Evaluation of an intensive strategy for follow-up and surveillance of primary breast cancer

Breast Cancer Circulating Tumor Cells: Current Clinical Applications and Future Prospects

BACKGROUND

Identification and characterization of circulating tumor markers, designated as "liquid biopsies," have greatly impacted the care of cancer patients. Although more recently referring to circulating tumor DNA (ctDNA), the term liquid biopsy initially was coined to refer to any blood-borne biomarker related to malignancy, including circulating tumor cells (CTCs) in blood. In this manuscript, we review the specific state of the art of CTCs in breast cancer.

CONTENT

Liquid biopsies might play a clinical role across the entire spectrum of breast cancer, from risk assessment, prevention, screening, and treatment. CTC counts have been shown to carry clear, independent prognostic information in the latter situation. However, the clinical utility of CTCs in breast cancer remains to be determined. Nonetheless, in addition to CTC enumeration, analyses of CTCs provide tumor molecular information representing the entire, often-heterogeneous disease, relatively noninvasively and longitudinally. Technological advances have allowed the interrogation of CTC-derived information, providing renewed hope for a clinical role in disease monitoring and precision oncology.

SUMMARY

This narrative review examines CTCs, their clinical validity, and current prospects of clinical utility in breast cancer with the goal of improving patient outcomes.

Changes of Tumor Markers in Patients with Breast Cancer during Postoperative Adjuvant Chemotherapy

Objective. Serum tumor marker (STM) elevation can detect metastasis earlier than imaging diagnosis and, although not recommended by guidelines, is still widely used in clinical practice for postoperative follow-up of breast cancer patients. The purpose of this study was to investigate the change rules of CEA and CA153 in patients with HER2-negative breast cancer during postoperative adjuvant chemotherapy and their influencing factors. Materials and Methods. The medical records of patients with HER2-negative early breast cancer who visited Xuanwu Hospital from September 2018 to June 2021 were retrospectively analyzed. Demographic characteristics and baseline data of CEA and CA153 at initial diagnosis were collected. Data of CEA, CA153, biochemistry (including ALT, AST, rGT, triglycerides, cholesterol, and blood glucose) and blood routine (including white blood cells, neutrophils, monocytes, lymphocytes, and platelets) were also collected before chemotherapy, at the end of chemotherapy and more than 3 months after the end of chemotherapy. LY/MONO, NEUT/LY, PLT/LY, and systemic immune inflammation index (SII) were calculated and statistically analyzed using SPSSAU software. Results. A total of 90 patients were enrolled, all of whom were female, with a mean age of $55.11\pm 10.60$  y. The value of CEA at initial diagnosis was $2.10\pm 1.11$  ng/mL, and high expression was mostly correlated with past history of chronic diseases and tumor lymph node metastasis; the value of CA153 was $11.80\pm 6.60$  U/mL, and high expression was correlated with high SII at initial diagnosis. Surgery did not affect the values of serum CEA and CA153. At the end of chemotherapy, CEA and CA153 were $2.68\pm 1.34$  ng/mL and $18.51\pm 8.50$  U/mL, respectively, which were significantly increased compared with those before chemotherapy, and were linearly correlated with the values before chemotherapy. They decreased (CEA $2.45\pm 1.19$  ng/mL, CA153 $10.87\pm 5.96$  U/mL) again three months after the end of chemotherapy, manifested as “spiking” phenomenon, which was associated with lymph node metastasis at diagnosis, body metabolic disorders, and chronic inflammatory status. Conclusion. CEA and CA153 were increased presenting as “spiking” phenomena in patients with early HER2-negative breast cancer during postoperative adjuvant chemotherapy, and the peak of increase was linearly correlated with the indicators before chemotherapy. Clinical attention should be paid to this change to avoid excessive diagnosis and treatment leading to medical resource consumption.

Temporality and Patterns of Metastatic Recurrence in Node-Positive Breast Cancer Following Trimodality Therapy: Opportunity for Improved Oligometastases Detection and Salvage Local Therapy

OBJECTIVES

There is evidence that detection and treatment of oligometastases (≤5 lesions) may improve survival in breast cancer patients. However, there are no current national guidelines for screening of early, asymptomatic metastases. This study examined the patterns and timing of recurrence with respect to survival in node-positive breast cancer (NPBC) patients at higher risk for developing metastases.

METHODS

A single-institution retrospective review of NPBC patients treated with trimodality therapy was performed to collect patient and disease characteristics, recurrence location, method of detection, and survival outcome. Univariate and multivariate analyses were done to identify factors associated with recurrence.

RESULTS

Ninety-four NPBC patients treated at a safety-net hospital between 2008 and 2019 were identified. Twenty-one developed recurrence and were divided into oligometastatic (OM) (n=10) or diffusely metastatic (DM) (n=11) subgroups. Median recurrence-free survival in OM and DM was 18 and 36 months, respectively. Median overall survival (OS) for OM was not reached. Median OS for DM was 57 months. Four patients with OM progressed to diffuse disease in a median period of 17 months; median survival thereafter was 57 months. All patients with recurrence had distant metastases on initial detection, with the most common site being bone (14). Recurrence was most frequently detected by computed tomography (CT) (13), with the majority of disease located within the thorax region.

CONCLUSIONS

All NPBC patients had distant metastasis at time of recurrence. Patients with OM had shorter interval to recurrence yet longer OS compared with DM. This study highlights improved surveillance imaging for timely detection of OM breast cancer that may yet be amenable to aggressive local salvage therapy to prevent progression to diffuse disease.

Detection of secondary metastatic breast cancer by measurement of plasma CA 15.3

BACKGROUND

Most current guidelines do not recommend the serial analysis of tumour marker CA 15.3 in the follow-up of asymptomatic patients treated for early breast cancer (EBC). These guidelines are based on small-scale studies carried out in an era with more limited treatment options than today. In our large academic centre, serial measurements of CA 15.3 are used routinely in the follow-up of EBC, whereas imaging for distant metastases is only carried out on indication.

PATIENTS AND METHODS

In this retrospective single-centre study, patients were included if they were treated for EBC between 1 January 2000 and 1 January 2018, diagnosed with secondary metastatic disease at least 6 months after initial surgery and had CA 15.3 available at the time of diagnosis of metastases. The primary objective was to evaluate the proportion of patients in whom metastatic disease was discovered by an increasing CA 15.3. Information on the method of metastases detection, CA 15.3 evolution and survival was collected after approval of the ethics committee.

RESULTS

At the moment of diagnosis of metastases, 451 of 730 included patients (62%) had CA 15.3 levels above the upper limit of normal (>30 kU/l). In 269 patients (37%), an increasing CA 15.3 was the first sign that led to the diagnosis of metastases. This was most frequent in luminal A-like tumours (48%) and in liver (45%) and bone (41%) localisation of metastases. By contrast, reported symptoms triggered the diagnosis of metastatic disease in 48% of the patients. Median overall survival was significantly longer when the relapse was discovered by CA 15.3 elevation versus those discovered by another trigger (abnormal clinical examination or history, abnormal laboratory tests or an incidental finding) (35 versus 22 months; P = 0.0027).

CONCLUSION

When CA 15.3 is systematically used in the follow-up of EBC patients, the diagnosis of metastatic disease is made in 37% by a CA 15.3 increase.

Screening women with a personal history of breast cancer: overview of the evidence on breast imaging surveillance

This work reviews the evidence on breast imaging for screening (surveillance) in women with a history of breast cancer (BC). Early detection of second BCs in these women improves their prognosis based on studies using mammography (usually with clinical examinations) for surveillance. Cohort studies have estimated that mammography surveillance has moderate sensitivity (65.4%) and good specificity (98.3%), and have shown that these women are at a higher risk of interval BC than age- and breast density-matched women without a history of BC. Studies of adjunct imaging (ultrasound, magnetic resonance imaging) for surveillance that have reported detection and accuracy measures have generally shown that adjunct imaging detected more second BCs than mammography and added substantially to the amount of false-positive results; however, little evidence exists regarding screening efficacy of adjunct imaging as part of routine surveillance.

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.

Usefulness of abbreviated breast MRI screening for women with a history of breast cancer surgery

PURPOSE

We investigated the usefulness of abbreviated breast MRI (AB-MRI), including fat-suppressed T2-weighted imaging, pre- and postcontrast image acquisition, and subtracted maximum-intensity projection imaging, for the screening of women with a history of breast cancer surgery.

METHODS

Between October 2014 and March 2016, a total of 799 AB-MRI examinations were performed for 725 women with a history of breast cancer surgery. The image acquisition time was 8.5 min. Screening mammography, ultrasound, and AB-MRI were generally performed around the same time. The cancer detection rate, positive predictive values for recall and biopsy, sensitivity and specificity of screening MRI, and rate of malignancy belonging to each breast imaging reporting and data system (BI-RADS) category were assessed.

RESULTS

AB-MRI detected 12 malignancies in 12 women (15.0 cancers per 1000 cases). Seven of these 12 malignancies were initially invisible on ultrasound and mammography, although subsequent targeted ultrasound revealed lesions corresponding to the MRI-detected lesions. The positive predictive values for recall and biopsy and sensitivity and specificity values for screening MRI were 12.4, 61.5, 100, and 89.2%, respectively. The rates of malignancies belonging to categories 1, 2, 3, and 4 of the BI-RADS were 0, 0, 4.8, and 57.1%, respectively.

CONCLUSIONS

The diagnostic performance of screening AB-MRI for women with a history of breast cancer surgery is acceptable, with the advantages of short examination and interpretation times and low costs. Thus, it could be used as a main screening modality that may replace conventional imaging in breast cancer survivors.

Clinical and imaging surveillance following breast cancer diagnosis

Breast cancer is the most common malignancy affecting women worldwide. Women have a 1 in 8 lifetime risk of breast cancer. Breast conservation therapy (BCT) is the most common method of definitive treatment. Patients who previously have had to undergo mastectomy may be now eligible for BCT or a multitude of options for reconstruction, either immediate or delayed. Surveillance imaging after a breast cancer diagnosis is important because there is an increased risk of recurrence developing in patients, and early detection has been shown to improve survival. There is currently no consensus on a protocol for imaging the postoperative breast. In patients who have undergone mastectomy, detection of recurrence has mostly been via clinical symptoms and physical exam, often at a later stage. New imaging modalities, such as magnetic resonance imaging (MRI), ultrasound (US), and positron emission mammography (PEM) are changing the way we image the postsurgical breast. MRI, coupled with physical exam and mammography, approaches 100% sensitivity and high specificity for the identification of recurrent disease. We present a review of major academic institutions' imaging protocols and discuss the advantages of including MRI in traditional mammographic and clinical exams.

Breast magnetic resonance imaging (MRI) surveillance in breast cancer survivors

PURPOSE

As the breast cancer survivor population increases, the topic of screening these women for recurrences is increasingly relevant. In our institution, we use both breast MRI and mammography in the surveillance of breast cancer survivors, although little data exists on the use of MRI in this setting. We present a retrospective analysis of our experience and compare the sensitivity and specificity of MRI vs. mammography in this setting.

METHODS

We identified women under 65 with a history of breast cancer and at least one follow-up MRI performed along with a mammogram done within 6 months of the MRI. We compared the outcomes of MRI and mammography in terms of biopsies performed as well as in detection of new cancers.

RESULTS

Of 617 charts reviewed, 249 patients met inclusion criteria, with 571 paired MRI/mammogram results. There were 27 biopsies performed due to MRI findings alone, 10 done due to mammographic findings alone, and 15 done based on abnormalities seen on both imaging modalities. There were 8 malignancies identified based on an abnormal MRI, 3 detected on both MRI and mammography, and none identified via mammography alone. Overall, MRI had a sensitivity of 84.6% (the 95% CI 54.6-98.1) and a specificity of 95.3% (the 95% CI 93.3-96.9); mammography a sensitivity of 23.1% (the 95% CI 5.0-53.8), and a specificity of 96.4% (the 95% CI 94.5-97.8).

CONCLUSIONS

Breast MRI is a useful surveillance modality in breast cancer survivors and may be more sensitive at detecting recurrences than mammography alone in this population.

The diagnostic value of 18F-FDG PET/CT in association with serum tumor marker assays in breast cancer recurrence and metastasis

Background. After initial treatment of breast cancer (BC), monitoring locoregional recurrence and distant metastases is a great clinical challenge. Objective. To evaluate the efficacy of PET/CT in association with serum tumor makers in BC follow-up. Methods. Twenty-six women with a history of modified radical mastectomy were evaluated by ¹⁸F-FDG PET/CT. The results of PET/CT were compared with those of conventional imaging techniques (CITs) (including mammography, chest radiography, CT, MRI, ultrasound, and bone scintigraphy). Serum tumor markers of CEA, CA 125, and CA 15-3 in the BC patients were also analyzed in association with the results of PET/CT. Results. Compared with CITs, PET/CT was more sensitive to detect the malignant foci and had better patient-based sensitivity and specificity. The mean CA 15-3 serum level was significantly higher in the confirmed positive patients of PET/CT results than in the confirmed negative ones, while there were no significant differences in the serum levels of CEA and CA 125 of both groups. Conclusion. PET/CT is a highly efficient tool for BC follow-up compared with CITs. The high serum levels of CA 15-3 in confirmed positive PET/CT patients indicated the clinical value of CA 15-3 in BC follow-up.

Impact on Survival of Regular Postoperative Surveillance for Patients with Early Breast Cancer

Purpose

The purpose of this study is to evaluate the role of regular postoperative surveillance to improve the prognosis of patients with breast cancer after curative surgery.

Materials and Methods

We retrospectively analyzed the medical records of 4,119 patients who received curative surgery for breast cancer at Samsung Medical Center between January 2000 and September 2008. Patients were divided into two groups (group I, regular postoperative surveillance; group II, control group) according to their post-therapy follow-up status for the first 5 years after surgery.

Results

Among the 3,770 patients selected for inclusion, groups I and II contained 3,300 (87%) and 470 (13%) patients, respectively. The recurrence rates at 5 years for groups I and II were 10.6% and 16.4%, respectively (hazard ratio, 0.85; 95% confidence interval [CI], 0.67 to 1.09; p=0.197). The 10-year mortality cumulative rates were 8.8% for group I and 25.4% for group II (hazard ratio, 0.28; 95% CI, 0.22 to 0.35; p < 0.001). In multivariate analysis for recurrence-free survival (RFS), age over 40 years (p < 0.001), histologic grade 1 (p < 0.001), and pathologic stage I (p < 0.001) were associated with longer RFS but not with follow-up status. Multivariate analysis for overall survival (OS) revealed that patients in group I showed significantly improved OS (hazard ratio, 0.29; 95% CI, 0.23 to 0.37; p < 0.001). Additionally, age over 40 years, histologic grade I, and pathologic stage I were independent prognostic factors for OS.

Conclusion

Regular follow-up for patients with breast cancer after primary surgery resulted in clinically significant improvements in patient OS.

Tumor marker usage and medical care costs among older early-stage breast cancer survivors

PURPOSE

Although American Society of Clinical Oncology guidelines discourage the use of tumor marker assessment for routine surveillance in nonmetastatic breast cancer, their use in practice is uncertain. Our objective was to determine use of tumor marker tests such as carcinoembryonic antigen and CA 15-3/CA 27.29 and associated Medicare costs in early-stage breast cancer survivors.

METHODS

By using Surveillance, Epidemiology, and End Results-Medicare records for patients diagnosed with early-stage breast cancer between 2001 and 2007, tumor marker usage within 2 years after diagnosis was identified by billing codes. Logistic regression models were used to identify clinical and demographic factors associated with use of tumor markers. To determine impact on costs of care, we used multivariable regression, controlling for other factors known to influence total medical costs.

RESULTS

We identified 39,650 eligible patients. Of these, 16,653 (42%) received at least one tumor marker assessment, averaging 5.7 tests over 2 years, with rates of use per person increasing over time. Factors significantly associated with use included age at diagnosis, diagnosis year, stage at diagnosis, race/ethnicity, geographic region, and urban/rural status. Rates of advanced imaging, but not biopsies, were significantly higher in the assessment group. Medical costs for patients who received at least one test were approximately 29% greater than costs for those who did not, adjusting for other factors.

CONCLUSION

Breast cancer tumor markers are frequently used among women with early-stage disease and are associated with an increase in both diagnostic procedures and total cost of care. A better understanding of factors driving the use of and the potential benefits and harms of surveillance-based tumor marker testing is needed.

Promoting quality and evidence-based care in early-stage breast cancer follow-up

Evidence-based guidelines for long-term follow-up of early-stage breast cancer patients developed by oncology societies in the United States and Europe recommend that breast cancer survivors undergo regular evaluation with history and physical examination, as well as annual mammography. Routine blood tests, circulating tumor markers, and/or surveillance imaging studies beyond mammography are not recommended in the absence of concerning symptoms or physical examination findings because of lack of supportive clinical evidence. Despite these guidelines, studies have shown that 20% to 40% of oncologists assess serum tumor markers as part of routine monitoring of early-stage breast cancer patients. As part of efforts to both address the financial challenges confronting the health-care system and optimize patient outcomes, the American Society of Clinical Oncology's Cost of Care Task Force identified adherence to breast cancer surveillance guidelines as an opportunity to improve care and reduce cost. However, these recommendations are based on trials done in an era of outdated technology and limited therapeutic options. It is possible that recent improvements in diagnostics and treatments could make earlier detection of recurrent disease important for improving both survival and quality of life outcomes. Research is necessary to further inform optimal breast cancer follow-up strategies, which could impact these recommendations. At this time, outside of well-conducted clinical trials, there is no role for ordering routine serial blood or imaging tests in monitoring for recurrence in early-stage breast cancer patients.

Follow-up care in breast cancer

Improved early diagnosis and treatment of breast cancer has resulted in a significant decrease in breast cancer-related mortality in many countries. Breast cancer survivors live longer. As a consequence, the prevalence of breast cancer survivors will rise and will put an increasing burden on follow-up oncology clinics. Follow-up of breast cancer patients should be aimed at the detection of curable disease and must comply with the needs of the patient. Regular physical examination may be useful for timely discovery of locoregional relapse, and screening mammography for the early detection of a second primary breast cancer or breast relapse after breast-conserving therapy. Onerous searching for distant metastases by routine investigations will not improve life expectancy of the patient and may even be harmful because of false-positive findings and false expectations and reassurance. Patients seek emotional support, information, physical and cosmetic recovery and prompt access to the oncologist in case of worrying complaints, signs or symptoms. Support, information and screening for relatively healthy patients can be provided by breast care nurse practitioners or family practitioners. For more complex issues, such as debilitating functional treatment regimens, estrogen deprivation symptoms, pregnancy after breast cancer or symptoms suspicious for a relapse, an experienced oncologist should be at hand.

Serum tumor markers in patients with breast cancer

Several serum tumor markers have been investigated in patients with breast cancer for assessing outcome, predicting recurrence and monitoring the therapeutic response. There is a general consensus concerning their limited application in diagnosing malignancy; however, serum tumor markers can be considered for the early detection of recurrence. The most effective markers for this indication are cancer antigens (CA)15-3 and 27.29, and c-erbB-2, although their efficacy in establishing disease progression has not been determined to date. In terms of evaluating prognosis and predicting response to therapy, only the expression of c-erbB-2 has clinical evidence. To conclude, at present, no serum tumor marker is cost effective, and none can be used with confidence in the decision making regarding breast cancer patients.

Is a comparative clinical trial for breast cancer tumor markers to monitor disease recurrence warranted? A value of information analysis

BACKGROUND

Breast cancer tumor markers are used by some clinicians to screen for disease recurrence risk. Since there is limited evidence of benefit, additional research may be warranted.

AIM

To assess the potential value of a randomized clinical trial of breast tumor marker testing in routine follow-up of high-risk, stage II-III breast cancer survivors.

MATERIALS & METHODS

We developed a decision-analytic model of tumor marker testing plus standard surveillance every 3-6 months for 5 years. The expected value of sample information was calculated using probabilistic simulations and was a function of: the probability of selecting the optimal monitoring strategy with current versus future information; the impact of choosing the nonoptimal strategy; and the size of the population affected.

RESULTS

The value of information for a randomized clinical trial involving 9000 women was US$214 million compared with a cost of US$30-60 million to conduct such a trial. The probability of making an alternate, nonoptimal decision and choosing testing versus no testing was 32% with current versus future information from the trial. The impact of a nonoptimal decision was US$2150 and size of population impacted over 10 years was 308,000. The value of improved information on overall survival was US$105 million, quality of life US$37 million and test performance US$71 million.

CONCLUSION

Conducting a randomized clinical trial of breast cancer tumor markers appears to offer a good societal return on investment. Retrospective analyses to assess test performance and evaluation of patient quality of life using tumor markers may also offer valuable areas of research. However, alternative investments may offer even better returns in investments and, as such, the trial concept deserves further study as part of an overall research-portfolio evaluation.

International guidelines for management of metastatic breast cancer (MBC) from the European School of Oncology (ESO)-MBC Task Force: Surveillance, staging, and evaluation of patients with early-stage and metastatic breast cancer

In clinical practice, the surveillance and follow-up of patients with breast cancer (BC) is quite variable. At the 7th European Breast Cancer Conference, the ESO-MBC Task Force convened a series of lectures, followed by open debate, on the use of physical examination, imaging, and laboratory tests in patients with early-stage BC, and for restaging evaluations and follow-up among patients with MBC. Based on the available data, the Task Force recommends against intensive, routine radiologic or blood-based surveillance (with the exception of mammography) in patients with early-stage BC. As systemic therapies for MBC continue to improve, this question might be re-visited in the context of a carefully controlled clinical trial in specific BC subtypes. For patients with MBC, response to therapy should generally be assessed 2-3 months after initiation of treatment, and thereafter every 2-4 months for endocrine therapy or every 2-4 cycles for chemotherapy, depending on the dynamics of the disease, the location and extent of metastatic involvement, and type of treatment. Additional testing should be performed irrespective of the planned intervals if progression of disease is suspected (e.g. in the case of specific symptoms). Use of tumor markers is not recommended for surveillance of early-stage patients, but may be helpful in monitoring response to therapy in patients with metastatic disease. However, change in tumor markers alone should not be used for decision-making. Moving forward, enhanced efforts to document quality of life over time should be made in order to more fully evaluate the risk/benefit ratio of available options.

Outcomes of surveillance for contralateral breast cancer in patients less than age 60 at the time of initial diagnosis

BACKGROUND

After an initial diagnosis of breast cancer, the risk of contralateral breast cancer is approximately 0.5% per year. Annual mammography is recommended to identify local recurrences and contralateral new primaries. Because the sensitivity of mammography tends to be lower in younger women, we conducted a retrospective review of the method of detection and pathologic stage of metachronous contralateral primary breast cancers according to age at diagnosis in a cohort of breast cancer patients.

METHODS

The Henrietta Banting Database contains information on cases of breast cancer diagnosed at Women's College Hospital from 1987 to 2004. From among 1992 women in the database, 71 patients were identified who were initially diagnosed before age 60 and who subsequently developed a contralateral breast cancer. Medical records were obtained for 53 of the 71 patients.

RESULTS

Of the 53 contralateral cancers, 33 (62%) were detected by mammography, including 4 in 16 patients (25%) diagnosed before age 50 and 29 in 37 patients (78%) diagnosed at age 50 or older (p ≤ 0.001).

CONCLUSIONS

Mammography has poor sensitivity for the surveillance of contralateral breast cancer in early-onset breast cancer patients. Other imaging modalities should be evaluated in this setting.

First indicators of relapse in breast cancer: evaluation of the follow-up program at our hospital

BACKGROUND

Guidelines for breast cancer patient follow-up have not been widely adopted in Japan. To assess our intensive follow-up program, we evaluated first relapse and its indicators in patients with breast cancer.

PATIENTS

Of 964 patients, 126 relapsed and 43 died in the median follow-up term of 45 months. Follow-ups were scheduled every 6-12 months for imaging and tumor marker (TM) evaluation.

RESULTS

Of 126 relapsed patients, 30 (23.8%) had symptoms of relapse. First indicators of relapse in 96 asymptomatic patients were physical examination in 24 patients (19%); imaging, 57 patients (45.3%); and TMs, 15 patients (11.9%). The most sensitive indicators were physical examination for local relapse, ultrasonography for regional lymph nodes, scintigraphy for bone, computed tomography for lung, and TMs for liver metastasis. During intensive follow-up, 43% of relapsed patients were identified by symptoms or physical examination. These patients had poor prognosis compare to patients identified by imaging or TMs in overall survival and post-relapse survival (p = 0.009 and 0.019, respectively). In all 964 patients, the relapse rates for stage I, IIA, IIB, and III tumors were 7.4, 7.9, 19.9, and 43.5%, respectively. The percentage of first relapse detected by imaging or TMs for stage I, IIA, IIB, and III were 4.7, 5.1, 11.8, and 19.8%, respectively. The cost of our follow-up program for 10 years was approximately 290,000 yen per patient.

CONCLUSION

A routine intensive follow-up program involving imaging and evaluation of TMs in all patients has low efficacy and high expenditure.

Surveillance mammography for detecting ipsilateral breast tumour recurrence and metachronous contralateral breast cancer: a systematic review

Objectives

To determine the diagnostic accuracy of surveillance mammography for detecting ipsilateral breast tumour recurrence and metachronous contralateral breast cancer in women previously treated for primary breast cancer.

Methods

A systematic review of surveillance mammography compared with ultrasound, magnetic resonance imaging (MRI), specialist-led clinical examination or unstructured primary care follow-up, using histopathological assessment for test positives and follow-up for test negatives as the reference standard.

Results

Nine studies met our inclusion criteria. Variations in study comparisons precluded meta-analysis. For routine ipsilateral breast tumour detection, surveillance mammography sensitivity ranged from 64–67% and specificity ranged from 85–97%. For MRI, sensitivity ranged from 86–100% and specificity was 93%. For non-routine ipsilateral breast tumour detection, sensitivity and specificity for surveillance mammography ranged from 50–83% and 57–75% and for MRI 93–100% and 88–96%. For routine metachronous contralateral breast cancer detection, one study reported sensitivity of 67% and specificity of 50% for both surveillance mammography and MRI.

Conclusion

Although mammography is associated with high sensitivity and specificity, MRI is the most accurate test for detecting ipsilateral breast tumour recurrence and metachronous contralateral breast cancer in women previously treated for primary breast cancer. Results should be interpreted with caution because of the limited evidence base.

Key Points

• Surveillance mammography is associated with high sensitivity and specificity

• Findings suggest that MRI is the most accurate test for detecting further breast cancer

• Robust conclusions cannot be made due to the limited evidence base

• Further research comparing surveillance mammography and other diagnostic tests is required

Mammographic surveillance in women with a personal history of breast cancer: how accurate? How effective?

We review the accuracy and potential effect of mammography in surveillance of women with a personal history of breast cancer (PHBC). A literature review was performed to identify studies on screening mammography or breast surveillance reporting data on the accuracy or detection capability of mammography, or the effect of early detection of second breast cancers, in women with a PHBC. Evidence on mammography screening in women with PHBC comes from non-randomised studies, and is generally limited by several factors including design limitations. The proportion of ipsilateral breast recurrences detected with mammography ranges between 50% and 80% (including cancers detected also on clinical examination) but is lower at 8%-51% for mammography-only detection. Mammography detects approximately 45%-90% of contralateral cancers. There is evidence of a potential benefit for asymptomatic/early-detected second breast cancers (range of estimated hazard ratios: 0.10-0.86) relative to symptomatic or clinical-detection, in various surveillance strategies that include mammography, however these estimates are likely to have overestimated screening benefit. New evaluations of screening women with a PHBC are needed from screening programs or population datasets, to provide comprehensive measures of screening accuracy and outcomes in this population of women.

18F-FDG-PET/CT in patients with breast cancer and rising Ca 15-3 with negative conventional imaging: a multicentre study

OBJECTIVES

Breast cancer is the second cause of death in women in Europe and North America. The mortality of this disease can be reduced with effective therapy and regular follow up to detect early recurrence. Tumor markers are sensitive in detecting recurrent or residual disease but imaging is required to customize the therapeutic option. Rising tumor markers and negative conventional imaging (US, X-mammography, CT and MR) poses a management problem. Our aim is to assess the role of 18F-FDG-PET/CT in the management of post-therapy patients with rising markers but negative conventional imaging.

MATERIALS AND METHODS

In the period from January 2008 to September 2009, 89 female patients with breast cancer who developed post-therapy rising markers (serum Ca 15-3 levels=64.8±16.3 U/mL) but negative clinical examination and conventional imaging were investigated with 18F-FDG-PET/CT.

RESULTS

Tumor deposits were detected in 40/89 patients in chest wall, internal mammary nodes, lungs, liver and skeleton. The mean SUVmax value calculated in these lesions was 6.6±1.7 (range 3.1-12.8). In 23/40 patients solitary small lesion were amenable to radical therapy. In 7 out of these 23 patients a complete disease remission lasting more than 1 year was observed.

CONCLUSIONS

18F-FDG-PET/CT may have a potential role in asymptomatic patients with rising markers and negative conventional imaging. Our findings agree with other studies in promoting regular investigations such as tumor markers and 18F-FDG-PET/CT rather than awaiting the developments of physical symptoms as suggested by current guidelines since the timely detection of early recurrence may have a major impact on therapy and survival.

Impact of surveillance on survival after laryngeal cancer in the medicare population

OBJECTIVES/HYPOTHESIS

Routine surveillance is advocated to detect recurrent disease after treatment for laryngeal cancer. This aim of this study was to determine the 1- and 5-year postrecurrence mortality for laryngeal cancers and evaluate whether more intensive surveillance improved survival.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients with recurrent cancers (1992-1999) were identified in a national cancer clinical database. Multivariate analysis was used to evaluate the effect of surveillance on postrecurrence survival.

RESULTS

Of 2,121 recurrent cancers identified, 913 were laryngeal. Patients with laryngeal cancer recurrence had 27% (P = .001) and 22% (P = .007) better odds of 1- and 5-year survival than other sites. The 1- and 5-year postrecurrence survival rates for laryngeal cancer patients were 72.4% and 41.3%, respectively. Glottic cancer cases had the best postrecurrence life expectancy. Multivariate regression revealed that clinical surveillance intensity had no independent impact on their survival (P < .05). However, patients with recurrent glottic cancer seen in surveillance had 23% improved odds of survival (P = .037).

CONCLUSIONS

More frequent surveillance visits was not associated with a survival advantage in the overall population. Patients with glottic cancer had a postrecurrence survival advantage if seen during the surveillance period. Laryngeal cancer patients had better postrecurrence survival than other head and neck sites.

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.

F-18-fluoro-2-deoxyglucose positron emission tomography/computed tomography in the follow-up of breast cancer with elevated levels of tumor markers

OBJECTIVE

The value of combined positron emission tomography (PET)/computed tomography (CT) in the follow-up of patients with breast cancer with elevated tumor markers but without proven metastases or local recurrence was assessed.

METHODS

Thirty-four women underwent PET/CT. The PET and CT images were first analyzed separately; fused findings were then interpreted, blinded to the results of the other modalities. The results of CT, PET, and PET/CT were compared with each other and correlated to the final diagnosis.

RESULTS

The PET/CT identified 149 malignant foci in 24 patients (71%). The CT detected 96 of these foci in 18 patients, whereas PET identified 124 foci in 17 patients. Differences between CT and PET were not significant. Differences between PET/CT and CT (P < 0.01) and PET/CT and PET (P < 0.01) were significant. The person-based sensitivity of PET/CT, PET, and CT was 96%, 88% and 96%, respectively. Specificity of PET/CT, PET, and CT was 89%, 78%, and 78%, respectively.

CONCLUSIONS

The PET/CT is a valuable modality for the follow-up of patients with breast cancer and elevated levels of tumor markers.

Surveillance mammography after breast conservation therapy in Hong Kong: effectiveness and feasibility of risk-adapted approach

Annual surveillance mammography is commonly recommended after breast conservation therapy (BCT). We retrospectively reviewed its effectiveness on 511 invasive and non-invasive breast cancers treated with BCT between 1994 and 2003. The median follow-up was 5.9 years. The 5-year actuarial ipsilateral breast tumour recurrence (IBTR) rate was 4.5% and contralateral breast cancer (CBC) rate was 2.0% (representing eight times increase in risk). IBTR of 43% and 62% CBC were first detected by surveillance mammography. The IBTR detection rates per 1000 mammograms were 5.2 for patients (n=349) with one or more IBTR risk factors (age 45, positive/close margins or histological grade 3) and 0.6 for patients (n=162) without. No survival difference was observed between different modes of IBTR detection (p=0.342). In conclusion, a risk-adapted approach of limiting ipsilateral surveillance to patients with IBTR risk is possible but its implementation will be complicated by the continued need of contralateral surveillance.

Breast Cancer: Pre- and Postoperative Imaging for Staging

Mammography is considered the "gold standard" in the evaluation of the breast from an imaging perspective. Multiple studies have demonstrated the benefit of mammography in detecting smaller cancers, leading to identification of early-stage breast cancers, which largely accounts for decreased mortality from breast cancer and the increased rate of breast conservation. Identification of a suspicious lesion on a mammogram prompts further evaluation including additional mammographic views, ultrasound examination, and biopsy. Recently, MRI and positron emission tomography are being offered as adjuncts to the preoperative workup to better stage the patient; however, there is still controversy over the most appropriate use of these modalities.

American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting

Purpose

To update the 1999 American Society of Clinical Oncology (ASCO) guideline on breast cancer follow-up and management in the adjuvant setting.

Methods

An ASCO Expert Panel reviewed pertinent information from the literature through March 2006. More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a randomized design.

Results

The evidence supports regular history, physical examination, and mammography as the cornerstone of appropriate breast cancer follow-up. All patients should have a careful history and physical examination performed by a physician experienced in the surveillance of cancer patients and in breast examination. Examinations should be performed every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter. For those who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed. Patients at high risk for familial breast cancer syndromes should be referred for genetic counseling. The use of CBCs, chemistry panels, bone scans, chest radiographs, liver ultrasounds, computed tomography scans, [18F]fluorodeoxyglucose–positron emission tomography scanning, magnetic resonance imaging, or tumor markers (carcinoembryonic antigen, CA 15-3, and CA 27.29) is not recommended for routine breast cancer follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination.

Conclusion

Careful history taking, physical examination, and regular mammography are recommended for appropriate detection of breast cancer recurrence.

The clinical use of staging bone scan in patients with breast carcinoma: reevaluation by the 2003 American Joint Committee on Cancer staging system

BACKGROUND

Using the new 2003 American Joint Committee on Cancer (AJCC) staging system, the authors evaluated the usefulness of the staging bone scan in patients with primary breast carcinoma.

METHODS

The authors examined 1939 patients with primary breast carcinoma for staging bone scan who were treated at a single institution. Pathologic stage was assigned retrospectively according to the 1988 and the 2003 AJCC staging systems.

RESULTS

Bone metastasis rates were 0.7% (4 of 586) for patients with Stage I disease, 0.7% (5 of 699) for patients with Stage IIA disease, 2.1% (10 of 479) for patients with Stage IIB disease, 4.5% (7 of 154) for patients with Stage IIIA disease, and 10.5% (2 of 19) for patients with Stage IIIB disease according to the 1988 AJCC staging system. The authors found a significant difference in the bone metastasis rate between patients with Stages IIA and IIB disease in the 1988 staging system (P = 0.039). Reevaluating the patients by the 2003 system resulted in significant upstaging, especially for patients with Stage II/III disease. According to the 2003 staging system, bone metastasis rates were 0.7% (4 of 586) for patients with Stage I disease, 0.6% (4 of 648) for patients with Stage IIA disease, 0.6% (2 of 310) for patients with Stage IIB disease, 4.0% (9 of 225) for patients with Stage IIIA disease, 16.7% (2 of 12) for patients with Stage IIIB disease, and 4.4% (7 of 158) for patients with Stage IIIC disease. It was noteworthy that there was a significant difference between Stages IIB and IIIA in the 2003 staging system (P = 0.010).

CONCLUSIONS

Stage reclassification using the new AJCC staging system resulted in upstaging of high-risk patients, as well as a significant decrease in the bone metastasis rate in patients with Stage IIB breast carcinoma. Considering the cost-effectiveness of staging bone scan, the data suggested that it was of little value for patients with Stage I and II breast carcinoma, but was highly recommended for patients with worse than Stage III disease by the new 2003 staging system.

Effectiveness of routine visits and routine tests in detecting isolated locoregional recurrences after treatment for early-stage invasive breast cancer: a meta-analysis and systematic review

PURPOSE

To review the effectiveness of routine visits and routine tests in detecting isolated locoregional recurrences in asymptomatic patients after treatment for early-stage invasive breast cancer.

METHODS

Systematic review and meta-analysis. The proportion of isolated locoregional recurrences diagnosed during routine visits or routine tests in asymptomatic patients was compared with the proportion of isolated locoregional recurrences in symptomatic patients.

RESULTS

Twelve studies that involved a total of 5,045 patients and 378 isolated locoregional recurrences were identified. Pooling data showed an overall estimate of 40% of isolated locoregional recurrences diagnosed during routine visits or routine tests in asymptomatic patients (95% CI, 35 to 45). Of these, 47% (95% CI, 39 to 54) were diagnosed after mastectomy, and 36% (95% CI, 28 to 43) were diagnosed after breast-conserving therapy (relative risk, 1.327; 95% CI, 1.014 to 1.738). Apart from differences in therapy, we have not been able to discern subgroups of patients for whom results were different.

CONCLUSION

Approximately 40% of isolated locoregional recurrences are diagnosed during routine visits and routine tests in asymptomatic patients treated for early-stage invasive breast cancer. We could not assess whether these were detected by either physical examination or other tests, nor if the detection of asymptomatic isolated recurrences had any influence on potential for cure or quality of life. As the overall quality of the included studies and the overall incidence of isolated locoregional recurrences are low, this systematic review highlights the need for prospective comparative studies on cost-effective strategies for the follow-up of patients after a diagnosis of breast cancer.

Double-reading of plain radiographs – no benefit with regard to earliness of diagnosis of cancer recurrence: a randomised follow-up study

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.

Patient's needs and preferences in routine follow-up after treatment for breast cancer

The purpose of the study was to analyse the needs of women who participated in a routine follow-up programme after treatment for primary breast cancer. A cross-sectional survey was conducted using a postal questionnaire among women without any sign of relapse during the routine follow-up period. The questionnaire was sent 2–4 years after primary surgical treatment. Most important to patients was information on long-term effects of treatment and prognosis, discussion of prevention of breast cancer and hereditary factors and changes in the untreated breast. Patients preferred additional investigations (such as X-ray and blood tests) to be part of routine follow-up visits. Less satisfaction with interpersonal aspects and higher scores on the Hospital Anxiety and Depression Scale (HADS) scale were related to stronger preferences for additional investigation. Receiving adjuvant hormonal or radiotherapy was related to a preference for a more intensive follow-up schedule. There were no significant differences between patients treated with mastectomy compared to treated with breast-conserving therapy. During routine follow-up after a diagnosis of breast cancer, not all patients needed all types of information. When introducing alternative follow-up schedules, individual patients’ information needs and preferences should be identified early and incorporated into the follow-up routine care, to target resources and maximise the likelihood that positive patient outcomes will result.

Follow-up care of patients treated for breast cancer: a structured review

Breast cancer follow-up services vary, with little evidence to support which practice is best. A systematic review methodology was employed to identify and integrate primary research on the effectiveness of follow-up services. From 4418 articles identified by searches, 38 were eligible for review inclusion. Data were not sufficiently homogenous to integrate statistically, however the following patterns of findings were observed: patient survival and quality of life were not affected by intensity of follow-up or location of care; patients held positive attitudes towards follow-up but psychological distress was consistently high regardless of location of services; few studies assessed patient involvement in treatment choices; studies' research quality was poor with inadequate measures of effectiveness or research designs. There is insufficient primary empirical evidence to draw broad conclusions regarding best practice for breast cancer follow-up care in terms of (a) patient involvement in care, (b) reductions in morbidity, and (c) cost effectiveness of service provision.

Comparison of clinical and molecular surveillance in patients with advanced nasopharyngeal carcinoma after primary therapy

BACKGROUND

The importance of detecting recurrence at an early stage in patients with malignant disease is well recognized. Circulating Epstein-Barr virus (EBV) DNA can be detected in patients with nasopharyngeal carcinoma (NPC). The objective of the current study was to assess the effectiveness of plasma EBV DNA monitoring in the early detection of NPC recurrence compared with conventional methods.

METHODS

Patients with NPC in two prospective clinical trials who had locoregional recurrences or distant metastases were recruited into the study. Clinical data on these patients were scrutinized for evidence of recurrence. EBV DNA copy numbers in the prospectively collected plasma samples were assayed retrospectively with real-time quantitative polymerase chain reaction analysis.

RESULTS

At the time of clinical recurrence, 65% of 26 patients with locoregional recurrences and all but 1 of 28 patients with distant failure had circulating EBV DNA. The difference between the time from completion of treatment to positivity for circulating EBV DNA and the time from completion of treatment to the first observed clinical abnormality was not statistically significant for patients with local recurrence (P=0.84). However, the time to the first detection of circulating EBV DNA was significantly shorter among patients with distant metastases (P<0.0001). The Kaplan-Meier estimated median time to the emergence of plasma EBV DNA was 190 days, with a 95% confidence interval (CI) of 95-300 days, and the median time to the first observed clinical abnormality was 295 days (95% CI, 276-361 days).

CONCLUSIONS

Monitoring plasma EBV DNA levels surpassed traditional methods for the early detection of distant failure in patients with NPC. The role of this technique should be evaluated in prospective studies that incorporate complementary advanced imaging technology.

Detection of bone metastases in routine follow-up after treatment for primary breast cancer

BACKGROUND AND OBJECTIVES

The effect of follow-up after primary treatment for breast cancer on overall survival remains highly questionable, and controversy still exists regarding the benefits of regular follow-up. We therefore attempted to assess the role of intensive follow-up in patients with bone metastases.

METHODS

We analyzed the survival of 87 breast cancer patients who relapsed first in bone diagnosed either with or without symptoms, from 1985 to 1998. Overall survival (OS) was the main outcome. Recurrence was coded as either asymptomatic, elevated tumor marker, or symptomatic.

RESULTS

The median disease free interval was 33 months in the asymptomatic group, 42 months in the elevated tumor marker group, and 43 months in the symptomatic group. Overall survival did not differ significantly between the groups. The median OS was 77 months in the asymptomatic group, 78 months in the elevated tumor marker group, and 79 months in the symptomatic group.

CONCLUSIONS

Our study showed that intensive testing, including assessment of serum tumor markers and bone scans, did not improve OS. The results of our study supported the American Society of Clinical Oncology (ASCO) recommendations that routine use of bone scans is not recommended.

Role of Chest X-ray in Diagnosis of the First Breast Cancer Relapse: A Randomized Trial

Between May 1991 and December 1995, follow-up after primary therapy for 472 consecutive patients with localized breast cancer was randomly assigned to assess the efficacy of routine chest X-ray in detecting intrathoracic relapse as the first metastatic event. One group had regular chest X-rays while the other group had chest radiographs only when clinically needed (spontaneous). Patients were followed up until December 1999 or death. In the routine group, 243 patients had 1429 chest X-rays (mean 5.9 chest X-rays per patient). In the spontaneous group, 229 patients had 411 chest X-rays (mean 1.8 chest X-rays per patient). Both sensitivity and specificity were somewhat higher in the spontaneous arm compared to the routine arm. Patient sensitivity was 30% in the regular arm and 36% in the spontaneous arm. Film sensitivity was 11% in the regular arm and 20% in the spontaneous arm. Patient specificity was 85% in the regular arm and 86% in the spontaneous arm. The predictive values were practically the same in both arms. Patient positive predictive values were 22% in both arms and film positive predictive values were 21% in the regular and 22% in the spontaneous arm. Patient negative predictive values were 90% in the regular and 92% in the spontaneous arm. Film negative predictive values were 93% in the regular and 89% in the spontaneous arm. The differences in accuracy were not statistically significant between the arms. There were no significant differences in disease free survival or overall survival. The 5-year disease free survival was 86% in the regular and 89% in the spontaneous arm and the overall survival was 88 and 85% in the regular versus spontaneous arm, respectively. Routine chest X-ray in the follow-up of breast cancer patient is evidently of little use and is not likely to be of benefit to the patient in terms of disease free survival or overall survival as compared to the spontaneous schedule.

Prospective evaluation of a follow-up schedule in cutaneous melanoma patients: recommendations for an effective follow-up strategy

PURPOSE

To prospectively examine and evaluate the results of follow-up procedures in a large cohort of cutaneous melanoma patients.

PATIENTS AND METHODS

This was a prospective study in 2,008 consecutive patients with stage I to IV cutaneous melanoma from 1996 to 1998 on the yield of stage-appropriate follow-up examinations according to the German guidelines. Documentation of patient and follow-up data comprised patient demography, primary tumor specifics, and any clinical and technical examinations performed. The detection of metastasis was classified as early or late, and the means of their detection and the resulting overall survival probabilities were examined.

RESULTS

A total of 3,800 clinical examinations and 12,398 imaging techniques were documented. Sixty-two second primary melanomas in 46 patients and 233 disease recurrences in 112 patients were detected during this time. In stage I to III disease, physical examination was responsible for the discovery of 50% of all recurrences. In the primary tumor stages, 21% of all recurrences were discovered by lymph node sonography, with the majority being classified as early detection. Forty-eight percent of the recurrences were classified as early detection, and these patients had a significant benefit of overall survival probability.

CONCLUSION

The results of our study suggest that an elaborated follow-up schedule in cutaneous melanoma is suitable for the early detection of second primary melanomas and early recurrences. The intensity of clinical and technical examinations can be reduced during follow-up of patients in the primary tumor stages and may be intensified in locoregional disease. Recommendations for an effective follow-up strategy are outlined.

Surveillance mammography after treatment of primary breast cancer: a systematic review

As the prevalence of diagnosed breast cancer increases, it is important to define how best to provide long-term follow-up. Whereas many aspects of follow-up remain controversial, guidelines recommend surveillance mammograms as the only investigation to be performed routinely. We conducted a systematic review of the literature to elucidate the effect of routine surveillance mammograms on detecting ipsilateral recurrence (IR) and contralateral breast cancers (CBC). The systematic review yielded 15 articles. All were observational studies and ranked as level II-2 or III evidence. There were no randomized controlled trials identified. Most of the ten studies on detection of IR did not report on outcomes after detection. When reported, most studies found that the method of detection of IR did not influence overall survival or disease-free survival. Two of the nine studies on detection of CBC found that the CBC was detected at an earlier stage than the initial breast cancer, but did not report on long-term outcomes. This systematic review highlights the need for further research to help better define the optimum surveillance mammography regimen.

The Place of Whole-Body PET FDG for the Diagnosis of Distant Recurrence of Breast Cancer

Purpose: To study the role of positron emission tomography 18F-fluorodeoxyglucose (PET FDG) imaging in patients with a suspicion of breast cancer recurrence.Procedures: Whole-body PET FDG was performed in 39 women. Thirty-four were included because of asymptomatic tumor marker increase. PET findings were confirmed by oriented imaging or by biopsy. Follow-up data were collected over a period of at least 12 months.Results: PET FDG depicted 37/39 sites in 31/33 patients with recurrence. PET missed one locoregional recurrence and in one patient peritoneal carcinomatosis developed 6 months after a negative PET. False positive PET FDG corresponded to lung infection, degenerative bone disease, and reconstruction artifact. The conventional imaging work-up depicted sites of recurrence in 6/33 patients.Conclusion: Whole-body PET FDG is highly sensitive for the detection of distant breast cancer recurrence. Prospective studies are mandatory to address its potential impact on patient management and survival.