ASCO BREAST CANCER GUIDELINES-REDUCE IMAGING AND BLOOD TESTING 

The American Society of Clinical Oncology (ASCO) has issued an "update" of its clinical practice guidelines on the follow-up and management of patients with invasive breast cancer who have completed primary therapy with curative intent.

It reads a lot like the 2006 version of the guidance, because the update committee concluded that "no revisions to the existing ASCO recommendations were warranted."

So why the reissue? Because that is part of the process, said Nancy Davidson, MD, from the University of Pittsburgh Cancer Institute in Pennsylvania, who is senior author of the guidelines, which were published online November 5 in theJournal of Clinical Oncology.

She and the other committee members reviewed 9 new systematic reviews and 5 new randomized clinical trials. But "the new data did not change the recommendations," she told Medscape Medical News.

Nonetheless, the new guidelines are still "very useful," said Steven Vogl, MD, a medical oncologist in private practice in the Bronx, New York, who might be best known for his incisive questions at the annual San Antonio Breast Cancer Symposium and other meetings.

"The reissue is to emphasize that the guidelines are still valid," he toldMedscape Medical News in an interview.

That currency serves multiple good purposes, he explained. According to Dr. Vogl, oncologists can offer the guidelines to patients who want, for example, unnecessary follow-up imaging and need reassurance from a timely source about forgoing such interventions. The guidelines also serve to protect clinicians in the event of a lawsuit. In addition, they can help inform gynecologists, surgeons, and other healthcare professionals about the current particulars of practice. "Most medical oncologists know these guidelines," Dr. Vogl pointed out.

Nevertheless, the guidelines are very much about discouraging unnecessary testing, said Dr. Vogl.

Dr. Davidson echoes those comments. "There is far more imaging and blood testing than needs to be done," she said, referring to bone scans, chest radiographs, liver ultrasounds, pelvic ultrasounds, computed tomography scans, fluorodeoxyglucose–positron emission tomography scans, magnetic resonance imaging, and tumor-marker blood tests, such as those for carcinoembryonic antigen (CEA), cancer antigen (CA) 15-3, and CA 27.29. These forms of imaging and blood testing are not recommended as part of follow-up in the guidelines.

Last year, such imaging and blood testing in early cancer patients who have no symptoms werespecifically identified by ASCO as being without an evidence base, she explained, referring to the Choosing Wisely campaign, organized by the American Board of Internal Medicine, to reduce unnecessary and wasteful medical practices.

"People assume that more is better, and that's not always the case," said Dr. Davidson. Potential false-positive results can lead to unnecessary invasive procedures and possible overtreatment.

Minimizing early breast cancer follow-up care in asymptomatic patients "is really good news," said Dr. Davidson. The guidelines "allow patients to be freer from oncology follow-up," she noted.

More Guideline Detail

Dr. Vogl said that he adheres to the guidelines, with 1 major exception.

"I routinely do tumor-marker blood tests," he said. This is in conflict with the recommendations, which state that tumor-marker testing is "not recommended for routine follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination."

In patients with hormone-positive disease, "I can occasionally detect a recurrence before it's symptomatic and I can keep a patient asymptomatic for a few years through hormonal manipulation," he explained.

A payoff is not common, he admitted, and "very few patients can be helped in this way." He emphasized that he is scrupulous about repeating any positive blood test to minimize unnecessary subsequent interventions: "If it is real, it will climb."

According to the ASCO guidelines, the cornerstones of early breast cancer follow-up care are regular history, physical examination, and mammography.

Physical examinations should be performed every 3 to 6 months in the first 3 years, every 6 to 12 months in years 4 and 5, and annually thereafter. For women who have undergone breast-conserving surgery, a post-treatment mammogram should be performed 1 year after the initial mammogram and at least 6 months after the completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed.

The use of complete blood counts and chemistry panels are not recommended.

It is possible that ASCO did the reissue to eliminate a time lapse between guidelines, noted Dr. Vogl. "Guidelines that have not been formally reviewed in more than 5 years, in the current information environment, are almost like no guidelines at all," he said.

The guideline authors have disclosed no relevant financial relationships, with one exception: a coauthor reports being a consultant to GE Healthcare. Dr. Vogl has disclosed no relevant financial relationships.

J Clin Oncol. Published online November 5, 2012. Abstract