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1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30. Review/Other-Tx N/A To provide the expected numbers of new cancer cases and deaths in 2013 nationally and by state, as well as an overview of current cancer statistics using data through 2009, including incidence, mortality, and survival rates and trends. The article also estimate the total number of deaths averted as a result of the decline in cancer death rates since the early 1990s, and provide the actual reported numbers of deaths in 2009 by age for the 10 leading causes of death and the 5 leading cancer types. In 2009, Americans had a 20% lower risk of death from cancer than in 1991, when cancer death rates peaked. Despite this substantial progress, all demographic groups have not benefitted equally, particularly for cancers such as colorectal and breast, for which mortality declines have been attributed to earlier detection and improvements in treatment. Further progress can be accelerated by applying existing cancer control knowledge across all segments of the population, with an emphasis on those groups in the lowest socioeconomic bracket as well as other disadvantaged populations. 4
2. Berry DA, Cronin KA, Plevritis SK, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med. 2005;353(17):1784-1792. Review/Other-Tx 7 groups To choose 7 groups to model the effect of screening and treatment on trends in the incidence of and rate of death from breast cancer. The proportion of the total reduction in the rate of death from breast cancer attributed to screening varied in the 7 models from 28% to 65% (median, 46%), with adjuvant treatment contributing the rest. The variability across models in the absolute contribution of screening was larger than it was for treatment, reflecting the greater uncertainty associated with estimating the benefit of screening. 4
3. Keating NL, Landrum MB, Guadagnoli E, Winer EP, Ayanian JZ. Surveillance testing among survivors of early-stage breast cancer. J Clin Oncol. 2007;25(9):1074-1081. Review/Other-Dx 44,511 women To describe follow-up care for breast cancer survivors, examine how surveillance testing varies by the types of physicians seen, and assess changes in testing rates over time. Nearly half of breast cancer survivors saw a medical oncologist in surveillance year 1, but only 27% saw a medical oncologist annually for 3 years. In adjusted analyses, women seeing medical oncologists had more bone scans, tumor antigen testing, chest x-rays, and chest/abdominal imaging than other women (all P<.001). Nevertheless, rates of testing decreased over time (all P<.001). Rates of tumor antigen testing and chest x-rays decreased faster and chest/abdominal imaging increased slower among women seeing medical oncologists than among other women (all P<.05). 4
4. O'Mara RE. Bone scanning in osseous metastatic disease. JAMA. 1974;229(14):1915-1917. Review/Other-Dx N/A Review comparing bone scan to roentgenogram in the detection of osseous metastatic disease. In patients with abnormal roentgenogram, the scan will usually show greater tumor involvement. The scan may also be helpful in areas like the sternum and scapula. Scan has small percentage of false-negatives (3%–8%). Since scan is highly sensitive but nonspecific, both procedures are recommended for accurate detection. 4
5. Ciatto S, Pacini P, Azzini V, et al. Preoperative staging of primary breast cancer. A multicentric study. Cancer. 1988;61(5):1038-1040. Observational-Dx 3,627 patients stage I = 1,038 To assess the cost-effectiveness of preoperative imaging to detect distant metastases in breast cancer with chest radiographs (all 3,627), bone scans (2,450), bone radiographs (1,708), liver sonography (836), and liver scintigraphy (435). The detection rate of preclinical asymptomatic distant metastases depended on the T and N category (TNM classification system), and was very low (chest radiograph: 0.30%, bone radiograph: 0.64%, bone scintigraphy: 0.90%, liver sonography: 0.24%, liver scintigraphy: 0.23%). The sensitivity, determined after a 6-month follow-up, was below 0.50% for all tests. The highest value (0.48%) was recorded for bone scintigraphy, which also had the lowest specificity (0.95%). Study does not recommend preoperative staging, especially for stage I cases. 4
6. Brar HS, Sisley JF, Johnson RH, Jr. Value of preoperative bone and liver scans and alkaline phosphatase in the evaluation of breast cancer patients. Am J Surg. 1993;165(2):221-223; discussion 224. Observational-Dx 133 bone scans, 63 liver scans, stage I = 21 Review results of 133 bone scans, 63 liver scans (CT, liver spleen radionuclide scan, or US) for preoperative staging of breast cancer (TNM classification) by assessing medical records at Medical College of Georgia, 1984-1990. Only 4/133 patients (3%) had positive bone scan that correlated with results of radiographs. Stage I = 0 positive. Only 1/63 patients had liver scan suggestive of possible metastases. In 103 with normal bone scans the majority (54%) had elevated alkaline phosphate levels; 9/30 patients (30%) with abnormal scans had normal alkaline phosphatase levels. 51/63 with elevated alkaline phoshatase levels had normal liver scans. Cost of scans=$74,000. 3
7. Coleman RE, Rubens RD, Fogelman I. Reappraisal of the baseline bone scan in breast cancer. J Nucl Med. 1988; 29(6):1045-1049. Observational-Dx 1,267 consecutive patients To assess the utility of bone scintigraphy in the staging of patients with breast carcinoma. In patients with tumors <2 cm, bone scintigraphy should not be acquired routinely. Bone scintigraphy is recommended as a baseline in all patients with stage 2, 3, or 4. 3
8. Khansur T, Haick A, Patel B, Balducci L, Vance R, Thigpen T. Evaluation of bone scan as a screening work-up in primary and local-regional recurrence of breast cancer. Am J Clin Oncol. 1987;10(2):167-170. Review/Other-Dx 265 patients Review scans to determine usefulness of bone scans in staging patients with primary (265) and local-regional recurrence (39) of breast cancer. Zero of 92 stage I cases had positive bone scans. Suggests limiting scans to the highest risk groups (positive nodes). 4
9. Kunkler IH, Merrick MV, Rodger A. Bone scintigraphy in breast cancer: a nine-year follow-up. Clin Radiol. 1985;36(3):279-282. Review/Other-Dx 465 patients To determine value of bone scintigraphy in women with histologically confirmed breast carcinoma by stage in patients followed at least 2 years and up to 9 years. The incidence of significant scintigraphic abnormalities ranged from 1.5% in patients with T0 and T1 node negative tumours to 20.3% in T4 node positive tumours. Patients with scintigraphic evidence of metastases had a significantly shorter survival than those without; 13.6% of the patients with an abnormality considered to be significant on the criteria employed in this study failed to develop confirmatory evidence of skeletal metastases during the period of follow-up. 4
10. McNeil BJ, Pace PD, Gray EB, Adelstein SJ, Wilson RE. Preoperative and follow-up bone scans in patients with primary carcinoma of the breast. Surg Gynecol Obstet. 1978;147(5):745-748. Observational-Dx 153 patients stage I=37 To evaluate the role of preoperative and postoperative bone scans in patients with localized carcinoma of the breast. Median follow-up of patients was 18 months. No abnormal scans found in the patients with stage I disease (lesions <2 cm with negative nodes). Greater yield for higher stages. 7% with stage I disease converted to positive scans over time (compared to 25% for stage II and 58% for stage III). False positives are also a significant problem in these patients. 3
11. Rosselli Del Turco M, Palli D, Cariddi A, Ciatto S, Pacini P, Distante V. Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up. JAMA. 1994;271(20):1593-1597. Experimental-Dx 1,243, stage I=56% To determine whether early detection of intrathoracic and bone metastases were effective in reducing breast cancer mortality. Clinical follow-up group (included physical examination and mammography) was compared with intensive follow-up group (added chest radiography and bone scan every 6 months). 640 (52%) node negative. In total, 393 recurrences (104 local and 289 distant) occurred. Increased detection of intrathoracic and bone metastases was evident in intensive follow-up group. However, there was no difference in overall 5-year survival rates. Periodic intensive follow-up with chest radiography and bone scan not recommended as routine policy. 1
12. Aukema TS, Rutgers EJ, Vogel WV, et al. The role of FDG PET/CT in patients with locoregional breast cancer recurrence: a comparison to conventional imaging techniques. Eur J Surg Oncol. 2010;36(4):387-392. Observational-Dx 56 patients To evaluate the impact of FDG-PET/CT on clinical management in patients with locoregional breast cancer recurrence amenable for locoregional treatment and to compare the PET/CT results with the conventional imaging data. In 32 patients (57%) PET/CT revealed additional tumor localizations. Distant metastases were detected in 11 patients on conventional imaging and in 23 patients on PET/CT images (P<0.01). In 25 patients (45%), PET/CT detected additional lesions not visible on conventional imaging. PET/CT had an impact on clinical management in 27 patients (48%) by detecting more extensive locoregional disease or distant metastases. In 20 patients (36%) extensive surgery was prevented and treatment was changed to palliative treatment. The sensitivity, specificity, accuracy, positive and negative predictive values of FDG-PET/CT were respectively 97%, 92%, 95%, 94% and 96%. PET/CT, in addition to conventional imaging techniques, plays an important role in staging patients with locoregional breast cancer recurrence since its result changed the clinical management in almost half of the patients. PET/CT could potentially replace conventional staging imaging in patients with a locoregional breast cancer recurrence. 3
13. Niikura N, Ueno NT. The Role of F-FDG-Positron Emission Tomography/Computed Tomography in Staging Primary Breast Cancer. J Cancer. 2010;1:51-53. Review/Other-Dx N/A To examine whether FDG-PET/CT may play a role in the initial staging of breast cancer by discussing studies comparing PET/CT with conventional imaging for diagnosing distant metastases and axillary and extra-axillary lymph node metastases. The use of PET/CT in the initial staging of primary breast cancer is not yet well defined and not recommended at present because there is limited evidence to support its use. However, because studies have shown that PET/CT may enable accurate detection of local lymph node metastases and distant metastases, PET/CT offers another option for use in primary breast cancer staging. For cases in which conventional imaging techniques (ie, US, CT, MRI, skeletal scintigraphy) do not provide adequate information, PET/CT could be used to obtain more detailed anatomical information. 4
14. Pennant M, Takwoingi Y, Pennant L, et al. A systematic review of positron emission tomography (PET) and positron emission tomography/computed tomography (PET/CT) for the diagnosis of breast cancer recurrence. Health Technol Assess. 2010;14(50):1-103. Review/Other-Dx 28 total studies To review the accuracy of PET and PET/CT for the diagnosis of breast cancer recurrence by assessing their value compared with current practice and compared with each other. Available evidence suggests that for the detection of breast cancer recurrence, PET, in addition to conventional imaging techniques, may generally offer improved diagnostic accuracy compared with current standard practice. However, uncertainty remains around its use as a replacement for, rather than an add-on to, existing imaging technologies. In addition, PET/CT appeared to show clear advantage over CT and PET alone for the diagnosis of breast cancer recurrence. Future research should include: prospective studies with patient populations clearly defined with regard to their clinical presentation; a study of diagnostic accuracy of PET/CT compared with conventional imaging techniques; a study of PET/CT compared with whole-body MRI; studies investigating the possibility of using PET/CT as a replacement for rather than an addition to conventional imaging tests; and using modelling of the impact of PET/CT on patient outcomes to inform the possibility of conducting large-scale intervention trials. 4
15. Morris PG, Lynch C, Feeney JN, et al. Integrated positron emission tomography/computed tomography may render bone scintigraphy unnecessary to investigate suspected metastatic breast cancer. J Clin Oncol. 2010;28(19):3154-3159. Observational-Dx 163 patients Retrospective, single-institution study to compare the diagnostic performance of integrated PET/CT and bone scintigraphy in women with suspected metastatic breast cancer. Overall, PET/CT and bone scintigraphy were highly concordant for reporting osseous metastases with 132 paired studies (81%); 32 (20%) were positive, and 100 (61%) were negative. 31 occurrences (19%) were discordant. 12 of these (39%) had pathology confirming osseous metastases: 9/18 were PET/CT positive and bone scintigraphy negative; 1/3 was PET/CT positive and bone scintigraphy equivocal; and 2/2 were PET/CT equivocal and bone scintigraphy negative. This study supports the use of PET/CT in detecting osseous metastases for suspected metastatic breast cancer. Whether PET/CT may supplant bone scintigraphy in this setting is unknown. 3
16. Hahn S, Heusner T, Kummel S, et al. Comparison of FDG-PET/CT and bone scintigraphy for detection of bone metastases in breast cancer. Acta Radiol. 52(9):1009-14, 2011 Nov 01. Observational-Dx 29 women To compare whole-body FDG-PET/CT and bone scintigraphy for the detection of bone metastases on a lesion basis in breast cancer patients. A total of 132 lesions were detected on bone scintigraphy, FDG-PET/CT or both. According to the reference standard, 70/132 lesions (53%) were bone metastases, 59/132 lesions (45%) were benign, and three lesions (2%) remained unclear. The sensitivity of bone scintigraphy was 76% (53/70) compared to 96% (67/70) for FDG-PET/CT. The specificity of bone scintigraphy and FDG-PET/CT was 95% (56/59) and 92% (54/59), respectively. According to the reference standard bone metastases were present in eight out of the 29 patients (28%), whereas 20 patients (69%) were free of bone metastases. One (3%) patient had inconclusive readings on both modalities as well as on MRI and follow-up studies. Bone scintigraphy and FDG-PET/CT correctly identified 7/8 patients with bone metastases and 20/20 patients free of metastases. 3
17. Withofs N, Grayet B, Tancredi T, et al. (1)(8)F-fluoride PET/CT for assessing bone involvement in prostate and breast cancers. Nucl Med Commun. 2011;32(3):168-176. Observational-Dx 34 patients To evaluate the accuracy of PET/CT to detect bone metastases in a breast and prostate cancer population, using MRI or thin-slice CT as a gold standard. Out of the 386 foci detected by PET/CT, 219 (56.7%) could be verified by CT or MRI. 86 additional foci were detected by bone scan (n = 46) or seen only by CT (n = 9), MRI (n = 23), or both CT and MRI (n = 8). The total number of verified lesions was therefore 274 (58.1%), including 119 (43.4%) benign and 155 (56.6%) bone metastases. The sensitivity, specificity, and accuracy of PET/CT were 76%, 84.2%%, and 80%, respectively. For bone scan, they were 44.8%, 79.2%, and 60%, respectively. Sensitivity significantly decreased for the lytic lesions. The accuracy of PET/CT was significantly superior to bone scan for pelvic and lumbar lesions. PET/CT provided a correct diagnosis (M+/M0) in 32/33 patients (one false positive) compared with 28/33 with bone scan (4 false positive, 1 false positive). 2
18. Loprinzi CL. It is now the age to define the appropriate follow-up of primary breast cancer patients. J Clin Oncol. 1994;12(5):881-883. Review/Other-Dx N/A Editorial to define the appropriate follow-up for patients with primary breast cancer. Recommends follow-up guidelines for stage I and II breast cancer patients. History and physical examination should be basis of follow-up. 4
19. Ravaioli A, Pasini G, Polselli A, et al. Staging of breast cancer: new recommended standard procedure. Breast Cancer Res Treat. 2002;72(1):53-60. Observational-Dx 1,218 patients, stage I = 497 Review data from cases of breast cancer to determine value of preoperative bone scan, chest radiograph, liver US. True positive, false positive, and false negative for bone scan 4 (0.8%), 13 (2.6%), 0; for chest radiograph 0, 3 (0.6%), 0; for liver US 0, 2 (0.4%), 1 (0.2%). Conclude that only laboratory analysis indicated for initial staging. 3
20. Vestergaard A, Herrstedt J, Thomsen HS, Dombernowsky P, Zedeler K. The value of yearly chest X-ray in patients with stage I breast cancer. Eur J Cancer Clin Oncol. 1989;25(4):687-689. Review/Other-Dx 263 patients To determine the value of yearly chest radiograph in patients with stage 1 breast cancer. For 1,599 examinations performed, unsuspected malignant changes were observed in only 0.25% (4 patients). Study concludes that repeated chest radiographs in patients with stage I breast cancer are not necessary. 4
21. Puglisi F, Follador A, Minisini AM, et al. Baseline staging tests after a new diagnosis of breast cancer: further evidence of their limited indications. Ann Oncol. 2005;16(2):263-266. Observational-Dx 516 patients, stage I =236 of 412, bone scan; stage I=232 of 412 liver US; stage I=234 of 428 chest radiograph To determine the usefulness of bone scan, liver US, and chest radiograph in the staging of asymptomatic women with newly diagnosed breast cancer. Reviewed results for 516 consecutive patients. At baseline, BS was carried out in 412 patients, LUS in 412 patients and CXR in 428 patients. Thirty-three patients were correctly diagnosed by the initial staging investigations as having metastatic disease (true positive cases). BS detected skeletal metastases in 6.31% of patients, LUS detected liver metastases in 0.72% of patients and CXR detected lung metastases in 0.93% of patients. Before imaging tests, all patients with either LUS or CXR evidence of metastases were previously classified as having stage III disease. On the other hand, only 26.9% of bone metastases were detected in patients with stage III. Accordingly, the detection rate in stage III patients was 14%, 5.6% and 7.2%, respectively for BS, LUS and CXR. 3
22. 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(20):1587-1592. Experimental-Dx 1,320 women To determine effectiveness of intensive follow-up testing for breast cancer metastases. Multicenter study at 26 hospitals randomized women to “intensive surveillance” (annual bone scan, annual liver echography, biannual chest radiograph and lab tests) at predetermined intervals and “control regimen” (patients seen by physicians at same frequency but only clinically indicated tests performed). Also evaluated quality of life issues. Of the women in this study, 739 (56%) were node negative, equally randomized to the 2 groups. No significant differences were found in distant metastasis-free survival between the 2 groups; early detection group started treatment only 1-month earlier on the average. No evidence of benefit from intensive surveillance emerged within subsets of patients grouped by nodal status. Concluded no benefit from frequent diagnostic tests added to routine medical surveillance. Results of quality of life assessment indicate that type of follow-up does not affect various dimensions of quality of life: perception, emotional well-being, body image, social functioning, symptoms or satisfaction with care. On the other hand, this study did not show that frequent testing increased stress. 1
23. Kim H, Han W, Moon HG, et al. The value of preoperative staging chest computed tomography to detect asymptomatic lung and liver metastasis in patients with primary breast carcinoma. Breast Cancer Res Treat. 2011;126(3):637-641. Observational-Dx 1,703 patients To investigate the clinical value of preoperative chest CT in detecting lung and liver metastases. Abnormal CT findings, including suspected metastases and indeterminate nodules in the lung or liver, were found in 266 patients (15.6%). Among these, 26 patients (1.5% of all patients and 9.8% of patients with abnormal CT findings) had true metastases, including 17 in the lungs, 3 in the liver, and 6 in both. True metastases were detected in 1 (0.2%), 0 (0%), and 24 (6.0%) patients with stage I, II, and III disease, respectively. The sensitivity, specificity, and positive predictive value of chest CT were 100, 89.1, and 11.3%, respectively, for lung metastasis and 100, 97.6, and 18.4%, respectively, for liver metastasis. All true metastatic lung lesions were all small-sized nodules, ranging from 0.2 to 1.5 cm in largest diameter, and could not be detected on chest X-rays. In conclusion, our results demonstrate the lack of usefulness of routine preoperative chest CT in detecting asymptomatic liver and lung metastasis in patients with early breast cancer. Chest CT, however, upstaged 6.0% of stage III patients to stage IV. 3
24. Patanaphan V, Salazar OM, Risco R. Breast cancer: metastatic patterns and their prognosis. South Med J. 1988;81(9):1109-1112. Review/Other-Dx 145 patients To examine metastatic patterns and prognosis of breast cancer. Most common first site of distant spread was bone (51%), lung (17%), brain (16%), and liver (6%). The remaining 10% of patients had multiple metastatic sites. No correlation between time until relapse and survival after metastasis. Patients in whom distant metastases developed relatively soon after the initial diagnosis had the same post-metastatic prognosis as patients whose disease metastasized later. No correlation was found between age at initial diagnosis and metastasis-free interval or survival after metastasis. 4
25. Friedman ML, Esposito FS. Comparison of CT scanning and radionuclide imaging in liver disease. Crit Rev Diagn Imaging. 1980;14(2):143-189. Review/Other-Dx N/A Review comparing CT scanning with radionuclide imaging in liver disease. For jaundiced patient, CT provides more specific information about the liver than radionuclide liver scan. For mass lesions of the liver, radionuclide scan is more sensitive than CT but less specific. 4
26. Yeh HC, Rabinowitz JG. Ultrasonography and computed tomography of the liver. Radiol Clin North Am. 1980;18(2):321-338. Review/Other-Dx N/A To compare US and CT in the evaluation of the liver. CT and US are recommended for the evaluation of the liver. CT and US have different physical principles, and therefore differences in techniques used and information provided. 4
27. Myers RE, Johnston M, Pritchard K, Levine M, Oliver T. Baseline staging tests in primary breast cancer: a practice guideline. CMAJ. 2001;164(10):1439-1444. Meta-analysis 5,407 bone scan patients; 1,625 liver US patients; 3,884 chest radiograph patients Review studies using bone scan, liver US, and chest radiograph for baseline staging in women with newly diagnosed breast cancer. 9 studies performed between 1985 and 1995 of 5,407 women undergoing bone scan detected skeletal metastasis in 7/1,419 women with stage I disease (0.5%). Liver US and chest radiograph detected metastatic disease in 0% and 0.1% of women, respectively. Study does not recommend routine use of bone scan, liver US, or chest radiograph as part of baseline staging. M
28. Ferrucci JT. Leo J. Rigler lecture. MR imaging of the liver. AJR Am J Roentgenol. 1986;147(6):1103-1116. Review/Other-Dx 142 patients, 3 observers Review technical and clinical advances of MRI of the liver. Also, performed a blinded retrospective study to compare MRI with CT in 42 patients. MRI discovered 14% more individual metastases and 3% more patients with liver cancer than CT. MRI also showed greater specificity (98%) than CT (91%) in distinguishing patients without liver metastases. Study suggest MRI can be appropriate as a primary screening method for detecting liver neoplasms if optimal pulse sequences are used. 4
29. Russell EJ, Geremia GK, Johnson CE, et al. Multiple cerebral metastases: detectability with Gd-DTPA-enhanced MR imaging. Radiology. 1987;165(3):609-617. Observational-Dx 16 patients, 2 observers To determine if Gd-DTPA-enhanced MRI improves detection of multiple cerebral metastases. 6/7 (86%) patients with multiple metastases, had at least one tumor nodule depicted by post-infusion MRI that was missed by one or both observers on review of pre-infusion images alone. Authors believe contrast enhancement improves detection of metastatic foci with MRI and that the findings indicate broader implications for the detection of multiple lesions from other causes. 2
30. Weisberg LA. The computed tomographic findings in intracranial metastases due to breast carcinoma. Comput Radiol. 1986;10(6):297-306. Review/Other-Dx 17 To review CT findings in intracranial metastases due to breast carcinoma. 16 patients showed neurological abnormalities on examination; 1 patient had no abnormalities. CT showed evidence of basal parasellar lesions (3 cases), orbital lesions (2 cases), or cerebral hemispheric (intracerebral or subdural) lesions (11 cases). CT showed evidence of bone lesions in 8 cases and there were accompanying parasellar (3 cases), orbital (2 cases), and subdural lesions (3 cases). 4
31. Khansur T, Haick A, Patel B, Balducci L, Vance R, Thigpen JT. Preoperative evaluation with radionuclide brain scanning and computerized axial tomography of the brain in patients with breast cancer. Am J Surg. 1988;155(2):232-234. Review/Other-Dx 226 patients with breast cancer, 34 patients with loco regional recurrence 131 scans; stage I = 52 patients Review clinical and radiological findings to determine value of radionuclide brain scanning and CT of brain in the pretreatment evaluation of patients with primary and loco regional recurrence of breast cancer. For primary breast cancer, 4/131 radionuclide scans suggested calvarial metastasis, and the findings were confirmed with bone scans and skull radiographs. One of 95 CT scans of brain showed brain metastasis. For locoregional recurrence, the results of 2/23 radionuclide scans and 1/11 CT scans were positive. CT brain scans only useful in the presence of neurological signs. Not one case of brain metastases was found in the absence of neurological signs and symptoms. 4
32. Tomasevic ZI, Rakocevic Z, Tomasevic ZM, et al. Incidence of brain metastases in early stage HER2 3+ breast cancer patients; is there a role for brain CT in asymptomatic patients? J BUON. 2012;17(2):249-253. Review/Other-Dx 258 patients To prospectively explore the incidence of BM during and after adjuvant trastuzumab administration in HER2 3+ early-breast carcinoma patients. 85 patients (33%) underwent brain CT in the absence of central nervous system symptoms. The median number of trastuzumab cycles at the time of brain CT was 9 (range 4-18). There were no brain metastases detected by brain CT in these 85 asymptomatic patients. However, during a median follow up of 18 months 5/258 patients (1.93%) developed brain metastases, but only 2 (0.77%) while still receiving adjuvant trastuzumab. The median time from breast cancer diagnosis to brain metastases was 24 months (range 14-43). 4
33. Brant-Zawadzki M. MR imaging of the brain. Radiology. 1988;166(1 Pt 1):1-10. Review/Other-Dx N/A To review clinical applications of MRI in the diagnosis of brain disorders. The greater sensitivity of MRI to pathologic alteration of cerebral tissues assures its replacement of CT as the first-line diagnostic imaging study for most patients with neurologic manifestations. 4
34. Davis PC, Hudgins PA, Peterman SB, Hoffman JC, Jr. Diagnosis of cerebral metastases: double-dose delayed CT vs contrast-enhanced MR imaging. AJNR Am J Neuroradiol. 1991;12(2):293-300. Review/Other-Dx 23 patients To compare double-dose delayed CT with contrast-enhanced MRI in the diagnosis of cerebral metastases. Contrast-enhanced MRI was better than double-dose delayed CT for lesion detection, anatomic localization of lesions, and differentiation of solitary vs multiple lesions. 4
35. Khatcheressian JL, Wolff AC, Smith TJ, et al. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol. 2006;24(31):5091-5097. Review/Other-Dx N/A To update the 1999 American Society of Clinical Oncology guideline on breast cancer follow-up and management in the adjuvant setting. The evidence supports regular history, physical examination, and mammography as the cornerstone of appropriate breast cancer follow-up. All patients should have a careful history and physical examination performed by a physician experienced in the surveillance of cancer patients and in breast examination. Examinations should be performed every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter. For those who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed. Patients at high risk for familial breast cancer syndromes should be referred for genetic counseling. The use of CBCs, chemistry panels, bone scans, chest radiographs, liver US, CT scans, FDG-PET scanning, MRI, or tumor markers (carcinoembryonic antigen, CA 15-3, and CA 27.29) is not recommended for routine breast cancer follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination. 4
36. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 3.2013. 2013; Available at: http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed October 20, 2013. Review/Other-Tx N/A NCCN clinical practice guidelines in oncology breast cancer. N/A 4
37. Lash TL, Fox MP, Buist DS, et al. Mammography surveillance and mortality in older breast cancer survivors. J Clin Oncol. 2007;25(21):3001-3006. Observational-Dx 1,846 patients To estimate the effectiveness of surveillance mammography in a cohort of breast cancer survivors with complete ascertainment of surveillance mammograms and negligible losses to follow-up. 178 women died of breast cancer during 5 years of follow-up. Each additional surveillance mammogram was associated with a 0.69-fold decrease in the odds of breast cancer mortality (95% CI, 0.52 to 0.92). The protective association was strongest among women with stage I disease, those who received mastectomy, and those in the oldest age group. 4
38. Lash TL, Fox MP, Silliman RA. Reduced mortality rate associated with annual mammograms after breast cancer therapy. Breast J. 2006;12(1):2-6. Observational-Dx 865 stage I or II breast cancer patients To assess the impact of annual mammography on all-cause mortality in breast cancer survivors by conducting a case-control analysis. The exposure variable was the number of mammograms received after completing primary therapy. Cases were decedents and we used risk-set sampling to match 8 controls to each case on follow-up time. The mortality rate declined with an increasing number of mammograms (P for trend=0.007). The age- and therapy-adjusted OR associating receipt of an additional mammogram, compared with receipt of no mammogram, equaled 0.77 (95% CI, 0.53–1.1). 4
39. Paszat L, Sutradhar R, Grunfeld E, et al. Outcomes of surveillance mammography after treatment of primary breast cancer: a population-based case series. Breast Cancer Res Treat. 2009;114(1):169-178. Review/Other-Dx 12,279 women To ascertain outcomes of surveillance mammography following treatment of early stage unilateral primary breast cancer in a population based case series. Eligible women comprising 591/1,200 and 310/400 produced a combined case series of 901/1,600 (56.3%). Women with =1 episode(s) of surveillance mammography numbered 721/901 (80.0%). We confirmed 84 cancer recurrences within the ipsilateral conserved breast events among 584 women initially treated by lumpectomy (14.4%), and 49 contralateral primary breast cancer events among all 901 women in the study population (5.4%). Among women having =1 episode(s), the 25th percentile of observed follow-up was 1,631 days, the 50th, 4,287 days, and the 75th 5,011 days. Among women without any surveillance mammography, the 25th percentile of observed follow-up was 440 days, the 50th, 891 days, and the 75th, 1,849 days. HR for death due to breast cancer associated with =1 episode of surveillance mammography was 0.28 (95% CI, 0.22–0.37), adjusted for age, stage, type of surgery, adjuvant chemotherapy, and tamoxifen. Among 84/584 women with cancer recurrence within the ipsilateral conserved breast, unadjusted HR = 0.36 (95% CI, 0.13, 1.00) and among 49/901 women with contralateral primary breast cancer, unadjusted HR = 0.86 (0.20–3.77). 4
40. Carlson RW. Chapter 70: Surveillance of Patients Following Primary Therapy. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Disease of the Breast. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. Review/Other-Dx N/A Book chapter. Book chapter. 4
41. Buchholz TA, Hunt KK. Chapter 37: Breast-Conserving Therapy: Conventional Whole Breast Irradiation. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Disease of the Breast. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. Review/Other-Dx N/A Book chapter. Book chapter. 4
42. Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;366(9503):2087-2106. Meta-analysis 42,000 patients in 78 randomized studies To determine the variations in local treatment that affects the risk of LRR through a meta-analysis of previous studies. About three-quarters of the eventual LR risk occurred during the first 5-years. In the comparisons that involved little (<10%) difference in 5-year LR risk there was little difference in 15-year breast cancer mortality. Among the 25,000 women in the comparisons that involved substantial (>10%) differences, however, 5-year LR risks were 7% active vs 26% control (absolute reduction 19%), and 15-year breast cancer mortality risks were 44.6% vs 49.5%. Improved local control may lead to decrease in breast cancer-specific mortality. Avoidance of a LR in a conserved breast (after BCT and radiation) and avoidance of a LR elsewhere (ie, the chest wall or regional nodes) after mastectomy are of comparable relevance to 15 year breast cancer mortality. M
43. Golshan M. Chapter 36: Mastectomy. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Disease of the Breast. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. Review/Other-Dx N/A Book chapter. Book chapter. 4
44. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57(2):75-89. Review/Other-Dx N/A To provide new evidence on breast MRI screening guidelines for the early detection of breast cancer in women. A guideline panel has reviewed this evidence and developed new recommendations for women at different defined levels of risk. Screening MRI is recommended for women with an approximately 20%–25% or greater lifetime risk of breast cancer, including women with a strong family history of breast or ovarian cancer and women who were treated for Hodgkin disease. There are several risk subgroups for which the available data are insufficient to recommend for or against screening, including women with a personal history of breast cancer, carcinoma in situ, atypical hyperplasia, and extremely dense breasts on mammography. 4
45. Brennan S, Liberman L, Dershaw DD, Morris E. Breast MRI screening of women with a personal history of breast cancer. AJR Am J Roentgenol. 2010;195(2):510-516. Observational-Dx 144 women To determine the cancer detection and biopsy rate among women who have breast MRI screening solely on the basis of a personal history of breast cancer. Of 144 women, 44 (31% [95% CI, 15%–29%]) underwent biopsies prompted by MRI examination. Biopsies revealed malignancies in 17 women (12% [95% CI, 7%–18%]) and benign findings only in 27 women (19% [95% CI, 13%–26%]). Of the 17 women in whom cancer was detected, 7 also had benign biopsy results. In total, 18 malignancies were found. One woman had 2 metachronous cancers. MRI screening resulted in a total of 61 biopsies, with a positive predictive value of 39% (95% CI, 27%–53%). The malignancies found included 17 carcinomas and 1 myxoid liposarcoma. Of the 17 cancers, 12 (71%) were invasive, 5 (29%) were DCIS, and 10 (59%) were minimal breast cancers. Of 17 cancers, 10 were detected by MRI only. The 10 cancers detected by MRI only, vs 7 cancers later found by other means, were more likely to be DCIS (4/10 [40%] vs 1/7 [14%]; P=0.25) or minimal breast cancers (7/10 [70%] vs 3/7 [43%]; P=0.26). 3
46. American College of Radiology. ACR Appropriateness Criteria®: Breast Cancer Screening. Available at: https://acsearch.acr.org/docs/70910/Narrative/. Review/Other-Dx N/A Breast Cancer Screening. Purpose is to assist practitioners in providing appropriate care for patients. N/A 4
47. Brandt KR, Craig DA, Hoskins TL, et al. Can digital breast tomosynthesis replace conventional diagnostic mammography views for screening recalls without calcifications? A comparison study in a simulated clinical setting. AJR Am J Roentgenol. 2013;200(2):291-298. Observational-Dx 146 women To evaluate digital breast tomosynthesis (DBT) as an alternative to conventional diagnostic mammography in the workup of noncalcified findings recalled from screening mammography in a simulated clinical setting that incorporated comparison mammograms and breast ultrasound results. Agreement between DBT and diagnostic mammography BI-RADS categories was excellent for readers 1 and 2 (kappa = 0.91 and kappa = 0.84) and good for reader 3 (kappa = 0.68). For readers 1, 2, and 3, sensitivity and specificity of DBT for breast abnormalities were 100%, 100%, and 88% and 94%, 93%, and 89%, respectively. The clinical workup averaged three diagnostic views per abnormality and ultrasound was requested in 49% of the cases. DBT was adequate mammographic evaluation for 93-99% of the findings and ultrasound was requested in 33-55% of the cases. 2
48. Gennaro G, Hendrick RE, Toledano A, et al. Combination of one-view digital breast tomosynthesis with one-view digital mammography versus standard two-view digital mammography: per lesion analysis. Eur Radiol. 2013;23(8):2087-2094. Observational-Dx 463 breasts of 250 patients To evaluate the clinical value of combining one-view mammography (cranio-caudal, CC) with the complementary view tomosynthesis (mediolateral-oblique, MLO) in comparison to standard two-view mammography (MX) in terms of both lesion detection and characterization. The 463 cases (breasts) reviewed included 258 with one to three lesions each, and 205 with no lesions. The 258 cases with lesions included 77 cancers in 68 breasts and 271 benign lesions to give a total of 348 proven lesions. The combination, DBT(MLO)+MX(CC), was superior to MX (CC+MLO) in both lesion detection (LDF) and lesion characterization (LCF) overall and for benign lesions. DBT(MLO)+MX(CC) was non-inferior to two-view MX for malignant lesions. 2
49. Waldherr C, Cerny P, Altermatt HJ, et al. Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening. AJR Am J Roentgenol. 2013;200(1):226-231. Observational-Dx 144 women To compare the diagnostic value of one-view digital breast tomosynthesis versus two-view full-field digital mammography (FFDM) alone, and versus a combined reading of both modalities. Eighty-six of the 144 patients were found to have breast cancer. The BI-RADS categories for one-view digital breast tomosynthesis were significantly better than those for two-view FFDM (p < 0.001) and were equal to those of the combined reading in both women admitted for diagnostic workup and women recalled from screening. The sensitivity and negative predictive values of digital breast tomosynthesis were superior to those of FFDM in fatty and dense breasts overall and in women admitted for diagnostic workup and in women recalled from screening. Only 11% of digital breast tomosynthesis examinations required additional imaging, compared with 23% of FFDMs. 3
50. Yang TL, Liang HL, Chou CP, Huang JS, Pan HB. The adjunctive digital breast tomosynthesis in diagnosis of breast cancer. Biomed Res Int. 2013;2013:597253. Observational-Dx 59 breasts of 57 patients. To compare the diagnostic performance of digital breast tomosynthesis (DBT) and digital mammography (DM) for breast cancers. A total of 59 breast cancers were reviewed, including 17 (28.8%) mass lesions, 12 (20.3%) focal asymmetry/density, 6 (10.2%) architecture distortion, 23 (39.0%) calcifications, and 1 (1.7%) intracystic tumor. Combo DBT was perceived to be more informative in 58.8% mass lesions, 83.3% density, 94.4% architecture distortion, and only 11.6% calcifications. As to the forced BIRADS score, 84.4% BIRADS 0 on DM was upgraded to BIRADS 4 or 5 on DBT, whereas only 27.3% BIRADS 4A on DM was upgraded on DBT, as BIRADS 4A lesions were mostly calcifications. A significant P value (<0.001) between the BIRADS category and index lesions was noted 3
51. Bernardi D, Ciatto S, Pellegrini M, et al. Application of breast tomosynthesis in screening: incremental effect on mammography acquisition and reading time. Br J Radiol. 2012;85(1020):e1174-1178. Observational-Dx 10 cancers and 90 negative controls To supplement the paucity of information available on logistical aspects of the application of three-dimensional (3D) mammography in breast screening. Average acquisition time (measured from start of first-view breast positioning to compression release at completion of last view) for seven radiographers, based on 20 screening examinations, was longer for 2D+3D (4 min 3 s; range 3 min 53 s-4 min 18 s) than 2D mammography (3 min 13 s; range 3 min 0 s-3 min 26 s; p<0.01). Average radiologists' reading time per screening examination (three radiologists reading case-mix of 100 screens: 10 cancers, 90 controls) was longer for 2D+3D (77 s; range 60-90 s) than for 2D mammography (33 s; range 25-46 s; p<0.01). 2D+3D screen-reading was associated with detection of more cancers and with substantially fewer recalls than 2D mammography alone. 2
52. Dang PA, Freer PE, Humphrey KL, Halpern EF, Rafferty EA. Addition of tomosynthesis to conventional digital mammography: effect on image interpretation time of screening examinations. Radiology. 2014;270(1):49-56. Observational-Dx 3665 examinations (1502 combined and 2163 digital mammography) To determine the effect of implementing a screening tomosynthesis program on real-world clinical performance by quantifying differences between interpretation times for conventional screening mammography and combined tomosynthesis and mammography for multiple participating radiologists with a wide range of experience in a large academic center. The mean number of studies interpreted in hour was 23.8 +/- 0.55 (standard deviation) (range, 14.4-40.4) for combined tomosynthesis and mammography and 34.0 +/- 0.55 (range, 20.4-54.3) for digital mammography alone. A mean of 10.2 fewer studies were interpreted per hour during combined tomosynthesis and mammography compared with digital mammography sessions (P < .0001). The mean interpretation time was 2.8 minutes +/- 0.9 (range, 1.5-4.2 minutes) for combined tomosynthesis and mammography and 1.9 minutes +/- 0.6 (range, 1.1-3.0) for digital mammography; interpretation time with combined tomosynthesis and mammography was 0.9 minute longer (47% longer) compared with digital mammography alone (P < .0001). With the increase in years of breast imaging experience, the overall additional time required to read images from combined tomosynthesis and mammography examinations decreased (R(2) = 0.52, P = .03). 2
53. Skaane P, Bandos AI, Eben EB, et al. Two-view digital breast tomosynthesis screening with synthetically reconstructed projection images: comparison with digital breast tomosynthesis with full-field digital mammographic images. Radiology. 2014;271(3):655-663. Experimental-Dx 24,901 examinations To compare the performance of two versions of reconstructed two-dimensional (2D) images in combination with digital breast tomosynthesis (DBT) versus the performance of standard full-field digital mammography (FFDM) plus DBT. Cancer detection rates were 8.0, 7.4, 7.8, and 7.7 per 1000 screening examinations for FFDM plus DBT in period 1, initial reconstructed 2D images plus DBT in period 1, FFDM plus DBT in period 2, and current reconstructed 2D images plus DBT in period 2, respectively. False-positive scores were 5.3%, 4.6%, 4.6%, and 4.5%, respectively. Corresponding reader-adjusted paired comparisons of false-positive scores revealed significant differences for period 1 (P = .012) but not for period 2 (ratio = 0.99; 95% confidence interval: 0.88, 1.11; P = .85) 1
54. Zuley ML, Guo B, Catullo VJ, et al. Comparison of two-dimensional synthesized mammograms versus original digital mammograms alone and in combination with tomosynthesis images. Radiology. 2014;271(3):664-671. Observational-Dx 123 patients To assess interpretation performance and radiation dose when two-dimensional synthesized mammography (SM) images versus standard full-field digital mammography (FFDM) images are used alone or in combination with digital breast tomosynthesis images. Probability of malignancy-based mean AUCs for SM and FFDM images alone was 0.894 and 0.889, respectively (difference, -0.005; 95% confidence interval [CI]: -0.062, 0.054; P = .85). Mean AUC for SM with tomosynthesis and FFDM with tomosynthesis was 0.916 and 0.939, respectively (difference, 0.023; 95% CI: -0.011, 0.057; P = .19). In terms of the reader-specific AUCs, five readers performed better with SM alone versus FFDM alone, and all eight readers performed better with combined FFDM and tomosynthesis (absolute differences from 0.003 to 0.052). Similar results were obtained by using a nonparametric analysis of forced BI-RADS ratings 3
55. Jain S, Fisher C, Smith P, Millis RR, Rubens RD. Patterns of metastatic breast cancer in relation to histological type. Eur J Cancer. 1993;29A(15):2155-2157. Observational-Dx 1,238 patients Examine clinical records of patients with operable breast cancer to identify patterns of metastatic breast cancer in relation to histological type. Infiltrating ductal carcinoma recurred more in lung (P<0.05), pleura (P<0.05) and brain (P<0.05). Infiltrating lobular carcinoma recurred more in metastasized to the bone marrow (P<0.01) and peritoneum (P<0.01). Bone involvement as the initial presentation of distant metastatic disease occurred in over 50% of women with infiltrating lobular carcinoma, significantly more commonly than in those with infiltrating ductal carcinoma (34%, P<0.01). 4
56. Muss HB, Tell GS, Case LD, Robertson P, Atwell BM. Perceptions of follow-up care in women with breast cancer. Am J Clin Oncol. 1991;14(1):55-59. Review/Other-Dx 101 with breast cancer (48-localized 53-metastatic) To examine the perceptions of patients regarding follow-up examinations in women with breast cancer. Only a third of the patients recognized the value of history in detecting recurrence, and two-thirds felt the physical examination was helpful. Study recommends greater emphasis on history and physical examination. 4
57. Loomer L, Brockschmidt JK, Muss HB, Saylor G. Postoperative follow-up of patients with early breast cancer. Patterns of care among clinical oncologists and a review of the literature. Cancer. 1991;67(1):55-60. Review/Other-Dx 80 oncologists Review literature and conduct a survey among oncologists to determine strategies for follow-up care after primary treatment of early-stage breast cancer. Yearly mammograms were recommended by more than 95% of respondents. History and physical examination are cost-effective in detecting recurrence during follow-up. 4
58. Rojas MP, Telaro E, Russo A, et al. Follow-up strategies for women treated for early breast cancer. Cochrane Database Syst Rev. 2005(1):CD001768. Review/Other-Dx 3,055 patients, 2 observers Collate 4 randomized controlled trials to determine the effectiveness of different policies for follow-up for distant metastasis on mortality, morbidity, and quality of life for women with stage I, II, and III breast cancer. No difference in survival for women with intensive screening compared with those who had only clinical examination and mammography. Patient satisfaction was higher for women with follow-up by general practitioner. 4
59. Panageas KS, Sima CS, Liberman L, Schrag D. Use of high technology imaging for surveillance of early stage breast cancer. Breast Cancer Res Treat. 2012;131(2):663-670. Observational-Dx 25,555 women To estimate the ambient rate of high technology radiologic imaging among women who lack any cancer diagnosis. Cases were individually matched to 75,669 female Medicare enrollees without cancer. Factors associated with high technology radiologic imaging utilization were evaluated. 40% of women with stage I–II breast cancer and 25% of controls had C1 high technology radiologic imaging during the surveillance interval (P=0.001). High utilization rates were observed for CT (30%) and bone scans (19%). The proportion of women who had a CT during the surveillance period increased in both cancer survivors and controls. Among breast cancer cases age <80, higher comorbidity index, stage II disease, and more recent diagnosis were independently associated with receipt of high technology radiologic imaging. Paralleling patterns observed in controls, high technology radiologic imaging utilization for surveillance following diagnosis of early stage breast cancer has steadily increased among Medicare beneficiaries. Strategies to foster judicious utilization of high technology radiologic imaging should be a priority. 4
60. Crivello ML, Ruth K, Sigurdson ER, et al. Advanced imaging modalities in early stage breast cancer: preoperative use in the United States Medicare population. Ann Surg Oncol. 2013;20(1):102-110. Review/Other-Dx 67,874 stage I/II breast cancer patients To evaluate patterns of imaging in early stage breast cancer usually reserved for advanced disease. There were 67,874 stage I/II breast cancer patients; 18.8% (n=12,740) had preoperative advanced imaging. The proportion of patients having CT scans, PET scans, and brain MRI increased from 5.7% to 12.4% (P<0.0001), 0.8% to 3.4% (P<0.0001) and 0.2% to 1.1% (P=0.008), respectively, from 1992 to 2005. Bone scans declined from 20.1% to 10.7% (P<0.0001). "Breast cancer" (174.x) was the only diagnosis code associated with 62.1% of PET scans, 37.7% of bone scans, 24.2% of CT, and 5.1% of brain MRI. One or more symptoms or metastatic site was suggested for 19.6% of bone scans, 13.0% of CT, 13.0% of PET, and 6.2% of brain MRI. Factors associated (P<0.05) with use of all modalities were urban setting, breast MRI and US. Breast MRI was the strongest predictor (P<0.0001) of bone scan (OR 1.63, 95% CI, 1.44–1.86), Brain MRI (OR 1.74, 95% CI, 1.15–2.63), CT (OR 2.42, 95% CI, 2.12–2.76), and PET (OR 5.71, 95% CI, 4.52–7.22). 4
61. Grunfeld E, Hodgson DC, Del Giudice ME, Moineddin R. Population-based longitudinal study of follow-up care for breast cancer survivors. J Oncol Pract. 2010;6(4):174-181. Observational-Dx 11,219 patients To describe the patterns of follow-up care provided to a population-based cohort of breast cancer survivors, and to assess factors associated with adherence to guidelines on follow-up care. Most women saw both oncologists and PCPs in each follow-up year. Approximately two thirds had surveillance mammograms in each follow-up year. Overall, two thirds had either fewer or greater than recommended oncology visits, one quarter had fewer than recommended surveillance mammograms, and half had greater than recommended surveillance imaging for metastatic disease. 4
62. Han PK, Klabunde CN, Noone AM, et al. Physicians' beliefs about breast cancer surveillance testing are consistent with test overuse. Med Care. 2013;51(4):315-323. Observational-Dx 1,098 medical oncologists and 980 PCPs To determine the extent to which physicians' breast cancer surveillance testing beliefs are consistent with test overuse, and to identify factors associated with these beliefs. A total of 1,098 medical oncologists and 980 PCPs completed the survey (response rate 57.5%). 84% of PCPs [95% CI, 81.4%–86.5%] and 72% of oncologists (95% CI, 69.8%–74.7%) reported beliefs consistent with blood test overuse, whereas 50% of PCPs (95% CI, 47.3%–53.8%) and 27% of oncologists (95% CI, 23.9%–29.3%) reported beliefs consistent with imaging test overuse. Among PCPs, factors associated with these beliefs included smaller practice size, lower patient volume, and practice ownership. Among oncologists, factors included older age, international medical graduate status, lower self-efficacy (confidence in knowledge), and greater perceptions of ambiguity (conflicting expert recommendations) regarding survivorship care. 3
63. Potosky AL, Han PK, Rowland J, et al. Differences between primary care physicians' and oncologists' knowledge, attitudes and practices regarding the care of cancer survivors. J Gen Intern Med. 2011;26(12):1403-1410. Observational-Dx 1,072 PCPs and 1,130 medical oncologists To compare PCPs and oncologists with regard to their knowledge, attitudes, and practices for follow-up care of breast and colon cancer survivors. Compared with PCPs, oncologists were less likely to believe PCPs had the skills to conduct appropriate testing for breast cancer recurrence (59% vs 23%, P<0.001) or to care for late effects of breast cancer (75% vs 38%, P<0.001). Only 40% of PCPs were very confident of their own knowledge of testing for recurrence. PCPs were more likely than oncologists to endorse routine use of non-recommended blood and imaging tests for detecting cancer recurrence, with both groups departing substantially from guideline recommendations. 3
64. Edelman MJ, Meyers FJ, Siegel D. The utility of follow-up testing after curative cancer therapy. A critical review and economic analysis. J Gen Intern Med. 1997;12(5):318-331. Review/Other-Dx N/A To review (1) basic principles of follow-up in patients who are in complete remission following curative therapy for cancer; (2) evaluate the available data on follow-up strategies for testicular cancer, Hodgkin's disease, non-Hodgkin's lymphoma, breast cancer, colorectal cancer, small cell and non-small cell lung cancer, and prostate cancer; and (3) analyze the cost of follow-up strategies. According to the currently available literature, repetitive follow-up laboratory and radiologic testing, except for nonseminomatous germ cell tumors, does not detect the vast majority of cancer relapses, nor does it result in a greater chance of cure or prolonged survival. The majority of recurrences at all disease sites will first be recognized as symptomatic changes in the patient's condition or alterations in the physical examination. A limited panel of blood tests and radiographic studies to detect recurrences, metachronous disease, and complications of therapy (malignant and nonmalignant), will suffice for most cancers. Though data are limited, this more restrictive policy of follow-up testing does not appear to adversely impact patient quality of life and result in dramatic cost of savings to the health care system. 4
65. Schapira DV, Urban N. A minimalist policy for breast cancer surveillance. JAMA. 1991;265(3):380-382. Review/Other-Dx N/A No abstract available. No abstract available. 4
66. Berrington de Gonzalez A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071-2077. Review/Other-Dx N/A To conduct detailed estimates of the future cancer risks from current CT scan use in the US according to age, sex, and scan type. The largest contributions were from scans of the abdomen and pelvis (n = 14000) (95% uncertainty limits, 6900-25000), chest (n = 4100) (95% uncertainty limits, 1900-8100), and head (n = 4000) (95% uncertainty limits, 1100-8700), as well as from chest CT angiography (n = 2700) (95% uncertainty limits, 1300-5000). One-third of the projected cancers were due to scans performed at the ages of 35 to 54 years compared with 15% due to scans performed at ages younger than 18 years, and 66% were in females. 4
67. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277-2284. Review/Other-Dx N/A To review the nature of CT scanning and its main clinical applications, both in symptomatic patients and in the screening of asymptomatic patients. The widespread use of CT represents probably the single most important advance in diagnostic radiology. However, as compared with radiography, CT involves much higher doses of radiation, resulting in a marked increase in radiation exposure in the population. 4
68. Hillman BJ, Goldsmith JC. The uncritical use of high-tech medical imaging. N Engl J Med. 2010;363(1):4-6. Review/Other-Dx N/A Summary of uncritical use of high-tech medical imaging. No results stated in abstract. 4