedimentation rate (ESR), 20 U/l in gamma-glutamyltransferase (GT) or 60 U/l in alkaline phosphatase (ALP) resulted in a combined sensitivity of 55% and specificity of 91% for relapses with distant metastases. Elevation of at least two blood tests gave a combined sensitivity of 31% and a specificity of 98%. The importance of using individual reference values in screening for recurrences is emphasised. Symptomatic relapse or relapse detected at interval visits were not independent prognostic factors. The blood tests ALP, ESR and GT were strong predictors of survival measured from relapse which increase their legitimacy in follow-up. A more frequent follow-up for patients with 4+ involved nodes is proposed: three visits annually the first 5 years vs. two visits annually for the others. We conclude that history, clinical examination, ALP, ESR and GT are sufficient as a baseline screening for relapse in breast cancer patients.

Influence of early diagnosis on prognosis of recurrent breast cancer

Between 1980 and 1986 676 patients with primary breast cancer were operated on with curative intention at the Department of Surgery, Hanusch Medical Center, Vienna, Austria. Of these, 133 had recurrences. The patients were closely followed at the Outpatient Clinic. The authors have retrospectively analyzed this patient collective to evaluate the impact of routine technical and laboratory-chemical follow-up programs on the detection rate of subclinical distant metastases and improvement of prognosis. There was no difference in outcome in terms of survival after recurrence and overall survival between patients with detection or recurrence in the asymptomatic stage who received general antitumoral therapy immediately, and a second group whose therapy was initiated upon clinical manifestation. The authors discuss the results in view of the screening costs. They emphasize the potential of follow-up programs due to timely detection of local recurrence, and observation of the contralateral breast, as well as the psychological aspect of a stable doctor-patient relationship.

A rational postoperative follow-up with carcinoembryonic antigen, tissue polypeptide antigen, and urinary hydroxyproline in breast cancer patients

Breast cancer patients (n = 224) aged 28 to 81 were postoperatively followed up with serial determinations of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), and urinary hydroxyproline (OHP). The clinical usefulness of these tumor markers to diagnose and monitor distant metastases was compared with that of the imaging techniques commonly used to monitor breast cancer patients (bone scanning [BS], liver echography [LE], chest radiograph, and skeletal radiograph). So far, 23 patients withdrew from the study, and distant metastases occurred in 33 patients. In 91% of the metastatic patients, constant elevation or progressive increase in serum CEA and/or TPA levels were the first pathologic findings of the relapse. Of the remaining 168 nonrelapsed patients, 122 were followed up longer than 24 months (43 +/- 17 months; mean +/- SD). In these 122 patients the false-positive results of CEA, TPA, and OHP were 0.8%, 2.4%, and 0%, respectively, when used simultaneously with clinical examination and the common laboratory examinations. BS and LE are the only imaging techniques that showed such a high sensitivity to be suitable in the postoperative follow-up of breast cancer patients. Nevertheless, because BS has a low specificity and is not harmless, it should be performed at longer intervals than tumor markers. Eventually, in the relapsed patients, TPA and OHP well reflected the response to treatment better than CEA and prevented useless radiologic examinations.

Metastatic pattern in recurrent breast cancer. Special reference to intrathoracic recurrences

The anatomical and temporal patterns of recurrence were studied in 401 patients with first recurrence of breast cancer. All patients underwent the same scheduled investigation program: history, physical examination, blood tests, bone scanning, bilateral iliac crest biopsy, radiologic bone survey, chest x-rays, and ultrasound scanning of the liver. The current article focuses on the diagnosis of intrathoracic (ITH) recurrence. Most patients recurred in a single site and 50% of the recurrences were diagnosed within the first 2 years from initial diagnosis. Chest x-ray revealed ITH recurrence in 27% (109 patients), and in 8% the lung, pleura, and/or mediastinum were the only signs of recurrence. Generally, the status of primary demographic, clinical, and pathoanatomical characteristics were not predictive as to the development of ITH recurrence, although patients with pleural recurrences often had centrally located primary tumors, locally advanced disease, and often received adjuvant radiotherapy. Clinical symptoms and signs of ITH recurrence were present in only one third of the patients, and the diagnostic specificity and sensitivity of serum lactate dehydrogenase were only 33% and 85%, respectively. Since ITH recurrences often are silent, and since recurrence in this site may have both prognostic and therapeutical implications, routine chest x-ray is indicated in all patients with first recurrence of breast cancer.

Preoperative staging of primary breast cancer. A multicentric study

This article reports on a consecutive series of 3627 breast cancer (BC) patients undergoing preoperative staging by chest x-ray (CXR), bone x-ray (BXR) or bone scintigraphy (BS), and liver ecography (LE) or liver scintigraphy (LS). The detection rate (DR) of preclinical asymptomatic distant metastases depended on the T and N category (TNM classification system), and was very low (CXR: 0.30%, BXR: 0.64%, BS: 0.90%, LE: 0.24%, LS: 0.23%). The sensitivity, determined after a 6-month follow-up, was below 0.50% for all tests. The highest value (0.48%) was recorded for BS, which also had the lowest specificity (0.95%). The entire preoperative staging policy using the studied tests seems questionable due to poor sensitivity and an extremely low DR of distant metastases.