COLUMBUS, Ohio--Many of the diagnostic tests and procedures following
treatment for breast cancer fail to extend survival, as demonstrated by
two randomized, prospective studies and nine retrospective studies, said
Victor G. Vogel, MD, MHS, director of the Comprehensive Breast Cancer Program
at the University of Pittsburgh.
Add to this the drawbacks of these follow-up tests, including cost,
and it becomes very difficult to justify their continued use, Dr. Vogel
said at the Ohio State University James Cancer Hospital and Research Institute
Third Annual Oncology Update.
The routine use of blood chemistry studies and tumor markers CEA and
CA 15-3 cannot be recommended based on a review of the literature, he stressed.
In addition, insufficient data exist to support follow-up surveillance
with chest x-ray, bone scan, hepatic ultrasound, abdominal or chest CT
scan, and the tumor marker CA 27-29.
"We can no longer keep doing something just because we want to,"
he said. "We cannot justify use of these tests in the face of the
data." He emphasized that he was referring to follow-up testing, not
testing during active treatment.
Despite intensive follow-up, 70% of cancer recurrences are identified
from symptoms by the patient herself, Dr. Vogel noted. In addition, the
best predictor of survival continues to be the size of the original tumor
and the extent of axillary node involvement.
A False Assumption
The existing belief among many physicians and patients is that the value
of follow-up monitoring is in the early detection of recurrent disease,
he said. The assumption is that since early detection of initial cancer
lengthens survival quite significantly, then early detection of recurrent
cancer must be beneficial, too.
However, studies show that early detection and early treatment of recurrent
cancer are not associated with improved survival. Rather, early warning
of cancer recurrence, such as provided by the serologic tumor markers CA
15-3 and CA 27-29, lengthens the period of recurrence without offering
a survival advantage.
"We have to ask ourselves whether we're doing more harm removing
years of life without recurrence," Dr. Vogel said, adding that looking
for disease recurrence in asymptomatic individuals may even be a "disservice."
Follow-up tests suffer from other drawbacks, Dr. Vogel noted. Blood
chemistry studies, chest x-rays, and CEA miss large numbers of recurrences.
Bone scans have a false-positive rate greater than 20%, and CA 15-3 has
a false-positive rate of about 6%. Hepatic ultrasound fails to offer a
CT scanning is very expensive and is unlikely to confer a benefit greater
than its cost, Dr. Vogel noted. Under managed care, there will be increased
pressure to justify, with scientific evidence, the ordering of expensive
The desire to provide intensive follow-up monitoring, despite the lack
of scientific evidence, is understandable, Dr. Vogel said. Despite all
of the efforts of cancer specialists, 40% to 50% of patients diagnosed
with breast cancer will eventually relapse and die. This creates anxiety
and the pressure to do something, he said.
A certain amount of follow-up monitoring is recommended, Dr. Vogel said.
Patients should be educated to monitor their symptoms, especially bone
pain and tenderness, and pulmonary, neurological, and gastrointestinal
symptoms. Breast self-examination should be done monthly.
Three-view mammography performed annually is recommended. However, no
prospective, randomized trial has been done to support this advice, Dr.
Vogel noted. If such a trial were done, it is possible that mammography
might be recommended more frequently or that two-view mammography might
be found adequate, he said.
Regular physician exams also remain an important part of follow-up monitoring
of the breast cancer patient, Dr. Vogel said. Based on the scientific evidence,
women should be seen every 3 to 6 months for the first 3 years, then every
6 months for the next 2 years. The majority of these visits will be to
reassure the patient, he said.
A pelvic exam and Pap smear should be done once a year. Women with a
history of breast cancer are known to have an increased risk of ovarian
cancer. At this time, routine annual endometrial sampling of women taking
tamoxifen (Nolvadex) is not recommended, Dr. Vogel said.
Five years after active treatment, the woman can be seen annually by
her primary care physician, Dr. Vogel said. Follow-up by a specialist is
unnecessary. "No special expertise is required to identify metastatic
disease when it recurs," he said.
However, Dr. Vogel noted, patients unprepared for this follow-up regimen
are very likely to resist what they perceive as relaxed vigilance. They
may oppose any change in physician or frequency of exams. One way to make
such transitions smoother is to explain the schedule of follow-up monitoring
very early in the patient's treatment, Dr. Vogel said.