Expert Urges Cutback on Breast Cancer Follow-up

ATLANTA—With 8 million new breast cancer patients each year worldwide, “we’re looking at a tremendous number of individuals being followed for recurrence,” Hyman B. Muss, MD, of Fletcher Allen Health Care, Burlington, Vermont, said at the Perspectives in Breast Cancer symposium.

Most patients want and expect intensive follow-up, yet, Dr. Muss said, studies show that “even with very frequent chest x-rays, bone scans, blood tests, ultrasound of the liver, etc, the vast majority of recurrences are found by signs and symptoms.”

The Patient’s Perspective

In a study at Wake Forest University in the early 1990s, 100 patients with metastatic and early stage breast cancer were asked their views on the ability of various tests to detect recurrence. Although most didn’t think the history was very helpful, they did think that examinations, x-rays, CT scans, and blood tests were most helpful.

“Patients are unaware that the history probably will detect more cases of recurrences than imaging,” Dr. Hyman Muss said (see article ).

When asked what tests they thought should be performed regularly (at every visit or every other visit), the majority of patients mentioned blood sugar testing, chest x-ray, CT scan, and liver scan. Interestingly, however, one third said they simply didn’t know.

“This is probably because we don’t talk to patients about follow-up or explain tests and their limitations,” Dr. Muss said. “Patients are not well educated and that’s our fault.”

Dr. Muss asked an obvious but key question about breast cancer follow-up: Why do it? The underlying assumption for follow-up of asymptomatic patients after a diagnosis of early stage breast cancer, he said, is that early detection of metastasis improves survival, but currently there is no evidence to show that this is the case.

Imaging studies and tumor markers may precede the development of signs and symptoms of metastases by three to six months, he noted, but early discovery has, to date, not translated into improved survival.

Dr. Muss cited two Italian studies looking at whether close follow-up of women with early-stage breast cancer saves lives, both published in JAMA in 1994. The patients were randomized to receive intensive or routine follow-up.

In both studies, there was no difference in survival between the intensive follow-up group and the controls, and in one study there were no differences in quality of life between the two groups. One of the trials did find earlier detection of relapse, he said, but the other, despite intensive imaging studies, did not.

On the other hand, frequent follow-up may be justified if it reduces morbidity. “My own bias is, yes, it can reduce morbidity if you find early problems,” he said. Early detection of bone or soft tissue metastases is likely to result in better disease control and presumably a better quality of life.

Likewise, he said, follow-up provides a forum for patient to discuss their concerns, and for physicians to counsel their patients and provide reassurance. “Patients are barraged with breast cancer material today,” Dr. Muss said, “and I spend much of my visit going over things in the press or talking about markers.”

Finally, he said, follow-up is important to ensure that annual mammography is being done, a test that can, in fact, improve survival.

When evidence of recurrence is found with testing, he said, patients will likely want something to be done. In a 1994 study, patients were asked if they would want treatment for asymptomatic metastatic disease.

“I was quite surprised to see that almost two thirds said they would want some type of treatment.” He went on to say that this nevertheless does not justify intensive follow-up because most of the therapies offered would be palliative.

When to Use Biomarkers

In one study, he said, a review of records over a period of 13 to 16 months showed that patients with an identified relapse had no more clinic visits than those who had not relapsed. “Many of these visits, in both the relapsed and nonrelapsed patients, were because of symptoms such as bone pain,” he said, “but you can’t tell acutely whether musculoskeletal problems are due to breast cancer, and evaluation can be expensive.”

Although, in general, he said, use of serologic tumor markers in breast cancer follow-up is problematic, this is one situation in which they could play a role. In a recent biomarker study, Dr. Muss and his colleagues found that in the three patients who had bone metastases, the mucin-associated CA27.29 antigen marker was positive, whereas it was negative in those patients who did not have bone disease.

He warned that routine monitoring with biomarkers should be done only if the clinician has a plan as to what to do if results are positive, as for example in clinical trials where a specific experimental therapy will be used to treat a recurrence.

ASCO Guidelines

Dr. Muss served on the ASCO expert panel whose rigorous review of the literature resulted in guidelines on breast cancer follow-up, published this year (J Clin Oncol 15:2149, 1997). He believes these guidelines provide an optimal schedule for most clinicians to follow. But because of patient expectations, widespread adoption of the guidelines poses problems.

Asco Guidlines for Breast Cancer Surveillance

“The reason follow-up doesn’t save lives is that breast cancer relapse, even if found early, is still incurable,” he said. “Whether you find one bone lesion or 10 doesn’t really matter in terms of patient survival, but it’s very hard to tell that to a patient.”

For this reason, patient education is key: Patients must be informed that use of extensive imaging and laboratory studies does not improve survival, he said. In addition, physicians need to educate their patients to recognize signs and symptoms of metastasis such as bone pain, pulmonary problems, GI pain, etc.

General adoption of the ASCO recommendations, he believes, requires the support of the National Institutes of Health. “I believe the NIH and NCI could help us greatly by having a consensus conference on breast cancer follow-up to provide very strong guidelines that we could all use. Such a recognized standard would protect physicians who follow the guidelines from lawsuits.”

Adoption of the ASCO recommendations would produce large savings, he said, “and, in my opinion, would not harm patients, at least not at this point in our knowledge of the treatment of breast cancer.” But he acknowledged the difficulty in adopting a “minimalist policy” even in his own practice. “I am trying to do so, albeit slowly. I believe the NIH could be of service to us here.”