Breast Cancer Screening Guidelines ACOG
Breast Cancer Screening Guidelines ACOG - A variety of research studies have been conducted on how often the tests should be performed in order to follow up after the initial treatment. Now, I will explain the items that are often practiced in Japan as a daily practice.
After the initial treatment, two prospective studies comparing the follow-up with regular examinations and mammography only, and other diagnostic and blood-test follow-up in addition to them, and a careful follow-up of various image diagnosis are performed, The survival rate was shown to be not improved. Also, these meta-analyses have no difference in survival rate, no recurrence survival rate, and no significant difference in sub-group analysis due to age, tumor diameter, or lymph node metastasis. Breast Cancer Screening Guidelines ACOG - For a recurrent example, the difference in the diagnosis method did not affect the survival rate even if it was diagnosed by a careful follow-up, and the case of a backward study which compares the medical history, the symptom, the body findings, and the example diagnosed by the Mammography.
In the early detection of remote metastasis and recurrence, the probability of healing (long-term recurrence after recurrent treatment) is obtained is low. In a systematic review of postoperative follow-up, the method of receiving mammography once a year is considered to be useful in medical and economical manner, as the death risk rises when the recurrence of the same side of the breast exceeds 2 cm. According to the 12 studies, meta-analysis 8, including patients with 5045, the ratio of a single-shot local recurrence was found by regular examination and periodic examination with no symptoms is 40%, and 60% of the others are found by subjective symptom. However, the effect of the detection of asymptomatic topical recurrence, survival rate and QOL improvement has not been proven. In addition, there is no research comparing the frequency of the follow-up and the content by the difference of the risk although the various recurrence risk classification 9) 10 is reported now.
The effects on survival, QOL, and the health care economy have not been proven by careful follow-up with various inspections after initial treatment. These should be discussed from a variety of viewpoints, such as the patient's safety and the medical economy, and in the future, we should conduct observational research based on EBM and incorporate a proven examination of usefulness into the guidelines.
Two prospective studies and some retrospective studies too, about three-quarters of the patients are aware of the symptoms of recurrence. In addition, 15% of recurrence is discovered by Visual palpation, and 14 is useful especially in the case of asymptomatic recurrence. It is recommended that within three years after the initial treatment that is likely to recur, every three to six months, four to five years, six to twelve months, and after five years, a careful interview and a view palpation of once a year.
After breast cancer, in a prospective study of the group subjected to a follow-up by a specialist and a group subjected to a follow-up by a family physician, the follow-up by the family physician does not delay the recurrence diagnosis, and the anxiety is exacerbated, The quality of life was not lowered. As for the frequency of follow-up, it was not possible to increase the anxiety of the patient even if the number of follow-ups was decreased according to the group which regularly performed, and the randomized comparison with the group limited to only one time in the mammography (1 to 2 years).
The interview and Palpation are important items in the follow-up. It is good to perform a careful interview and the view palpation at a reasonable interval and to do the inspection according to it when some appeals and abnormal findings are admitted. A follow-up by a family doctor is recommended according to patient's hope.
(2) Mammography
In the follow-up, there is no randomized comparison test considering the use of mammography. Breast Cancer Screening Guidelines ACOG - After breast cancer, in the non-randomized comparison test 24, which was compared with the presence or absence of regular mammography, the contralateral breast cancer diagnosed by the regular mammography was shown to be early in the clinical stage as compared with the case diagnosed only by palpation. After breast-sparing therapy, about half of the local recurrence that can be cured is found in Follow Upman Monograph. In comparison with Screening Man Moglap for Follow Upman Monograph and healthy women after breast cancer, the Follow Upman Monograph is more sensitive than screening, but by mammography, 66% of the new breast cancer was discovered in both sides. However, the recurrence of the preserved breast found in the mammography was no significant difference in the survival rate after the recurrence treatment, although many patients had early clinical stage rather than when they were found in palpation. Similarly, for the same side mammography after breast-sparing therapy, the effect on survival has not been proven.
On the other hand, it was shown that the Follow Upman Monograph for the elderly aged 65 years and older persons were suppressed by the cancer Registration database, which extracted and analyzed data of the number of Follow Upman Monograph, death, and date of death. Study on the relationship between the presence of Follow Upman Monograph from Canada database and the death of breast cancer after surgery It was proved that the death of breast cancer decreased by Follow Upman Monograph. From these, regular mammography is useful.
(3) Patient education on recurrent symptoms, self-examination
After the initial treatment of breast cancer, there are no reports about the effects of the educational program on patients, or outcomes, although 40% of the two-side breast cancer is found by self-examination. In the large-scale randomized comparison test conducted in Shanghai for Breast self-examination for more than 260,000 healthy women, breast cancer mortality rate reduction effect is not proven, even if the self-examination, the tumor diameter of the discovered breast cancer, the presence of lymph node metastasis, There was no difference in the presence of remote metastases. Although it is considered important for clinicians to educate and encourage self-palpation in their interactions with patients in daily practice, there is no data indicating the usefulness of patient education.
(4) Gynecological Checkup
After breast cancer treatment, there is no randomized comparison test for the usefulness of gynecological screening for the detection of duplicate cancers. After surgery, if you are taking tamoxifen as an endocrine therapy, it is known that the risk of endometrial cancer is increased from, 3 to 5 times rise depending on the dosage. However, the effectiveness of regular biopsy in the person taking tamoxifen is not clear. On the other hand, experts agree that it is necessary to have a careful interview about the genital bleeding.
(5) Blood test
In our country, there is no study that shows the usefulness of regular blood tests after initial treatment, although blood tests have been performed regularly for the purpose of finding bone metastasis due to abnormalities of hepatic metastasis, phosphatase values, and calcium values due to liver function test values. We evaluated the follow-up including the blood test, the positive and backward studies did not acknowledge the usefulness of blood tests.
(6) Tumor marker
As tumor markers after initial treatment of breast cancer, CEA and CA15 — 3 are often measured. In the event of a recurrence, CA15 — 3, rose, the average of 5 to 6 months before the occurrence of symptoms or other tests, can predict a recurrence by the rise of CA15. However, the result of the tumor marker does not prove the significance of treating the asymptomatic latent metastasis.
(7) Chest X-ray
There is no research that shows the usefulness of regular chest X-rays after initial treatment. We evaluated the follow-up including the chest X-ray, the positive and backward studies did not recognize the usefulness of chest X-rays. In the study comparing the case that the chest X-ray was performed regularly and when the symptoms appeared, the medical expenses were reduced by not recognizing a significant difference in the survival rate and enforcing it only when symptoms appeared.
(8) Chest Abdominal CT
After the initial treatment, there is no positive research on chest abdominal ct. In the two retrospective studies, the effect of CT was examined after initial treatment, but none of the usefulness was recognized. There is no research that shows the usefulness of periodic CT for asymptomatic patients.
One prospective study showed that the follow-up items included liver ultrasound tests, but the prognosis did not improve even after regular inspections. There are no studies that show the usefulness of regular liver ultrasound tests for asymptomatic patients.
(10) Breast MRI
The breast MRI is highly useful for recurrent retrieval in the breast after breast-sparing therapy, sensitivity, specificity, and negative reaction certainly. However, in one retrospective study, the usefulness of regular MRI for asymptomatic patients was not recognized as a follow-up after initial treatment.
(11) Head MRI
In recent years, it has been shown that the recurrence form of the breast cancer has different characteristics by subtype. Especially in HER2-positive breast cancer and triple-negative breast cancer, the frequency of cerebral metastasis is higher than that of luminal-type breast cancer, and it has been shown to be poor prognosis. On the other hand, in the case of HER2-positive breast cancer, a group that began early treatment for patients with brain metastasis discovered with no symptoms although the mortality associated with the brain metastasis was significantly less than that of the group that started the treatment after acknowledging the symptoms, there was no significant difference in the total survival rate in both groups.
(12) Bone scintigraphy
After breast cancer treatment, the most frequent first recurrence site is a bone metastasis, the prognosis improvement effect by regular bone scintigraphy after initial treatment has not been proven. In the retrospective study of the findings of bone metastasis compared with the presence of symptoms, a periodic test containing bone scintigraphy was found, and treatment was not allowed to prolong the survival period.
In NSABP Report, the asymptomatic bone metastasis is 0.65% (52/7984 Scan), the Ludwig Breast Cancer Study Group report, and the bone scintigraphy to the axillary lymph node metastasis positive breast cancer, The early detection of bone metastasis is 2.4% and its frequency is low.
(13) FDG — PET
Breast Cancer Screening Guidelines ACOG - After the initial treatment, there is no prospective research on FDG — pet. FDG — Pet Inspection in the detection of breast cancer recurrence, compared to the image inspection (conventional imaging; CI), which has been performed up to now such as mammography, ultrasound, CT, MRI, X-ray, and bone scintigraphy, more sensitivity and specificity is high. However, there is a variation in sensitivity and specificity among the reports, and the usefulness of FDG — pet in conjunction with CI, is not an alternative to CI. There is no study showing usefulness in terms of survival, QOL, and medical economics.
In the early detection of remote metastasis and recurrence, the probability of healing (long-term recurrence after recurrent treatment) is obtained is low. In a systematic review of postoperative follow-up, the method of receiving mammography once a year is considered to be useful in medical and economical manner, as the death risk rises when the recurrence of the same side of the breast exceeds 2 cm. According to the 12 studies, meta-analysis 8, including patients with 5045, the ratio of a single-shot local recurrence was found by regular examination and periodic examination with no symptoms is 40%, and 60% of the others are found by subjective symptom. However, the effect of the detection of asymptomatic topical recurrence, survival rate and QOL improvement has not been proven. In addition, there is no research comparing the frequency of the follow-up and the content by the difference of the risk although the various recurrence risk classification 9) 10 is reported now.
Breast Cancer Screening Guidelines ACOG
In the retrospective study of the France, patients who underwent follow-up guidelines following the initial treatment of breast cancer and the economic effects of non-patients were investigated, but if they do not conform to the guidelines, It was shown that the cost of medical care for 2.2 times (first year) to 3.6 times (third year) was incurred.The effects on survival, QOL, and the health care economy have not been proven by careful follow-up with various inspections after initial treatment. These should be discussed from a variety of viewpoints, such as the patient's safety and the medical economy, and in the future, we should conduct observational research based on EBM and incorporate a proven examination of usefulness into the guidelines.
Related: Breast Cancer Screening Guidelines 2016(1) Interview and Visual Palpation
Two prospective studies and some retrospective studies too, about three-quarters of the patients are aware of the symptoms of recurrence. In addition, 15% of recurrence is discovered by Visual palpation, and 14 is useful especially in the case of asymptomatic recurrence. It is recommended that within three years after the initial treatment that is likely to recur, every three to six months, four to five years, six to twelve months, and after five years, a careful interview and a view palpation of once a year.
After breast cancer, in a prospective study of the group subjected to a follow-up by a specialist and a group subjected to a follow-up by a family physician, the follow-up by the family physician does not delay the recurrence diagnosis, and the anxiety is exacerbated, The quality of life was not lowered. As for the frequency of follow-up, it was not possible to increase the anxiety of the patient even if the number of follow-ups was decreased according to the group which regularly performed, and the randomized comparison with the group limited to only one time in the mammography (1 to 2 years).
The interview and Palpation are important items in the follow-up. It is good to perform a careful interview and the view palpation at a reasonable interval and to do the inspection according to it when some appeals and abnormal findings are admitted. A follow-up by a family doctor is recommended according to patient's hope.
(2) Mammography
In the follow-up, there is no randomized comparison test considering the use of mammography. Breast Cancer Screening Guidelines ACOG - After breast cancer, in the non-randomized comparison test 24, which was compared with the presence or absence of regular mammography, the contralateral breast cancer diagnosed by the regular mammography was shown to be early in the clinical stage as compared with the case diagnosed only by palpation. After breast-sparing therapy, about half of the local recurrence that can be cured is found in Follow Upman Monograph. In comparison with Screening Man Moglap for Follow Upman Monograph and healthy women after breast cancer, the Follow Upman Monograph is more sensitive than screening, but by mammography, 66% of the new breast cancer was discovered in both sides. However, the recurrence of the preserved breast found in the mammography was no significant difference in the survival rate after the recurrence treatment, although many patients had early clinical stage rather than when they were found in palpation. Similarly, for the same side mammography after breast-sparing therapy, the effect on survival has not been proven.
On the other hand, it was shown that the Follow Upman Monograph for the elderly aged 65 years and older persons were suppressed by the cancer Registration database, which extracted and analyzed data of the number of Follow Upman Monograph, death, and date of death. Study on the relationship between the presence of Follow Upman Monograph from Canada database and the death of breast cancer after surgery It was proved that the death of breast cancer decreased by Follow Upman Monograph. From these, regular mammography is useful.
(3) Patient education on recurrent symptoms, self-examination
After the initial treatment of breast cancer, there are no reports about the effects of the educational program on patients, or outcomes, although 40% of the two-side breast cancer is found by self-examination. In the large-scale randomized comparison test conducted in Shanghai for Breast self-examination for more than 260,000 healthy women, breast cancer mortality rate reduction effect is not proven, even if the self-examination, the tumor diameter of the discovered breast cancer, the presence of lymph node metastasis, There was no difference in the presence of remote metastases. Although it is considered important for clinicians to educate and encourage self-palpation in their interactions with patients in daily practice, there is no data indicating the usefulness of patient education.
(4) Gynecological Checkup
After breast cancer treatment, there is no randomized comparison test for the usefulness of gynecological screening for the detection of duplicate cancers. After surgery, if you are taking tamoxifen as an endocrine therapy, it is known that the risk of endometrial cancer is increased from, 3 to 5 times rise depending on the dosage. However, the effectiveness of regular biopsy in the person taking tamoxifen is not clear. On the other hand, experts agree that it is necessary to have a careful interview about the genital bleeding.
In our country, there is no study that shows the usefulness of regular blood tests after initial treatment, although blood tests have been performed regularly for the purpose of finding bone metastasis due to abnormalities of hepatic metastasis, phosphatase values, and calcium values due to liver function test values. We evaluated the follow-up including the blood test, the positive and backward studies did not acknowledge the usefulness of blood tests.
(6) Tumor marker
As tumor markers after initial treatment of breast cancer, CEA and CA15 — 3 are often measured. In the event of a recurrence, CA15 — 3, rose, the average of 5 to 6 months before the occurrence of symptoms or other tests, can predict a recurrence by the rise of CA15. However, the result of the tumor marker does not prove the significance of treating the asymptomatic latent metastasis.
(7) Chest X-ray
There is no research that shows the usefulness of regular chest X-rays after initial treatment. We evaluated the follow-up including the chest X-ray, the positive and backward studies did not recognize the usefulness of chest X-rays. In the study comparing the case that the chest X-ray was performed regularly and when the symptoms appeared, the medical expenses were reduced by not recognizing a significant difference in the survival rate and enforcing it only when symptoms appeared.
(8) Chest Abdominal CT
After the initial treatment, there is no positive research on chest abdominal ct. In the two retrospective studies, the effect of CT was examined after initial treatment, but none of the usefulness was recognized. There is no research that shows the usefulness of periodic CT for asymptomatic patients.
See also: Breast Cancer Screening Guidelines(9) Liver ultrasound test
One prospective study showed that the follow-up items included liver ultrasound tests, but the prognosis did not improve even after regular inspections. There are no studies that show the usefulness of regular liver ultrasound tests for asymptomatic patients.
(10) Breast MRI
The breast MRI is highly useful for recurrent retrieval in the breast after breast-sparing therapy, sensitivity, specificity, and negative reaction certainly. However, in one retrospective study, the usefulness of regular MRI for asymptomatic patients was not recognized as a follow-up after initial treatment.
(11) Head MRI
In recent years, it has been shown that the recurrence form of the breast cancer has different characteristics by subtype. Especially in HER2-positive breast cancer and triple-negative breast cancer, the frequency of cerebral metastasis is higher than that of luminal-type breast cancer, and it has been shown to be poor prognosis. On the other hand, in the case of HER2-positive breast cancer, a group that began early treatment for patients with brain metastasis discovered with no symptoms although the mortality associated with the brain metastasis was significantly less than that of the group that started the treatment after acknowledging the symptoms, there was no significant difference in the total survival rate in both groups.
(12) Bone scintigraphy
After breast cancer treatment, the most frequent first recurrence site is a bone metastasis, the prognosis improvement effect by regular bone scintigraphy after initial treatment has not been proven. In the retrospective study of the findings of bone metastasis compared with the presence of symptoms, a periodic test containing bone scintigraphy was found, and treatment was not allowed to prolong the survival period.
In NSABP Report, the asymptomatic bone metastasis is 0.65% (52/7984 Scan), the Ludwig Breast Cancer Study Group report, and the bone scintigraphy to the axillary lymph node metastasis positive breast cancer, The early detection of bone metastasis is 2.4% and its frequency is low.
See also: Breast Cancer Screening Family HistoryHowever, the improvement of the diagnostic accuracy of bone scintigraphy and the appearance of the bisphosphonate formulation have also changed the treatment method of the bone metastasis now. In the case of the significance of the clinical bone scintigraphy, the thesis that it is necessary to reconsider the progress example considered to be the especially high frequency of bone metastasis is seen. Even if the effect of the survival period is not clear, in the sense of decreasing bone-related events (SRE), it is considered that it will be necessary to consider in the future, but at this time, there is no reliable basis for recommending regular bone scintigraphy for patients with no symptoms. On the other hand, the bone metastasis of patients with symptoms is diagnosed by bone scintigraphy, and treatment can be expected to alleviate symptoms and improve QOL.
Breast Cancer Screening Guidelines ACOG - After the initial treatment, there is no prospective research on FDG — pet. FDG — Pet Inspection in the detection of breast cancer recurrence, compared to the image inspection (conventional imaging; CI), which has been performed up to now such as mammography, ultrasound, CT, MRI, X-ray, and bone scintigraphy, more sensitivity and specificity is high. However, there is a variation in sensitivity and specificity among the reports, and the usefulness of FDG — pet in conjunction with CI, is not an alternative to CI. There is no study showing usefulness in terms of survival, QOL, and medical economics.