Evidence-based Guidelines and Recommendations - PowerPoint Presentation

Slide1

Evidence-based Guidelines and Recommendations

Ongoing

Surveillance

A

fter

A

ctive Breast Cancer Therapy Slide2

ASCO 2006 Update

Breast

Cancer Follow-Up Guidelines

Experts from the American Society of Clinical Oncology (ASCO) get together every few years to review the latest trials and evidence related to ongoing surveillance for breast cancer survivors

Most recent meeting in 2006 produced a number of guidelines, included in these slidesSlide3

Main finding

“The

evidence supports regular history, physical examination, and mammography as the cornerstone

of appropriate

breast cancer

follow-up.”

J L

Khatcheressian

,

A C Wolff

,

T J Smith

,

E

Grunfeld

,

H B Muss

,

VG

.

Vogel, F

Halberg

,

M R

. Somerfield, and

N E Davidson.

American Society of Clinical Oncology 2006 Update of

the Breast

Cancer Follow-Up and Management Guidelines

in the

Adjuvant

Setting. Journal of Clinical Oncology 2006.

24:5091-5097

. Slide4

Recommendations for Physical Examinations

Breast self-examination

All women should be counseled to perform monthly breast self-examination.

History/physical examination

Every 3 to 6 months for the first 3 years after primary therapy; every 6 to 12 months for years 4 and 5; then annually.

Pelvic examination

Regular gynecologic follow-up is recommended for all women. Patients who receive

tamoxifen should be advised to report any vaginal bleeding to their physicians.

J L

Khatcheressian

, A C Wolff, T J Smith, E

Grunfeld

, H B Muss, VG. Vogel, F

Halberg

, M R. Somerfield, and N E Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006.

24:5091-5097. Slide5

2006 ASCO Guidelines

U.S. Preventive Services Task

Force Guidelines

Recommend doctors to teach women how to do monthly self-examinations for follow-up

In 2009, released recommendations against teaching monthly self-exams for screening

No specific recommendations for breast cancer follow-up

Screening

for Breast Cancer. USPSTF November 2009. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htmBreast Self-ExaminationJ L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006. 24:5091-5097. Slide6

ASCO Guidelines on Mammograms

First

post-treatment mammogram 1 year after the initial mammogram (leading to diagnosis)No earlier

than 6 months after

radiation therapy

After the first year, mammograms every 6 months or one year

J L

Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006. 24:5091-5097. Slide7

What is not recommended for routine follow-up?

Routine blood tests

Complete Blood Counts

and liver function tests are not recommended.

Imaging studies

Chest x-ray, bone scans, liver ultrasound, CT scans, FDG-PET scans, and breast MRI are not recommended.

Tumor markers

CA 15-3, CA 27.29, and CEA are not recommended.

J L

Khatcheressian

, A C Wolff, T J Smith, E

Grunfeld

, H B Muss, VG. Vogel, F

Halberg

, M R. Somerfield, and N E Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006.

24:5091-5097. Slide8

The Evidence

Trials showing no

difference in overall survival or disease-free survival

between:

Those followed with intensive imaging

and

lab tests

Those followed with routine clinical visits and mammographyNo evidence that breast MRI improves outcomes like survival when used as routine follow-up in breast cancer survivors without symptomsEvidence to show that additional imaging can result in unnecessary surgical proceduresJ L Khatcheressian, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006. 24:5091-5097. Slide9

Italy

A study looked at intensive

diagnostic follow-up after treatment of primary breast cancer in breast cancer clinics around Italy.

1243 participants

Patients in

two

treatment groups had physical examination and

mammographyPatients of the intensive follow-up group also had chest X-ray and bone scan every 6 monthsNo significant difference in 5-year overall mortality observed between the two follow-up groupsM. Rosselli Del Turco, D. Palli, A. Cariddi, S. Ciatto, P. Pacini, V. Distante. Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up. JAMA. 1994 May 25; 271(20): 1593–1597. Slide10

GIVIO Trial

1320 patients from 26 hospitals in Italy were

randomly assigned to two groups:

intensive surveillance (including bone

scan, liver echography, chest

X-rays,

and laboratory

tests)control regimen in which patients were seen by their physicians at the same frequency but only clinically indicated tests were performedThe study found no significant difference between the two groups in survival after an average of 6 yearsNo significant difference in time to detection of recurrence Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. A multicenter randomized controlled trial. The GIVIO Investigators. Jama. 1994;271:1587–92. Slide11

Breast MRI

MRI is the most sensitive breast imaging tool (88-100%)

Sensitivity = the % of positive cases identified correctlyExpensive and only moderate specificity (37-70%)

Specificity = the % of negative cases identified correctly

MRI is most valuable when conventional imaging is unable to detect the presence or extent of a malignancy, not in routine use

J L

Khatcheressian

, A C Wolff, T J Smith, E Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006. 24:5091-5097. Slide12

Caveats

The ASCO guidelines are voluntary

They do not apply to all womenThey do not stand in the place of physician judgment

More complex clinical situations call for more sensitive tests

J L

Khatcheressian

, A C Wolff, T J Smith, E

Grunfeld, H B Muss, VG. Vogel, F Halberg, M R. Somerfield, and N E Davidson. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. Journal of Clinical Oncology 2006. 24:5091-5097. Slide13

Where to Read More

ASCO and USPSTF Guidelines

http

://

jco.ascopubs.org/content/24/31/5091.full.pdf

http://

www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

StudiesImpact of follow-up testing on survival and health-related quality of life in breast cancer patients. A multicenter randomized controlled trial. The GIVIO Investigators. Jama. 1994;271:1587–92. http://www.ncbi.nlm.nih.gov/pubmed/8182811 M. Rosselli Del Turco, D. Palli, A. Cariddi, S. Ciatto, P. Pacini, V. Distante. Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up. JAMA. 1994 May 25; 271(20): 1593–1597. http://www.ncbi.nlm.nih.gov/pubmed/7848404