Transcript Ongoing Surveillance After Active Therapy

Ongoing Surveillance After
Active Breast Cancer Therapy
EVIDENCE-BASED GUIDELINES
A N D R E C O M M E N D A TI O N S
ASCO 2006 Update
Breast Cancer Follow-Up Guidelines
 Experts from the American Society of Clinical
Oncology (ASCO) get together every few years to
review the latest trials and evidence related to
ongoing surveillance for breast cancer survivors
 Most recent meeting in 2006 produced a number of
guidelines, included in these slides
Main
finding
 “The evidence supports regular
history, physical examination,
and mammography as the
cornerstone of appropriate breast
cancer follow-up.”

J L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG.
Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society
of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and
Management Guidelines in the Adjuvant Setting. Journal of Clinical
Oncology 2006. 24:5091-5097.
Recommendations for Physical Examinations
Breast self-examination
All women should be counseled to perform
monthly breast self-examination.
History/physical examination
Every 3 to 6 months for the first 3 years
after primary therapy; every 6 to 12 months
for years 4 and 5; then annually.
Pelvic examination
Regular gynecologic follow-up is
recommended for all women. Patients who
receive tamoxifen should be advised to
report any vaginal bleeding to their
physicians.
J L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of
Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology
2006. 24:5091-5097.
Breast Self-Examination
2006 ASCO Guidelines
U.S. Preventive Services
Task Force Guidelines
 Recommend doctors to
 In 2009, released
teach women how to do
monthly selfexaminations for
follow-up
J L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss,
VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson.
American Society of Clinical Oncology 2006 Update of the Breast
Cancer Follow-Up and Management Guidelines in the Adjuvant
Setting. Journal of Clinical Oncology 2006. 24:5091-5097.
recommendations
against teaching
monthly self-exams for
screening
 No specific
recommendations for
breast cancer follow-up

Screening for Breast Cancer. USPSTF November 2009.
http://www.uspreventiveservicestaskforce.org/uspstf/usp
sbrca.htm
ASCO Guidelines on Mammograms
 First post-treatment mammogram 1 year after the
initial mammogram (leading to diagnosis)
 No earlier than 6 months after radiation therapy
 After the first year, mammograms every 6 months or
one year
J L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E
Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management
Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006. 24:5091-5097.
What is not
recommended
for routine
follow-up?
Routine blood
tests
Imaging studies
Tumor markers
Complete Blood
Counts and liver
function tests are not
recommended.
Chest x-ray, bone
scans, liver
ultrasound, CT scans,
FDG-PET scans, and
breast MRI are not
recommended.
CA 15-3, CA 27.29,
and CEA are not
recommended.
J L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield,
and N E Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and
Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006. 24:5091-5097.
The Evidence
 Trials showing no difference in overall survival or
disease-free survival between:
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Those followed with intensive imaging and lab tests
Those followed with routine clinical visits and mammography
 No evidence that breast MRI improves outcomes like
survival when used as routine follow-up in breast
cancer survivors without symptoms
 Evidence to show that additional imaging can result
in unnecessary surgical procedures
J L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of
Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology
2006. 24:5091-5097.
Italy
 A study looked at intensive diagnostic follow-up after
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treatment of primary breast cancer in breast cancer
clinics around Italy.
1243 participants
Patients in two treatment groups had physical
examination and mammography
Patients of the intensive follow-up group also had
chest X-ray and bone scan every 6 months
No significant difference in 5-year overall mortality
observed between the two follow-up groups
M. Rosselli Del Turco, D. Palli, A. Cariddi, S. Ciatto, P. Pacini, V. Distante. Intensive diagnostic follow-up after treatment of primary breast cancer. A
randomized trial. National Research Council Project on Breast Cancer follow-up. JAMA. 1994 May 25; 271(20): 1593–1597.
GIVIO Trial
 1320 patients from 26 hospitals in Italy were
randomly assigned to two groups:
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intensive surveillance (including bone scan, liver echography,
chest X-rays, and laboratory tests)
control regimen in which patients were seen by their
physicians at the same frequency but only clinically indicated
tests were performed
 The study found no significant difference between
the two groups in survival after an average of 6 years
 No significant difference in time to detection of
recurrence
Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. A multicenter randomized controlled trial. The GIVIO
Investigators. Jama. 1994;271:1587–92.
Breast MRI
 MRI is the most sensitive breast imaging tool (88-
100%)
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Sensitivity = the % of positive cases identified correctly
 Expensive and only moderate specificity (37-70%)
 Specificity = the % of negative cases identified correctly
 MRI is most valuable when conventional imaging is
unable to detect the presence or extent of a
malignancy, not in routine use
J L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of
Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology
2006. 24:5091-5097.
Caveats
 The ASCO guidelines are voluntary
 They do not apply to all women
 They do not stand in the place of physician judgment
 More complex clinical situations call for more
sensitive tests
J L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of
Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical
Oncology 2006. 24:5091-5097.
Where to Read More
ASCO and USPSTF Guidelines
 http://jco.ascopubs.org/content/24/31/5091.full.pdf
 http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm
Studies
 Impact of follow-up testing on survival and health-related quality of life in
breast cancer patients. A multicenter randomized controlled trial. The GIVIO
Investigators. Jama. 1994;271:1587–92.
http://www.ncbi.nlm.nih.gov/pubmed/8182811
 M. Rosselli Del Turco, D. Palli, A. Cariddi, S. Ciatto, P. Pacini, V. Distante.
Intensive diagnostic follow-up after treatment of primary breast cancer. A
randomized trial. National Research Council Project on Breast Cancer followup. JAMA. 1994 May 25; 271(20): 1593–1597.
http://www.ncbi.nlm.nih.gov/pubmed/7848404