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Leoni M, Sadacharan R, Louis D, Falcini F, Rabinowitz C, Cisbani L, De Palma R, Yuen E, Grilli R. Variation among Local Health Units in Follow-Up Care of Breast Cancer Patients in Emilia-Romagna, Italy. TUMORI JOURNAL 2018; 99:30-4. [DOI: 10.1177/030089161309900105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background This study examines the patterns of follow-up care for breast cancer survivors in one region in Italy. Methods and study design This retrospective analysis included 10,024 surgically treated women, with incident cases of breast cancer in the years 2002–2005 who were alive 18 months after their incidence date. Rates of use of follow-up mammograms, abdominal echogram, bone scans and chest x-rays were estimated from administrative data and compared by Local Health Unit (LHU) of residence. Logistic regression analyses were performed to assess possible “overuse”, accounting for patient age, cancer stage, type of surgery and LHU of residence. Results A total of 7168 (72.1%) women received a mammogram within 18 months of their incidence date, while 6432 (64.2%) had an abdominal echogram, 3852 (38.4%) had a bone scan and 5231 (52.2%) had a chest x-ray. The rates of use of abdominal echograms, bone scans and chest x-rays were substantially higher in the population of breast cancer survivors than in the general female population. Taking account of patient age, cancer stage at diagnosis and type of surgery, multivariate analyses demonstrated significant variation in the use of these tests by LHU of residence. Conclusions The observed variation in the use of abdominal echograms, bone scans and chest x-rays supports the conclusion that there is substantial misuse of these tests in the population of postsurgical breast cancer patients in the Emilia-Romagna region in Italy. In the absence of a documented survival benefit, overtesting has both a human and financial cost. We recommend additional review of the methods of follow-up care in breast cancer patients in the LHUs of Emilia-Romagna, with the aim of developing, disseminating and evaluating the implementation of specific guidelines targeting primary care physicians and oncologists providing care to breast cancer survivors. Patient education materials may also help to reduce unnecessary testing.
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Affiliation(s)
- Maurizio Leoni
- Ospedale Civile Ravenna, Ravenna, Italy
- Agenzia Sanitaria e Sociale Regionale, Regione Emilia-Romagna, Italy
| | - Radha Sadacharan
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel Louis
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Carol Rabinowitz
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Elaine Yuen
- Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Roberto Grilli
- Agenzia Sanitaria e Sociale Regionale, Regione Emilia-Romagna, Italy
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2
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Järvenpää R, Holli K, Hakama M. Resource savings in the single reading of plain radiographs by oncologist only in cancer patient follow-up: a randomized study. Acta Oncol 2009; 44:149-54. [PMID: 15788294 DOI: 10.1080/02841860510007602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Ritva Järvenpää
- Department of Diagnostic Radiology, Tampere University Hospital, Tampere, Finland.
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3
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Bristow AR, Agrawal A, Evans AJ, Burrell HC, Cornford EJ, James JJ, Hamilton L, Robertson JFR, Chan SY, Lawton PA, Cheung KL. Can computerised tomography replace bone scintigraphy in detecting bone metastases from breast cancer? A prospective study. Breast 2008; 17:98-103. [PMID: 17890090 DOI: 10.1016/j.breast.2007.07.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2007] [Revised: 07/24/2007] [Accepted: 07/25/2007] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The aim of this study was to determine whether bone scans (BS) can be avoided if pelvis was included in CT thorax and abdomen to detect bony metastases from breast cancer. MATERIALS AND METHODS Results of 77 pairs of CT (thorax, abdomen, and pelvis) and BS in newly diagnosed patients with metastatic breast cancer (MBC) were compared prospectively for 12 months. Both scans were blindly assessed by experienced radiologists and discussed at multidisciplinary team meetings regarding the diagnosis of bone metastases. RESULTS CT detected metastatic bone lesions in 43 (98%) of 44 patients with bone metastases. The remaining patient had a solitary, asymptomatic bony metastasis in shaft of femur. BS was positive in all patients with bone metastases. There were 11 cases of false positive findings on BS. CONCLUSION Our findings suggest routine BS of patients presenting with MBC is not required if CT (thorax, abdomen, and pelvis) is performed.
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Affiliation(s)
- A R Bristow
- Division of Breast Surgery, University of Nottingham, UK
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4
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Järvenpää R, Holli K, Hakama M. Double-reading of plain radiographs – no benefit with regard to earliness of diagnosis of cancer recurrence: a randomised follow-up study. Eur J Cancer 2004; 40:1668-73. [PMID: 15251155 DOI: 10.1016/j.ejca.2004.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2004] [Revised: 03/01/2004] [Accepted: 03/02/2004] [Indexed: 11/20/2022]
Abstract
The aim of this study was to estimate the effect of the radiologist's interpretation of plain radiographs on the earliness of diagnosis of cancer recurrences. Data consisted of patients who had undergone primary treatment and were resident in the Tampere University Hospital Area in Finland during 1991-1997. Consecutive patients were randomised in a double-reading arm (an oncologist and a radiologist independently interpreting radiographs), and in a single-reading arm (interpretation by an oncologist only; if necessary, a radiologist's clinical report was obtained following a separate request). The time of diagnosis of recurrence and death were estimated by the cumulative probabilities of actuarial method with the Wilcoxon (Gehan) test. There were 869 eligible participants, mostly breast cancer patients (n = 516). In total, 227 recurrences were diagnosed, and of these 55 on plain radiographs, which is 24.2% of the total number of recurrences. There was no statistically significant difference between the arms in the number of recurrences (P = 0.85) or in the time of detecting the recurrence (P = 0.64). Altogether, 225 (25.9%) died from cancer and 38 (4.4%) from other causes. There was no statistically significant difference (P = 0.34) in survival between the two arms during the follow-up to 5 years. Double-reading of plain radiographs does not offer any extra benefit for the detection of recurrences or for patient's survival compared with single-reading.
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Affiliation(s)
- Ritva Järvenpää
- Department of Diagnostic Radiology, Tampere University Hospital, Tampere, Finland.
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5
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Abstract
Adenocarcinoma of the breast is the most common cancer of American women. Increased incidence and reduced mortality have generated a population of more than 2 million breast cancer survivors who require medical follow-up. In addition to therapy-related complications, these women are at risk for locoregional recurrence, distant relapse, and the development of second primary breast tumors. Medical surveillance after primary breast cancer treatment has historically included regular patient history and physical examinations, complete blood cell counts, comprehensive blood chemistries, tumor markers, mammography, chest x-rays, and sometimes computed tomography (CT) and nuclear medicine bone scans. The use of such intensive surveillance was based on the presumption that detecting disease recurrence at its earliest stage would offer the chance of cure, improved survival, or at least improved quality of life. Here we review the evidence that such intensive surveillance is not cost-effective, and in fact has no significant impact on the overall survival or quality of life of women diagnosed with early-stage breast cancer. Finally, we present an evidence-based approach to breast cancer surveillance after therapy that is consistent with several clinical practice guidelines, maximizing outcome and minimizing cost.
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Affiliation(s)
- Leisha A Emens
- Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA
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6
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El-Tamer M, Hussain S, Weedon J, Chalchal H, Chakrabarti A, Sohn C, Braverman AS. Prognoses of T4 breast cancer subsets. Ann Surg Oncol 2002; 9:340-5. [PMID: 11986185 DOI: 10.1007/bf02573868] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The relative prognoses of subsets of patients with T4 breast tumors, since the advent of neoadjuvant therapy, are unknown, although inflammatory carcinoma (T4d) is considered to have the worst prognosis. METHODS Subsets of T4 patients were analyzed for the incidence of distant metastases at presentation (M1; n = 263). T4M0 patients treated with neoadjuvant therapy (n = 126) were analyzed for relapse-free survival (RFS). T4d tumors with (Cut/CW+) and without (Cut/CW-) skin nodules, posterior fixation, or both were analyzed separately. RESULTS Fewer patients with T4d (Cut/CW-) tumors had distant metastases at presentation than T4d (Cut/CW+) patients or T4b and T4c patients (P =.001,.001, and.009, respectively). RFS was longer for T4b patients than for T4c patients (P =.018) or T4d (Cut/CW+) patients (P =.003). RFS of the T4d (Cut/CW+) patients was shorter than for T4d (Cut/CW-) patients (P =.050). CONCLUSIONS The incidence of distant metastases at presentation was lowest, and RFS was longest, for patients with T4d tumors not grossly involving the skin or posterior structures. Patients whose tumors grossly invaded both skin and posterior structures (T4c) or those with T4d tumors grossly invading either most frequently presented with distant metastases and had the shortest RFS.
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Affiliation(s)
- Mahmoud El-Tamer
- Department of Surgery, Columbia Presbyterian Medical Center, New York, New York, USA
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7
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Jacobson AF, Shapiro CL, Van den Abbeele AD, Kaplan WD. Prognostic significance of the number of bone scan abnormalities at the time of initial bone metastatic recurrence in breast carcinoma. Cancer 2001; 91:17-24. [PMID: 11148555 DOI: 10.1002/1097-0142(20010101)91:1<17::aid-cncr3>3.0.co;2-k] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND To gain insight into the factors that contribute to the more favorable prognosis associated with recurrence limited to bone in patients with breast carcinoma, the authors analyzed the number of sites of initial involvement identified on radionuclide bone scans in relation to long term outcome. METHODS Records of 641 patients with clinical Stage I-III breast carcinoma that originally was diagnosed in 1974-1985 were reviewed. During follow-up, 295 patients (46%) experienced distant recurrence, including 116 with bone as the sole initial site of metastatic disease. Radionuclide bone scans identified the initial site(s) of recurrence in 113 of these latter 116 patients, and these studies were categorized by the number of skeletal lesions subsequently confirmed as metastases (1, 2, or > or = 3). Survival from time of recurrence and time of original diagnosis was analyzed using Kaplan-Meier methods, and factors associated with recurrence and mortality were examined using logistic and Cox regression. RESULTS Median survival from time of recurrence was 35 months in the patients with bone-only metastases, compared with 11-26 months for all other sites of visceral recurrence exclusive of bone. Number of positive lymph nodes and estrogen receptor status were the only predictive variables for recurrence. Median survival from time of recurrence and time of original diagnosis for the 3 bone scan categories was: 1 lesion (n = 47), 53 and 86 months; 2 lesions (n = 22), 38 and 68 months; and > or = 3 lesions (n = 44), 22 and 58 months (P < 0.0001 and P < 0.005 for 1 and 2 lesions vs. > or = 3). In the "bone-only" group, the number of scan lesions was the strongest predictor of length of survival. CONCLUSIONS Patients with breast carcinoma who experience a recurrence in bone at only one or two sites initially have a survival advantage over those with more extensive (> or = 3 sites) skeletal metastases and those with metastatic disease involving other visceral organs.
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Affiliation(s)
- A F Jacobson
- Nuclear Medicine Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington 98108, USA.
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8
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Chen EA, Carlson GA, Coughlin BF, Reed WP, Garb JL, Frank JL. Routine chest roentgenography is unnecessary in the work-up of stage I and II breast cancer. J Clin Oncol 2000; 18:3503-6. [PMID: 11032591 DOI: 10.1200/jco.2000.18.20.3503] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Clinical practice guidelines of many professional societies call for routine staging chest x-rays (SCXR) for all patients with invasive cancer. Given the estimated 157,000 patients annually for whom this recommendation pertains, this screening examination represents a considerable health care expenditure. If it were shown that SCXR rarely changed the management of low-risk subsets of this population, it might be possible to selectively omit this practice from the care of these patients with substantial resultant cost savings. PATIENTS AND METHODS All patients with clinical stage I and II breast cancer presenting to the Baystate Medical Center from 1989 through 1997 were identified through the Tumor Registry. Their hospital records were reviewed for clinical presentation and documentation of SCXR. RESULTS One thousand four hundred ninety-four patients were identified with clinical stage I and II disease. SCXR were available for review on 1,003 patients. Only one asymptomatic patient was upstaged to stage IV based on a SCXR. Two patients with primary lung tumors were also identified. These data demonstrate an asymptomatic pulmonary metastasis detection rate of 0. 099% (95% confidence interval, 0.0% to 0.6%). The total charges of SCXR for this group approached $180,000. CONCLUSION These data demonstrate the low diagnostic yield and high cost of routine SCXR in the management of asymptomatic patients with clinical stage I and stage II breast cancer. Because other studies have shown that SCXR changes neither quality of life nor overall survival, SCXR should be limited to symptomatic patients in whom metastatic disease is suspected.
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Affiliation(s)
- E A Chen
- Departments of Surgery and Radiology, Baystate Medical Center, Springfield, MA 01199, USA
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9
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Bradburn MJ, Altman DG, Smith P, Fentiman IS, Rubens RD. Time trends in breast cancer survival: experience in a single centre, 1975-89. Br J Cancer 1998; 77:1944-9. [PMID: 9667672 PMCID: PMC2150356 DOI: 10.1038/bjc.1998.322] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The aim of this retrospective cohort study was to investigate whether survival of patients with breast cancer has changed over the period 1975-89. A total of 2604 women diagnosed as having invasive breast cancer at a clinical oncology unit in London were followed up for between 5 and 20 years. Patients were divided into four groups according to menstrual status (pre or post) and the staging of cancer (operable or inoperable). For each group, survival from diagnosis was compared between three consecutive 5-year cohorts, both with and without adjustments made for relevant prognostic factors. No temporal patterns were found in patients with inoperable cancer, in whom the survival rate was consistently low. Of women with operable cancers, differences were seen only among post-menopausal women, for whom the best survival patterns were seen in patients diagnosed between 1985-89. This is probably due to tamoxifen being commonly prescribed as adjuvant treatment for this cohort of patients. We cannot explain an apparently worse survival in the group of patients presenting in the early 1980s compared with that observed in the late 1970s.
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Affiliation(s)
- M J Bradburn
- Imperial Cancer Research Fund Medical Statistics Group, Centre for Statistics in Medicine, Institute of Health Sciences, Oxford, UK
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10
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Abstract
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.
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11
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Abstract
Bone metastases are a frequent cause of morbidity in patients with malignant disease. Pain is the commonest symptom; it can be treated successfully in the majority of patients by local external beam irradiation. Controversy exists over which regimen should be used, with a single dose necessitating only one treatment visit to the radiotherapy department, or a fractionated course requiring several visits. Many radiotherapists continue to use fractionated regimens despite the current evidence that single fractions are as effective. Many reasons exist for this, including departmental policy and training, fears of recurrence, problems with retreatment of previously treated areas, fears of increased early and late morbidity, and attempts at promoting recalcification. The majority of these reasons are theoretical and have yet to be substantiated. In many patients, symptomatic bone metastases are widespread, and hemibody irradiation, although more toxic, should be considered in order to avoid the need for repeated courses of local treatment.
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12
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Brown ML. BONE SCINTIGRAPHY IN BENIGN AND MALIGNANT TUMORS. Radiol Clin North Am 1993. [DOI: 10.1016/s0033-8389(22)02638-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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13
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Coleman RE, Fogelman I, Habibollahi F, North WR, Rubens RD. Selection of patients with breast cancer for routine follow-up bone scans. Clin Oncol (R Coll Radiol) 1990; 2:328-32. [PMID: 2278890 DOI: 10.1016/s0936-6555(05)80995-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Routine radionuclide bone scans have not been considered cost-effective for the routine follow-up after treatment of primary breast cancer. However subgroups of patients exist in whom early relapse in the skeleton is likely and this study examines again the role of the bone scan in routine follow-up. Serial radionuclide bone scans were performed every 6 months during the first 2 years of follow-up of 560 patients with breast cancer. Tumor characteristics which predict early relapse in bone were identified and the scan conversion rate from negative to positive determined for each prognostic group. A total of 199 (28%) of patients have relapsed, 50 (9%) with first recurrence in bone within two years of diagnosis. All were identified on the bone scan with a median lead time of 4 months over radiological evidence of bone involvement. The overall scan conversion rate was 2.8%. This was significantly higher in poor prognosis patients with T4 tumours (6.3%), more than four involved axillary lymph nodes (6.1%) and inoperable tumours (6.5%), than in good prognosis patients with T1 tumours (1.1%), negative axillary lymph node involvement (1.2%) or well-differentiated ductal grade tumours (1.1%). We do not recommend routine bone scans in the follow-up of all patients with breast cancer. In patients with a good prognosis after primary treatment they cannot be considered cost-effective. However, in those with features which predict early recurrence in the skeleton the frequency of scan conversion is sufficient to justify serial bone scanning during the first two years of follow-up.
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Affiliation(s)
- R E Coleman
- Imperial Cancer Research Fund Clinical Oncology Unit, London, UK
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14
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Schünemann H, Langecker PJ, Ellgas W, Leonhardt A, Merkl H. Value of bone scanning in the follow-up of breast cancer patients. A study of 1000 cases. J Cancer Res Clin Oncol 1990; 116:486-91. [PMID: 2229139 DOI: 10.1007/bf01612999] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The aim of the study was to assess the value of routine bone scintigrams, independent of the primary tumor stage or the presence of symptoms, in the postsurgical follow-up of breast cancer patients for the early detection of bone metastases. For this purpose 1,000 patients with postsurgical breast cancer without previous documentation of metastatic disease, who were admitted to the special oncology hospital, Onkologische Klinik Bad Trissl, entered a prospective study in 1987-1988. The parameters followed were the TNM stage of the primary tumor, the presence of pain, bone pain as revealed by a thorough physical examination, and the patient's history for the assessment of risk factors. In addition, a whole-body skeletal scintigram, supplementary X-rays, and additional diagnostic measures were performed, if necessary, to detect bone metastases. It was shown that in 856 of 894 patients (groups 1-6) without clinical symptoms, the clinical examination and radiological and scintigraphic diagnostic measurements, demonstrating the absence of bone metastases, gave matching results, but in 12 of the 894 patients the results of all examinations remained questionable. In another 12 of the 894 patients (groups 1-3) radiological and/or scintigraphical evidence for the presence of bone metastases was found. In 14 of 79 cases (groups 7-10) with clinically suspicious symptoms these were proven to be signs of metastases by subsequent scintigrams, supplementary X-rays, and additional diagnostic measures. In 65 of the 79 patients with clinically suspicious symptoms, bone metastases could not be confirmed by obtaining bone scintigrams or X-rays while in the other 14 patients (groups 9 and 10) evidence for the presence of bone metastases was found in the scintigrams and/or X-rays. However, 10 of these 14 patients were high-risk patients for developing bone metastases as they had axillary lymph node infiltration. The other 4 patients were of the low-risk group as they had positive receptor status or no axillary lymph node infiltration at the time of primary diagnosis. In 13 of 27 patients (groups 11-14) with clinical symptoms indicating the presence of bone metastases this diagnosis was confirmed by scintigrams and/or X-rays (groups 11 and 12), while it was possible to exclude the presence of bone metastases in spite of the symptoms in 11 of the 27 patients. In the other 3 patients the results of the additional examinations remained questionable.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- H Schünemann
- Onkologische Klinik Bad Trissl im Tumorzentrum München, Federal Republic of Germany
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15
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Kamby C. The pattern of metastases in human breast cancer: methodological aspects and influence of prognostic factors. Cancer Treat Rev 1990; 17:37-61. [PMID: 2224869 DOI: 10.1016/0305-7372(90)90075-q] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- C Kamby
- Department of Oncology ONK, Finsen Institute-Rigshospitalet, Copenhagen, Denmark
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16
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Filderman AE, Coppage L, Shaw C, Matthay RA. Pulmonary and Pleural Manifestations of Extrathoracic Malignancies. Clin Chest Med 1989. [DOI: 10.1016/s0272-5231(21)00662-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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17
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Abstract
This study evaluates the usefulness of routine follow-up of breast cancer patients. In all, 416 patients who were treated with curative intent for breast cancer were followed according to a fixed follow-up schedule for a minimum of 2.5 years and a maximum of 13.5 years (mean about 5 years). During the 4533 routine out-patient visits, 4116 chest radiographs, 3889 pelvic radiographs and about 17,000 laboratory tests were carried out routinely. In the follow-up period, 148 patients were found to have distant recurrence of whom 34 (23 per cent) had asymptomatic metastases and 114 symptomatic metastases. Of the 8005 routinely performed radiographs, 24 (0.3 per cent) revealed asymptomatic metastases, and the 17,000 laboratory tests led to the discovery of six asymptomatic bone and four asymptomatic liver recurrences. Screening for metastases did not result in a reduction of the lead time to the diagnosis of asymptomatic metastases; the disease-free interval was equal in both symptomatic and asymptomatic patients. Of the 46 locoregional recurrences 42 were found by physical examination during a routine follow-up visit and 37 had not been noticed by the patient. Seventeen second primary breast cancers were diagnosed, six of which were in stage I (less than 2 cm). Mammography was not a part of the routine follow-up scheme. It is concluded that routine follow-up of breast cancer patients by history and physical examination is sufficient to detect local recurrence and a second primary tumour as well as giving the opportunity to track signs and symptoms of distant recurrence at an early stage. Performing annual or biannual mammography is advisable, but the use of other costly routine investigations in the follow-up is not justifiable, as no therapeutic advantages can be expected.
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Affiliation(s)
- E J Rutgers
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam
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18
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Jungi WF, Streit AI, Schmid L, Senn HJ. Detection of recurrence: a critical assessment of existing methods and programs. Recent Results Cancer Res 1989; 115:83-91. [PMID: 2696045 DOI: 10.1007/978-3-642-83337-3_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- W F Jungi
- Medizinische Klinik C, Kantonsspital, St. Gallen, Switzerland
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19
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White H, Parker MC. Follow-up of Surgical Cancer Patients. Surg Oncol 1989. [DOI: 10.1007/978-3-642-72646-0_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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20
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Grimard L, Eapen L, McDermot R, Genest P, Nair R. Does parasternal irradiation reduce thoracic vertebral metastases in breast cancer? Int J Radiat Oncol Biol Phys 1988; 14:565-9. [PMID: 3343166 DOI: 10.1016/0360-3016(88)90276-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A review of 197 patients with bone metastases from breast carcinoma was undertaken to assess the effect of adjuvant parasternal irradiation on the distribution of those metastases. A total of 128 patients (Group I) received radiation. The control group consisted of 69 patients (Group II) who did not receive adjuvant radiation. The dose absorbed by the mid-thoracic vertebrae (T3 to T8) varied from 10 Gy in 3 weeks to 20 Gy in 4 weeks. The distribution of bone metastases was analyzed at the initial development in the 197 patients. Repeat assessments (X ray/scans) were available for analysis in 132 patients. Patients in Group I had less metastases from T3 to T8: 37/128 (29%), vs 30/69 (43.5%) for patients in Group II: (chi 2 = 3.62; p less than 0.10). For the 132 patients with serial assessments, the difference at last evaluation was more significant: 45/86 (52%) in Group I, vs 36/46 (78%) in Group II: (chi 2 = 7.44; p less than 0.01). The data shows that patients receiving low-dose exit beam irradiation from the parasternal field have fewer mid-thoracic bone metastases. Potential implications are discussed.
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Affiliation(s)
- L Grimard
- Ottawa Regional Cancer Centre, Civic Hospital Division, Ontario, Canada
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21
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Maisey MN. Imaging techniques in breast cancer. What is new? What is useful? A review. EUROPEAN JOURNAL OF CANCER & CLINICAL ONCOLOGY 1988; 24:61-8. [PMID: 3276534 DOI: 10.1016/0277-5379(88)90177-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- M N Maisey
- Division of Radiological Sciences, United Medical School, Guy's Hospital, London, U.K
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22
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Kamby C, Vejborg I, Daugaard S, Guldhammer B, Dirksen H, Rossing N, Mouridsen HT. Clinical and radiologic characteristics of bone metastases in breast cancer. Cancer 1987; 60:2524-31. [PMID: 3664434 DOI: 10.1002/1097-0142(19871115)60:10<2524::aid-cncr2820601030>3.0.co;2-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Metastatic bone disease was evaluated in 380 consecutive patients at the time of first metastasis of breast cancer. Studies included radiographic examination, radionuclide examination, and bone marrow biopsy. Radiographs of the skeleton demonstrated metastases in 120 patients (32%), and in 40 of these patients (13%) the bone was the only site of metastases. The diagnostic efficiency was 82% for bone scanning, 80% for pain evaluation, 59% for s-calcium analyses, and 77% for s-alkaline phosphatase analyses. Bone scanning is an effective method to exclude metastatic bone disease (sensitivity: 96%). A positive scan, however, requires radiologic confirmation (specificity: 66%). Bone scanning of the skeleton should be the initial staging procedure in all patients with recurrent breast cancer with no clinical or biochemical signs of bone metastases. Bilateral posterior iliac crest bone marrow aspirations and bone biopsies were positive in 82 out of the 320 patients who underwent biopsy. The frequency of positive bone marrow biopsy was significantly correlated with both the site of radiographic metastases and with the total number of involved bone regions. Routine bone marrow biopsies are indicated in patients with a positive bone scan, but a negative x-ray examination. In these cases biopsies should be performed bilaterally.
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Affiliation(s)
- C Kamby
- Department of Oncology ONA, Finsen Institute, Copenhagen, Denmark
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23
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Abstract
Interest in cancer of the breast has begun to yield a concentrated sequence of specific information as to its basic nature, dietary influences, and its hormonal and genetic determinants. Clearly, the advent of improved early diagnosis has allowed the presentation to the clinician of a more favorable aspect of the tumor than has previously been seen, and has altered the overall clinical character of the disease. These advances open the possibilities of greatly expanded and enhanced treatment options, both for the informed physician and the inquiring patient. The rewards of early diagnosis include the possibilities of functional reconstruction, which may alter the potential patient attitude to such an extent that even earlier diagnosis will be achieved in years ahead. The complex issues of multimodality therapy and the honest and valid stratification of patients are the key issues in the further study of this challenging illness.
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24
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Ormiston MC, Timoney AG, Qureshi AR. Is follow up of patients after surgery for breast cancer worthwhile? J R Soc Med 1985; 78:920-1. [PMID: 4067960 PMCID: PMC1290000 DOI: 10.1177/014107688507801108] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The effectiveness of routine outpatient follow up in detecting recurrent disease after 'curative' surgery for breast cancer has been evaluated in a retrospective study of 148 patients. In all, 32 patients developed recurrent cancer. In 3 cases, asymptomatic disease was discovered by routine X-rays. In 25 cases, the patient noticed local disease or complained of symptoms due to distant spread, and over half of these returned to the clinic before the next routine appointment. In only 4 cases was routine examination by a doctor solely responsible for the discovery of recurrent disease. It is concluded that routine follow up made little contribution to the welfare of these patients.
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25
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Goris ML, Bretille J. Skeletal scintigraphy for the diagnosis of malignant metastatic disease to the bones. Radiother Oncol 1985; 3:319-29. [PMID: 3892595 DOI: 10.1016/s0167-8140(85)80045-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The use of skeletal scintigraphy for the detection of metastatic disease of the bone is reviewed. The review is based on published data for sensitivity, specificity, yield and prognostic value. The analysis, and interpretation of published data is complicated by the variation in criteria. It appears nonetheless, that for a number of tumors the relative (in comparison with other methods) and absolute (based on outcome prediction) sensitivity is high. For certain tumors in early stages, and in asymptomatic patients the yield (of positive studies) is low, even when the prognostic value is high. Those factors should be weighed with the availability of therapeutic options to determine the clinical efficacy of skeletal scintigraphy.
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26
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Viola P, Carnovali M, Marcangeli M, Martignoni G, Montoli A, Panozzo M, Pavia G, Confalonieri C. Follow-Up after Mastectomy for Breast Cancer. Observations in 96 Patients. TUMORI JOURNAL 1985; 71:187-91. [PMID: 4002349 DOI: 10.1177/030089168507100215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
From 1978 to 1982 at the Oncology Unit of the Rho Hospital, we followed 96 women who had been operated for breast cancer. In 22 cases (23%) the first signs of recurrence were changes in the following: physical examination (9), symptoms (7), ESR (3), bone scan (2), alkaline phosphatase (1), chest X-ray (1). An adequate follow-up schedule is based on the following: a) limited examinations causing little disturbance to the patient, easily feasible, sensitive, specific, and of limited cost; b) lead-intervals of various tests set according to the risk of relapse; c) critical periodic review of the series, with constant updating of information in the literature.
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27
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Abstract
This article reviews recent literature on a variety of primary and secondary bone tumors in an attempt to indicate the use of bone scans in the peri- and posttreatment phases. The data indicate that the yields and value of bone scans are tumor specific and that for some tumors (particularly breast and prostate) interpretation of studies on patients undergoing hormonal or chemotherapy can be complicated by the "flare phenomenon." Data are still needed on the rate of development of bone metastases in the follow-up period on a stage-specific and therapy-specific basis.
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