Liz Meszaros, MDLinx | August 07, 2017
Many patients with stage I/II who are asymptomatic for metastases may undergo unnecessary chest CT as part of their initial workup, despite NCCN Clinical Practice Guidelines in Oncology that recommend only standard imaging with bilateral mammography, ultrasound, and sometimes, breast MRI, but not chest CT in these patients. While nearly a third of them were found to have pulmonary nodules, only 1.3% were diagnosed with pulmonary metastases, according to research published in the June issue of JNCCN—Journal of the National Comprehensive Cancer Network.
“The overwhelming majority of nodules found in this study’s patient population classified as false positive results,” said Barbara Dull, MD, Siteman Cancer Center, Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO. “Not only do the costs of the chest CT and subsequent imaging and work-up put a cost constraint on the already burdened health care system, but the psychological impact of such results on a patient and their family is enormous.”
Dr. Dull and her fellow researchers conducted this study to determine the use and results of chest CT in such patients, and included 3,321 patients with clinical stage I/II breast cancer diagnosed from 1998 to 2012 who did not receive neoadjuvant chemotherapy. Of these patients, 62.1% had clinical stage I breast cancer at diagnosis, and 37.9% stage II. Staging chest CT was performed in 11% of patients with stage I and in 36.2% of those with stage II breast cancer.
Pulmonary nodules were found in 26.9% of patients who underwent CT, of which 69.6% were ≤ to 5 mm, 25.0% were 5 mm to 10 mm, 3.2% 11 mm to 20 mm, and 2.2% were ≥ 20 mm. Ultimately, only 1.3% of patients who underwent chest CT were diagnosed with pulmonary metastases an average of 25 months after initial CT.
The NCCN Guidelines are the recognized standard for clinical policy in cancer care. Their recommendations for patients with early-stage breast cancer are reinforced by the American Society of Clinical Oncology, the European Society for Medical Oncology, and Britain’s National Institute for Health and Clinical Excellence.
“Even with numerous guidelines and recommendations, staging studies are routinely performed in patients with stage I and II breast cancer. Despite NCCN recommendations, many patients with asymptomatic early-stage breast cancer continue to undergo chest CT as part of their initial evaluation. Adherence to the NCCN Guidelines and other evidence-based recommendations will spare patients unnecessary testing and, in an era of increasing health care costs, also curb excessive spending,” said Dr. Dull.
“I hope patients and their physicians are reassured by findings like these,” added senior author Amy Cyr, MD, Washington University School of Medicine.
“Chest CT and other staging studies are of extremely low yield for identifying metastases in patients with early-stage breast cancer, and even for the 1.3% of patients in our cohort ultimately diagnosed with pulmonary disease, many were not diagnosed because of that original CT scan, but were instead diagnosed on scans as long as two years after diagnosis, suggesting even lower utility. Unfortunately, for the 26.9% of patients with positive CT scans (the vast majority of which were false positives), the subsequent evaluation needed not only raises health care costs and anxiety, but also has the potential to delay oncologic treatment,” concluded Dr. Cyr.