Breast screening for survivors of breast cancer: A systematic review

The COVID-19 pandemic and its effects on follow-up of patients with early breast cancer: A patient survey

PURPOSE

Despite limited evidence supporting its effectiveness, most guidelines recommend long-term, routinely scheduled in-person surveillance of patients with early breast cancer (EBC). The COVID-19 pandemic led to increased use of virtual care. This survey evaluated patient perspectives on follow-up care.

METHODS

Patients with EBC undergoing surveillance were surveyed about follow-up protocols, perceptions, and interest in clinical trials assessing different follow-up strategies.

RESULTS

Of 402 approached patients 270 completed the survey (response rate 67%). Median age 62.5 years (range 25-86) and median time since breast cancer diagnosis was 3.8 years (range < 1-33 years). Most (n = 148/244, 60%) were followed by more than one provider. Routine follow-ups with breast examination were mostly conducted by medical/radiation oncologists every 6 months (n = 110/236, 46%) or annually (n = 106/236, 44%). Participants felt routine follow-up was useful to monitor for recurrence, manage side effects of cancer treatment and to provide support/reassurance. Most participants felt regular follow-up care would detect recurrent cancer earlier (n = 214/255, 96%) and increase survival (n = 218/249, 88%). The COVID-19 pandemic reduced the number of in-person visits for 54% of patients (n = 63/117). Patients were concerned this reduction of in-person visits would lead to later detection of both local (n = 29/63, 46%) and distant recurrences (n = 25/63, 40%). While many felt their medical and radiation oncologists were the most suited to provide follow-up care, 55% felt comfortable having their primary care provider (PCP) conduct surveillance. When presented with a scenario where follow-up has no effect on earlier detection or survival, 70% of patients still wanted routine in-person follow-up for reassurance (63%) with the goal of earlier recurrence detection (56%).

CONCLUSIONS

Despite limited evidence of effectiveness of routine in-person assessment, patients continue to place importance on regularly scheduled in-person follow-up.

Estimating the incidence of breast cancer recurrence using administrative data

BACKGROUND

Breast cancer is the most common cancer among women, but most cancer registries do not capture recurrences. We estimated the incidence of local, regional, and distant recurrences using administrative data.

METHODS

Patients diagnosed with stage I-III primary breast cancer in Ontario, Canada from 2013 to 2017 were included. Patients were followed until 31/Dec/2021, death, or a new primary cancer diagnosis. We used hospital administrative data (diagnostic and intervention codes) to identify local recurrence, regional recurrence, and distant metastasis after primary diagnosis. We used logistic regression to explore factors associated with developing a distant metastasis.

RESULTS

With a median follow-up 67 months, 5,431/45,857 (11.8%) of patients developed a distant metastasis a median 23 (9, 42) months after diagnosis of the primary tumor. 1086 (2.4%) and 1069 (2.3%) patients developed an isolated regional or a local recurrence, respectively. Patients with distant metastatic disease had a median overall survival of 15.4 months (95% CI 14.4-16.4 months) from the time recurrence/metastasis was identified. In contrast, the median survival for all other patients was not reached. Patients were more likely to develop a distant metastasis if they had more advanced stage, greater comorbidity, and presented with symptoms (p < 0.0001). Trastuzumab halved the risk of recurrence [OR 0.53 (0.45-0.63), p < 0.0001].

CONCLUSION

Distant metastasis is not a rare outcome for patients diagnosed with breast cancer, translating to an annual incidence of 2132 new cases (17.8% of all breast cancer diagnoses). Overall survival remains high for patients with locoregional recurrences, but was poor following a diagnosis of a distant metastasis.

Breast and thyroid cancer: A multicenter study with Accrual to Clinical Trials Network

OBJECTIVE

To investigate a possible link between breast and thyroid cancer.

METHODS

A multicenter retrospective review of patients in the electronic medical records of six Accrual to Clinical Trial (ACT) institutions with both breast cancer and thyroid carcinoma. Each center queried its data using a predefined data dictionary. Information on thyroid and breast cancer included dates of diagnosis, histology, and patient demographics.

RESULTS

A random-effects model was used. There were 4.24 million women's records screened, 44 605 with breast cancer and 11 846 with thyroid cancer. The relative risks observed at each institution ranged from 0.49 to 13.47. The combined risk ratio (RR) estimate was 1.77 (95% confidence interval: 0.50-5.18).

CONCLUSION

There was no association between the risk of developing thyroid cancer and being a breast cancer survivor compared to no history of breast cancer, but the range of relative risks among the participating institutions was wide. Our findings warrant further study of more institutions with larger sample size. Additionally, further analysis of the significance of regional RR differences may be enlightening.

Differences in breast cancer diagnosis by patient presentation in Ontario: a retrospective cohort study

BACKGROUND

In Ontario, patients with breast cancer typically receive their diagnoses through the Ontario Breast Screening Program (OBSP) after an abnormal screen, through screening initiated by a primary care provider or other referring physician, or through follow-up of symptoms by patients' primary care providers. We sought to explore the association of the route to diagnosis (screening within or outside the OBSP or via symptomatic presentation) with use of OBSP-affiliated breast assessment sites (O-BAS), wait times until diagnosis or treatment, health care use and overall survival for patients with breast cancer.

METHODS

In this retrospective cohort study, we used the Ontario Cancer Registry to identify adults (aged 18-105 yr) who received a diagnosis of breast cancer from 2013 to 2017. We excluded patients if they were not Ontario residents or had missing age or sex, or who died before diagnosis. We used logistic regression to evaluate factors associated with categorical variables (whether patients were or were not referred to an OBAS, whether patients were screened or symptomatic) and Cox proportional hazards regression to identify factors associated with all-cause mortality.

RESULTS

Of 51 460 patients with breast cancer, 42 598 (83%) received their diagnoses at an O-BAS. Patients whose cancer was first detected through the OBSP were more likely than symptomatic patients to be given a diagnosis at an O-BAS (adjusted odds ratio 1.68, 95% confidence interval [CI] 1.57 to 1.80). Patients screened by the OBSP were given their diagnoses 1 month earlier than symptomatic patients, but diagnosis at an O-BAS did not affect the time until either diagnosis or treatment. Patients referred to an O-BAS had significantly better overall survival than those who were not referred (adjusted hazard ratio 0.73, 95% CI 0.66 to 0.80).

INTERPRETATION

Patients screened through the OBSP were given their diagnoses earlier than symptomatic patients and were more likely to be referred to an O-BAS, which was associated with better survival. Our findings suggest that individuals with signs and symptoms of breast cancer would benefit from similar referral processes, oversight and standards to those used by the OBSP.

The COVID-19 pandemic: An opportunity to rethink and harmonise the frequency of follow-up visits for patients with early stage breast cancer

PURPOSE

While routine, in-person follow-up of early-stage breast cancer patients (EBC) after completion of initial treatment is common, the COVID-19 pandemic has resulted in unprecedented changes in clinical practice. A systematic review was performed to evaluate the evidence supporting different frequencies of routine follow-up.

METHODS

MEDLINE and the Cochrane Collaboration Library were searched from database inception to July 16, 2020 for randomized controlled trials (RCTs) and prospective cohort studies (PCS) evaluating different frequencies of routine follow-up. Citations were assessed by pairs of independent reviewers. Risk of Bias (RoB) was assessed using the Cochrane RoB tool for RCTs and the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies. Findings were summarized narratively.

RESULTS

The literature search identified 3316 studies, of which 7 (6 RCTs and 1 PCS) were eligible. Study endpoints included; quality of life (QoL; 5 RCTs and 1 PCS), disease free survival (DFS) (1 RCT), overall survival (OS) (1 RCT) and cost-effectiveness (1 RCT). The results showed reduction in follow-up frequency had no adverse effect on: QoL (6 studies, n = 920), DFS (1 trial, n = 472) or OS (1 trial, n = 472), but improved cost-effectiveness (1 trial, n = 472). Four RCTs specifically examined follow-up on-demand versus scheduled follow-up visits and found no statistically significant differences in QoL (n = 544).

CONCLUSION

While no evidence-based guidelines suggest that follow-up of EBC patients improves DFS or OS, routinely scheduled in-person assessment is common. RCT data suggests that reduced frequency of follow-up has no adverse effects.

Participation in breast cancer screening among breast cancer survivors -A nationwide register-based cohort study

The aim of this study was to analyse if breast cancer survivors without other breast imaging surveillance attend population-based screening differently than women not previously diagnosed with breast cancer. Further, to analyse if any differences depended on the women's age and years since previous cancer diagnosis. The study was a register-based retrospective cohort study of all women invited to participate in the national breast cancer screening programme in 2015-2016. Participation rates were calculated for breast cancer survivors without breast imaging within 21 months (2-4 years, 4-6 years, 6-10 years and more than 10 years after diagnosis) and for women without previous breast cancer. Relative differences in participation rates between the two groups were calculated. A total of 679,990 women were included in the study (2.6% breast cancer survivors). For breast cancer survivors, participation rates increased with increasing number of years since the previous cancer diagnosis peaking at 80.3% if the cancer diagnosis was more than 10 years ago. For women with no previous breast cancer, participation rate was 80.3%. The relative difference in participation was highest close to the breast cancer diagnosis and for the youngest women participation rates remained lower among breast cancer survivors even more than 10 years after the diagnosis. In conclusion, regardless of age and years since previous breast cancer diagnosis, breast cancer survivors had lower or similar participation rates than women with no previous cancer diagnosis. This indicated that as many as one fifth of the breast cancer survivors are at risk of inadequate surveillance.

Breast cancer survivors' risk of interval cancers and false positive results in organized mammography screening

BACKGROUND

Breast cancer survivors are increasing followed for new breast cancers / recurrences by mammography screening only. We aimed at assessing how often breast cancer survivors get a false positive or false negative result at mammography screening.

METHODS

All mammography screenings performed between 2007 and 2017 in the Danish national mammography screening programme were included. Screenings in women with a breast cancer diagnosis prior to invitation were included in the "breast cancer survivors" group, while remaining screenings were included in the "no previous breast cancer" group. We compared the proportion of false positive screenings and the proportion of breast cancers detected at screening among breast cancer survivors and women without previous breast cancer. The analyses were further stratified according to whether the women had a diagnostic breast imaging in the 21 months prior to the screening.

RESULTS

At initial screenings, breast cancer survivors had a significant lower false positive risk than other women, while the risk was similar at subsequent screenings. Breast cancer survivors had a significant lower proportion of breast cancers detected at screening compared to other women. This was true both for women who had a diagnostic breast imaging in the 21 months prior to screening and those who did not.

CONCLUSION

This study shows that breast cancers survivors have a smaller amount of their new breast cancers detected at mammography screening, when compare to the amount of new breast cancers detected at mammography screening among women without previous breast cancer. The lower sensitivity does not seem to be due to different behavior among breast cancer survivors.