NCCN: Chest CT in Early-Stage Breast Cancer Occurring Despite Recommendations

A recent study shows that many women with early-stage breast cancer are still undergoing unnecessary chest CT, despite NCCN recommendations.

The National Comprehensive Cancer Network (NCCN) currently recommends that women diagnosed with early-stage breast cancer undergo standard imaging with bilateral mammography and ultrasound, and in some cases, breast MRI. Administration of chest computed tomography (CT) is not recommended for patients asymptomatic for distant metastases.

However, results from a recent study show that many asymptomatic women still underwent chest CT and that only a minority of women with stage I or stage II disease were diagnosed with pulmonary metastases.

The study by Barbara Dull, MD, of the Siteman Cancer Center at Barnes Jewish Hospital and Washington University School of Medicine in St. Louis, Missouri, looked at data from a prospective database of 3,321 patients diagnosed with early-stage cancer. Of the patients included in the study, 11% of patients with stage I disease and 36% of patients with stage II disease underwent chest CT within 6 months of diagnosis. Of the patients who underwent CT, 26.9% had pulmonary nodules. Those patients who underwent chest CT for staging had an average of 2.34 subsequent CTs, and only 1.3% were ultimately diagnosed with pulmonary metastases.

“The overwhelming majority of nodules found in this study’s patient population classified as false-positive results,” Dull said. “Not only do the costs of the chest CT and subsequent imaging and work-up put a cost constraint on the already burdened health care system, but the psychological impact of such results on a patient and their family is enormous.”

The study showed that patients who underwent chest CT were generally younger and more likely to have unfavorable tumor markers, but there was no significant difference between patients diagnosed with metastases and those with false-positive CT results.

The researchers wrote that improved adherence to the NCCN recommendations could help to spare patients unnecessary testing and curb excessive health care spending. The NCCN recommendations are supported by other leading organizations including the American Society of Clinical Oncology, European Society for Medical Oncology, and Britain’s National Institute for Health and Clinical Excellence.

In a commentary published with the study, Pamela J. DiPiro, MD, of Dana-Farber/Brigham and Women’s Cancer Center, wrote: “Notwithstanding the publicized potential risks of radiation exposure and the disputable value of chest CT in early-stage breast cancer, referring clinicians still order it, not infrequently, based on anecdotal cases, concerns regarding legal ramifications, or to satisfy insistent patients. At all stages of cancer care, including at presentation, during neoadjuvant or adjuvant therapy, and with advanced disease, evidence-based guidelines are needed to help direct treating physicians and their patients in selecting appropriate and indicated imaging studies.”