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Ongoing Surveillance A fter A ctive Breast Cancer Therapy

Ongoing Surveillance A fter A ctive Breast Cancer Therapy . Evidence-based Guidelines and Recommendations. ASCO 2006 Update Breast Cancer Follow-Up Guidelines.

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Ongoing Surveillance A fter A ctive Breast Cancer Therapy

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  1. Ongoing Surveillance After Active Breast Cancer Therapy Evidence-based Guidelines and Recommendations

  2. 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 slides

  3. “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. Main finding

  4. Recommendations for Physical Examinations • 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.

  5. Breast Self-Examination 2006 ASCO Guidelines U.S. Preventive Services Task Force Guidelines • 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. 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.htm

  6. 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.

  7. What is not recommended for routine 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.

  8. 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 mammography • No evidence that breast MRI improves outcomes like survival when used as routine follow-up in breast cancer survivors without symptoms • Evidence to show that additional imaging can result in unnecessary surgical procedures • 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.

  9. 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 mammography Patients of the intensive follow-up group also had chest X-ray and bone scan every 6 months No significant difference in 5-year overall mortality observed between the two follow-up groups 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.

  10. 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 performed • The study found no significant difference between the two groups in survival after an average of 6 years • No 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.

  11. Breast MRI • MRI is the most sensitive breast imaging tool (88-100%) • Sensitivity = the % of positive cases identified correctly • Expensive 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.

  12. Caveats The ASCO guidelines are voluntary They do not apply to all women They 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.

  13. 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 Studies 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. 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

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