Early-Stage Breast Cancer

MIAMI BEACH—The prevailing evidence shows that routine use of laboratory studies and imaging to monitor for recurrence in asymptomatic patients with early-stage breast cancer is of no value, a recommendation that is part of the guidelines of both the American Society of Clinical Oncology and the National Comprehensive Cancer Network. The topic was discussed here at the Miami Breast Cancer Conference by Hyman B. Muss, MD, Director of Oncology at the University of North Carolina and Director of Geriatric Oncology at the Lineberger Comprehensive Cancer Center. Muss noted that both ASCO and the NCCN suggest that routine follow-up care be limited to clinical history and physical examinations, yearly mammography, gynecologic examinations (especially for women taking tamoxifen), and assessment for genetic counseling. Because metastatic breast cancer remains incurable regardless of the volume of disease when first detected, routine use of costly, high-technology studies should be discouraged, he said. “The most difficult issue about applying these guidelines is convincing patients that some of the amazing technologies we have—circulating tumor cells, tumor markers, exquisite imaging procedures—don't save lives.” The current guidelines are prudent, Muss said, and are also part of ASCO's Choosing Wisely list of tests and procedures to question (www.choosingwisely.org/doctor-patient-lists/american-society-of-clinical-oncology)—“I recommend that we all adhere to these follow-up guidelines,” Muss said. Perception off on Tumor Markers Assaying tumor markers in the follow-up is controversial in the setting of early-stage disease, he noted. Even though there is no evidence that these assays are useful in this setting, there is a strong perception among patients and some physicians that the tests are helpful. “I tell women [who want tumor marker tests] that about 30 percent of women who die of breast have tumor markers that are normal,” he said. It's a psychological burden for the patient and for the oncologist when the tumor marker finding goes up slightly but nothing is found on CT scans and other tests—“The patient is sitting by the telephone for months after [the test], and it is miserable.” Still, recurrences can come on very quickly, Muss said, and some 30 to 40 percent of occurrences are found between routine visits. “Instruct your patients on the signs and symptoms of metastasis,” he said: Bone: pain and tenderness; Skin: characteristics of lesions; Lung: dyspnea, pleurisy; CNS: focal findings, loss of function; and Gastrointestinal: pain, fatigue. “And give everybody the ASCO follow-up guidelines,” he said. “They're easy to get and print out from cancer.net/survivorship—and document it!” Who Should Do the Follow Up? “Are oncologists the best resource for serving these patients?” Muss asked. “We [oncologists] are running out of manpower, and there is evidence that family physicians do as good a job in monitoring for recurrence as oncologists.” He noted a Canadian study several years ago of 968 patients with early-stage breast cancer assessed nine to 15 months after diagnosis, randomly selected between 1997 and 2001 for follow-up with either an oncologist or a family physician (Grunfeld et al: JCO 2006;6:848-855). The family physicians were provided with appropriate guidelines. The recurrence rates were 11.2 percent for family doctors and 13.2 percent for oncologists; mortality rates were 6.0 versus 6.2 percent, respectively; and the rates of serious events were 3.5 versus 3.7 percent. “In other words, in terms of the patients' physical and mental health, there was no difference between the family doctors or oncologists doing the follow-up,” Muss said. He added, however, that the situation is a bit different today, with the importance of compliance with endocrine therapy—the standard of care for follow-up, in addition to detect clinical recurrence, is to monitor compliance with endocrine therapy. “The majority of breast cancer survivors now have ER-positive disease, but there is tremendous drop-off in compliance with endocrine therapy. And if they are on aromatase inhibitors, you've got to pay attention to bone health.” What's the Rush? Finally, Muss addressed that underlying question: “What's the rush to find metastatic disease?” He listed nine clinical trials of first-line chemotherapy for metastatic breast cancer, in which median survival was 15 to 20 months. “And some trials now are up to 25 months,” he said. “That improvement may be due to better medical treatments or to lead time bias with better imaging or to both, but in any case there is no hurry to find incurable disease in patients who are asymptomatic.” It is even questionable whether such studies detect metastasis earlier than waiting for symptoms of metastasis to appear, he said. “We are not doing patients any service, not with the current state of technology.”

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