Staging for distant metastases in operable breast cancer: a suggested expansion of the ESMO guideline recommendation for staging imaging of node-negative, hormonal receptor-negative disease

Radiological Staging for Distant Metastases in Breast Cancer Patients with Confirmed Local and/or Locoregional Recurrence: How Useful are Current Guideline Recommendations?

BACKGROUND

Breast cancer patients with local and/or locoregional recurrence (LR) are at higher risk of developing distant metastases (DM) at a later time. Once LR has been confirmed, some international interdisciplinary guidelines recommend performing radiological examinations for DM to determine the course of further therapy (curative or palliative approach). This study analyzed the metastatic patterns of patients with LR with particular regard to the frequency of concurrent diagnosis of LR and DM; in other words: are radiological staging procedures actually justified for DM at the time of diagnosis of LR?

METHODS

This study included all patients (n = 1368) who were diagnosed and treated for nonmetastatic breast cancer (Stage I-III) at the University Women's Hospital Basel, Switzerland between 1990 and 2009.

RESULTS

In 137 patients, LR was diagnosed without a history of DM: in-breast/thoracic wall only, n = 90 (65.7%); involvement of axillary/supra-/infraclavicular lymph nodes, n = 47 (34.3%). DM was found at the time of diagnosis of LR in 44 patients (32.1%). Concurrent diagnosis of LR and DM occurred significantly more often in patients with lymph node recurrence compared with those with in-breast/chest wall recurrence (48.9% vs. 23.3%; p = 0.004).

CONCLUSIONS

Approximately one-third of patients with a LR had synchronous DM at the time of their local/locoregional event. For this reason, routine systemic staging imaging at the time of LR should be an absolute requirement for planning further therapy. Confirmation of DM may spare the patients radical surgical interventions with questionable impact on survival in the face of an incurable disease.

Imaging for metastatic disease in patients with newly diagnosed breast cancer: are doctor's perceptions in keeping with the guidelines?

RATIONALE, AIMS AND OBJECTIVES

Despite multiple guidelines advocating against routine radiological evaluation for metastases in women with early stage breast cancer, imaging is still frequently overused. The objective of this study was to assess doctor's views on imaging guidelines, and an attempt to establish why personal and local clinical practice patterns regarding imaging may differ from current guidelines.

METHODS

Canadian doctors who treat breast cancer were invited by email to complete an online survey developed by members of the research team.

RESULTS

Responses were received from 173 physicians (26% response rate). Most (82%) indicated awareness of at least one published imaging guideline. Sixty per cent indicated that they had read the recommendations of the 2012 American Society of Clinical Oncology 'Top 5' list for choosing wisely in oncology imaging and, of those, 81% agreed with it. However, most indicated that this recommendation has not influenced them to order less imaging. Over 95% of doctors identified suspicious history, physical examination findings and inflammatory breast cancer as important factors for performing imaging. The majority did not feel that patient demand, fear of litigation or ease of access to imaging influenced their ordering for imaging.

CONCLUSIONS

The majority of breast cancer doctors are aware of and generally agree that guidelines pertaining to staging imaging for early breast cancer are reflective of evidence. Despite this, adherence is variable and factors such as local practice patterns and disease biology may play a role. Alternative strategies, beyond simply publishing recommendations, are therefore required if there is to be a sustained change in doctor behaviour.