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.
COLUMBUS, Ohio--Many of the diagnostic tests and procedures followingtreatment for breast cancer fail to extend survival, as demonstrated bytwo randomized, prospective studies and nine retrospective studies, saidVictor G. Vogel, MD, MHS, director of the Comprehensive Breast Cancer Programat 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. Vogelsaid at the Ohio State University James Cancer Hospital and Research InstituteThird Annual Oncology Update.
The routine use of blood chemistry studies and tumor markers CEA andCA 15-3 cannot be recommended based on a review of the literature, he stressed.In addition, insufficient data exist to support follow-up surveillancewith chest x-ray, bone scan, hepatic ultrasound, abdominal or chest CTscan, 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 thedata." He emphasized that he was referring to follow-up testing, nottesting during active treatment.
Despite intensive follow-up, 70% of cancer recurrences are identifiedfrom symptoms by the patient herself, Dr. Vogel noted. In addition, thebest predictor of survival continues to be the size of the original tumorand the extent of axillary node involvement.
A False Assumption
The existing belief among many physicians and patients is that the valueof follow-up monitoring is in the early detection of recurrent disease,he said. The assumption is that since early detection of initial cancerlengthens survival quite significantly, then early detection of recurrentcancer must be beneficial, too.
However, studies show that early detection and early treatment of recurrentcancer are not associated with improved survival. Rather, early warningof cancer recurrence, such as provided by the serologic tumor markers CA15-3 and CA 27-29, lengthens the period of recurrence without offeringa survival advantage.
"We have to ask ourselves whether we're doing more harm removingyears of life without recurrence," Dr. Vogel said, adding that lookingfor disease recurrence in asymptomatic individuals may even be a "disservice."
Follow-up tests suffer from other drawbacks, Dr. Vogel noted. Bloodchemistry 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 hasa false-positive rate of about 6%. Hepatic ultrasound fails to offer asurvival benefit.
CT scanning is very expensive and is unlikely to confer a benefit greaterthan its cost, Dr. Vogel noted. Under managed care, there will be increasedpressure to justify, with scientific evidence, the ordering of expensivetests.
The desire to provide intensive follow-up monitoring, despite the lackof scientific evidence, is understandable, Dr. Vogel said. Despite allof the efforts of cancer specialists, 40% to 50% of patients diagnosedwith breast cancer will eventually relapse and die. This creates anxietyand 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 bonepain and tenderness, and pulmonary, neurological, and gastrointestinalsymptoms. Breast self-examination should be done monthly.
Three-view mammography performed annually is recommended. However, noprospective, randomized trial has been done to support this advice, Dr.Vogel noted. If such a trial were done, it is possible that mammographymight be recommended more frequently or that two-view mammography mightbe found adequate, he said.
Regular physician exams also remain an important part of follow-up monitoringof 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 every6 months for the next 2 years. The majority of these visits will be toreassure the patient, he said.
A pelvic exam and Pap smear should be done once a year. Women with ahistory of breast cancer are known to have an increased risk of ovariancancer. At this time, routine annual endometrial sampling of women takingtamoxifen (Nolvadex) is not recommended, Dr. Vogel said.
Five years after active treatment, the woman can be seen annually byher primary care physician, Dr. Vogel said. Follow-up by a specialist isunnecessary. "No special expertise is required to identify metastaticdisease when it recurs," he said.
However, Dr. Vogel noted, patients unprepared for this follow-up regimenare very likely to resist what they perceive as relaxed vigilance. Theymay oppose any change in physician or frequency of exams. One way to makesuch transitions smoother is to explain the schedule of follow-up monitoringvery early in the patient's treatment, Dr. Vogel said.