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McDonald ES, Scheel JR, Lewin AA, Weinstein SP, Dodelzon K, Dogan BE, Fitzpatrick A, Kuzmiak CM, Newell MS, Paulis LV, Pilewskie M, Salkowski LR, Silva HC, Sharpe RE, Specht JM, Ulaner GA, Slanetz PJ. ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer. J Am Coll Radiol 2024; 21:S168-S202. [PMID: 38823943 DOI: 10.1016/j.jacr.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Elizabeth S McDonald
- Research Author, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John R Scheel
- Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Alana A Lewin
- Panel Chair, New York University Grossman School of Medicine, New York, New York
| | - Susan P Weinstein
- Panel Vice Chair, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Basak E Dogan
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amy Fitzpatrick
- Boston Medical Center, Boston, Massachusetts, Primary care physician
| | | | - Mary S Newell
- Emory University Hospital, Atlanta, Georgia; RADS Committee
| | | | - Melissa Pilewskie
- University of Michigan, Ann Arbor, Michigan; Society of Surgical Oncology
| | - Lonie R Salkowski
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - H Colleen Silva
- The University of Texas Medical Branch, Galveston, Texas; American College of Surgeons
| | | | - Jennifer M Specht
- University of Washington, Seattle, Washington; American Society of Clinical Oncology
| | - Gary A Ulaner
- Hoag Family Cancer Institute, Newport Beach, California; University of Southern California, Los Angeles, California; Commission on Nuclear Medicine and Molecular Imaging
| | - Priscilla J Slanetz
- Specialty Chair, Boston University School of Medicine, Boston, Massachusetts
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Management of Locally Advanced Breast Cancer. Breast Cancer 2022. [DOI: 10.1007/978-981-16-4546-4_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Arnaout A, Varela NP, Allarakhia M, Grimard L, Hey A, Lau J, Thain L, Eisen A. Baseline staging imaging for distant metastasis in women with stages I, II, and III breast cancer. ACTA ACUST UNITED AC 2020; 27:e123-e145. [PMID: 32489262 DOI: 10.3747/co.27.6147] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background In Ontario, there is no clearly defined standard of care for staging for distant metastasis in women with newly diagnosed and biopsy-confirmed breast cancer whose clinical presentation is suggestive of early-stage disease. This guideline addresses baseline imaging investigations for women with newly diagnosed primary breast cancer who are otherwise asymptomatic for distant metastasis. Methods The medline and embase databases were systematically searched for evidence from January 2000 to April 2019, and the best available evidence was used to draft recommendations relevant to the use of baseline imaging investigation in women with newly diagnosed primary breast cancer who are otherwise asymptomatic. Final approval of this practice guideline was obtained from both the Staging in Early Stage Breast Cancer Advisory Committee and the Report Approval Panel of the Program in Evidence-Based Care. Recommendations These recommendations apply to all women with newly diagnosed primary breast cancer (originating in the breast) who have no symptoms of distant metastasis Staging tests using conventional anatomic imaging [chest radiography, liver ultrasonography, chest-abdomen-pelvis computed tomography (ct)] or metabolic imaging modalities [integrated positron-emission tomography (pet)/ct, integrated pet/magnetic resonance imaging (mri), bone scintigraphy] should not be routinely ordered for women newly diagnosed with clinical stage i or stage ii breast cancer who have no symptoms of distant metastasis, regardless of biomarker status. In women newly diagnosed with stage iii breast cancer, baseline staging tests using either anatomic imaging (chest radiography, liver ultrasonography, chest-abdomen-pelvis ct) or metabolic imaging modalities (pet/ct, pet/mri, bone scintigraphy) should be considered regardless of whether the patient is symptomatic for distant metastasis and regardless of biomarker profile.
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Affiliation(s)
- A Arnaout
- Department of Surgery, The Ottawa Hospital and The University of Ottawa, Ottawa, ON
| | - N P Varela
- Program in Evidence-Based Care, Ontario Health (Cancer Care Ontario), and Department of Oncology, McMaster University, Hamilton, ON
| | - M Allarakhia
- Patient Representative, The Ottawa Hospital, Ottawa, ON
| | - L Grimard
- Department of Radiation Medicine, The Ottawa Hospital, Ottawa, ON
| | - A Hey
- Regional Primary Care, Northeast Cancer Centre, Sudbury, ON
| | - J Lau
- Department of Radiology, The University of Ottawa, Ottawa, ON
| | - L Thain
- Ontario Health (Cancer Care Ontario) Regional Imaging, Southlake Regional Health Centre, Newmarket, and Mackenzie Health, Richmond Hill, ON
| | - A Eisen
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON
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Li F, Armato SG, Giger ML, MacMahon H. Clinical significance of noncalcified lung nodules in patients with breast cancer. Breast Cancer Res Treat 2016; 159:265-71. [PMID: 27503305 DOI: 10.1007/s10549-016-3937-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/03/2016] [Indexed: 12/21/2022]
Abstract
Patients with breast cancer are increasingly likely to have chest computed tomography (CT) performed. In many cases, small lung nodules will be detected, raising concern for metastases and causing considerable patient anxiety. The majority of these nodules, however, are benign, though the specific probability of malignancy is uncertain in any given case. Therefore, we analyzed the results of chest CT scans of a large number of patients with breast cancer, to determine characteristics and clinical significance of noncalcified lung nodules. 3313 patients were investigated, and 4889 CT scans from 1325 patients were retrospectively reviewed. Among the 1325 patients, 812 (59 %) had at least one noncalcified lung nodule, of which 330 (41 %) had malignant nodules, 197 (24 %) had large (≥10 mm) nodules, and 586 (72 %) had multiple nodules. Large nodules were more often malignant than benign (P < 0.001). In patients with multiple large nodules, the rate of malignancy rate was 83 %, and most of these were metastases. In the case of very small (2-4 mm) nodules, the malignancy rates for solitary and multiple nodules were 8 and 20 %, respectively. Lung metastases were more likely with breast cancer cell grade 3 (22 %) than grade 1-2 (10 %) (P < 0.001) and when patients were clinical stage 2-3 (14 %) than stage 0-1 (7.9 %) (P = 0.03). Lung metastases are highly likely in patients with multiple nodules greater than 10 mm. Higher cancer cell grades and clinical stage are also related to an increased likelihood of lung metastases. The great majority of small lung nodules in breast cancer patients are benign.
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Affiliation(s)
- Feng Li
- Department of Radiology, The University of Chicago, 5841 S. Maryland Avenue, MC 2026, Chicago, IL, 60637, USA.
| | - Samuel G Armato
- Department of Radiology, The University of Chicago, 5841 S. Maryland Avenue, MC 2026, Chicago, IL, 60637, USA
| | - Maryellen L Giger
- Department of Radiology, The University of Chicago, 5841 S. Maryland Avenue, MC 2026, Chicago, IL, 60637, USA
| | - Heber MacMahon
- Department of Radiology, The University of Chicago, 5841 S. Maryland Avenue, MC 2026, Chicago, IL, 60637, USA
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Chagpar A, Babiera G, Aguirre J, Caropreso P, Hughes T. Variation in metastatic workup for patients with invasive breast cancer. Am J Surg 2015; 210:1147-54.e2; discussion 1153-4. [PMID: 26518161 DOI: 10.1016/j.amjsurg.2015.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite guidelines, surgeons vary in the metastatic workup they order for their breast cancer patients. METHODS Surgeons were surveyed as to their practices in ordering staging studies for their breast cancer patients using a Web-based survey. Nonparametric analyses were performed to determine factors associated with guideline adherence. RESULTS Two hundred fifty-three surgeons responded to the survey; 55.8% had practices with ≥50% breast patients; 7.3% of respondents stated they always did a metastatic workup before surgery, 8.6% never did; only 52.4% ordered a metastatic workup only in patients with clinical stage III disease. Surgeons who had ≥50% breast-related practices were more likely to follow these guidelines (P = .031). Only 17% stated that a computed tomography chest/abdomen and bone scan was their "usual" metastatic workup. CONCLUSIONS Nearly 40% of surgeons perform metastatic workup when they are not indicated, and few adhere to National Comprehensive Cancer Network guidelines in terms of the tests ordered.
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Affiliation(s)
- Anees Chagpar
- Department of Surgery, Yale University School of Medicine, 20 York Street, First Floor, Suite A, New Haven, CT, 06510, USA; Breast Center, Smilow Cancer Hospital at Yale-New Haven, 20 York Street, First Floor, Suite A, New Haven, CT, 06510, USA.
| | - Gildy Babiera
- The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Jose Aguirre
- Department of Surgery, Hospital de los Valles, Quito, Ecuador
| | | | - Tyler Hughes
- Department of Surgery, McPherson Medical and Surgical Associates, McPherson, KS, USA
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