E. R. Berger1,2, J. R. Schumacher3, D. Vanness3, L. O’Dwyer5, D. P. Winchester4, C. C. Greenberg3 1American College Of Surgeons,Division Of Continuous Quality Improvement,Chicago, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Department Of Surgery,Maywood, IL, USA 3University Of Wisconsin School Of Medicine And Public Health,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA 4American College Of Surgeons,Cancer Programs,Chicago, IL, USA 5Northwestern University Feinberg School Of Medicine,Galter Health Sciences Library,Chicago, IL, USA
Introduction: Almost 3 million breast cancer survivors in the United States are receiving post-treatment surveillance. Current ASCO and NCCN guidelines recommend against the routine use of biomarkers or advanced imaging for asymptomatic patients. These guidelines do not account for heterogeneity in individual patient risk or the significant advances in imaging and treatments that have been made since the studies on which these guidelines are based were conducted. As a result, utilization remains high. We performed a systematic review to assess recent evidence supporting surveillance with biomarkers or advanced body imaging for detection of distant recurrence after treatment for breast cancer.
Methods: A systematic search was conducted in March 2015 using MEDLINE(PubMed), Embase, and Cochrane CENTRAL Register of Controlled Trials for articles on breast cancer, diagnostic imaging, recurrence, and surveillance, and their word variants. After the removal of duplicates, a total of 2887 results were screened. Studies were excluded if conducted for screening/staging primary breast cancer, if patients had not been treated with curative intent, if patients were symptomatic, or if the study was conducted prior to the year 2000.
Results:Twenty nine studies met the inclusion criteria. Twenty three studies documented utilization of routine biomarkers and imaging for asymptomatic surveillance. Only two studies compared surveillance with guideline concordant care (clinical visits and mammography) with a more intensive protocol involving advanced imaging. The majority of studies used cross-sectional imaging and biomarkers as the comparison group despite recommendations against them. Nineteen studies evaluated the use of PET/CT in detecting recurrence compared to other cross sectional imaging in the setting of rising tumor markers (CA 15-3, CEA). There was no overall or disease-free survival benefits in any study. PET/CT demonstrated a consistently higher sensitivity and specificity in detecting distant recurrence compared to biomarkers and/or conventional imaging alone.
Conclusion:Our review found that current research mostly focused on investigating newer surveillance modalities, such as PET/CT, rather than generating evidence for or against current recommended guidelines. These studies suggest that although PET/CT is more accurate in detecting distant recurrence than other modalities, surveillance using advanced imaging or biomarkers did not yield significant improvements in survival for the post-treatment population. Because these studies did not consider patient risk factors or molecular subtypes, the question of whether surveillance using biomarkers or cross-sectional imaging might be valuable for subpopulations remains unanswered. Until evidence accounting for patient heterogeneity is generated, use of biomarkers and advanced imaging for asymptomatic surveillance among breast cancer survivors is likely to continue despite guidelines discouraging their use.