Jessica R Schumacher1, Heather B Neuman1, Menggang Yu2, David J Vanness3, Yajuan Si4, Elizabeth S Burnside5, Kathryn J Ruddy6, Ann H Partridge7,8, Deborah Schrag7,8, Stephen B Edge9, Ying Zhang2, Elizabeth A Jacobs10, Jeffrey Havlena1, Amanda B Francescatti11, David P Winchester11, Daniel P McKellar11,12, Patricia A Spears13, Benjamin D Kozower14, George J Chang15, Caprice C Greenberg16. 1. Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, WI, USA. 2. Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA. 3. Department of Health Policy and Administration, Penn State University, State College, PA, USA. 4. Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA. 5. Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA. 6. Department of Oncology, Mayo Clinic Comprehensive Cancer Center, Rochester, MN, USA. 7. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA. 8. Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. 9. Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA. 10. Department of Medicine, The University of Texas at Austin, Austin, TX, USA. 11. Commission on Cancer, American College of Surgeons, Chicago, IL, USA. 12. Department of Surgery, Wright State University, Dayton, OH, USA. 13. Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. 14. Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA. 15. Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. 16. Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Abstract
BACKGROUND: Guidelines for follow-up after locoregional breast cancer treatment recommend imaging for distant metastases only in the presence of patient signs and/or symptoms. However, guidelines have not been updated to reflect advances in imaging, systemic therapy, or the understanding of biological subtype. We assessed the association between mode of distant recurrence detection and survival. METHODS: In this observational study, a stage-stratified random sample of women with stage II-III breast cancer in 2006-2007 and followed through 2016 was selected, including up to 10 women from each of 1217 Commission on Cancer facilities (n = 10 076). The explanatory variable was mode of recurrence detection (asymptomatic imaging vs signs and/or symptoms). The outcome was time from initial cancer diagnosis to death. Registrars abstracted scan type, intent (cancer-related vs not, asymptomatic surveillance vs not), and recurrence. Data were merged with each patient's National Cancer Database record. RESULTS: Surveillance imaging detected 23.3% (284 of 1220) of distant recurrences (76.7%, 936 of 1220 by signs and/or symptoms). Based on propensity-weighted multivariable Cox proportional hazards models, patients with asymptomatic imaging compared with sign and/or symptom detected recurrences had a lower risk of death if estrogen receptor (ER) and progesterone receptor (PR) negative, HER2 negative (triple negative; hazard ratio [HR] = 0.73, 95% confidence interval [CI] = 0.54 to 0.99), or HER2 positive (HR = 0.51, 95% CI = 0.33 to 0.80). No association was observed for ER- or PR-positive, HER2-negative (HR = 1.14, 95% CI = 0.91 to 1.44) cancers. CONCLUSIONS: Recurrence detection by asymptomatic imaging compared with signs and/or symptoms was associated with lower risk of death for triple-negative and HER2-positive, but not ER- or PR-positive, HER2-negative cancers. A randomized trial is warranted to evaluate imaging surveillance for metastases results in these subgroups.
BACKGROUND: Guidelines for follow-up after locoregional breast cancer treatment recommend imaging for distant metastases only in the presence of patient signs and/or symptoms. However, guidelines have not been updated to reflect advances in imaging, systemic therapy, or the understanding of biological subtype. We assessed the association between mode of distant recurrence detection and survival. METHODS: In this observational study, a stage-stratified random sample of women with stage II-III breast cancer in 2006-2007 and followed through 2016 was selected, including up to 10 women from each of 1217 Commission on Cancer facilities (n = 10 076). The explanatory variable was mode of recurrence detection (asymptomatic imaging vs signs and/or symptoms). The outcome was time from initial cancer diagnosis to death. Registrars abstracted scan type, intent (cancer-related vs not, asymptomatic surveillance vs not), and recurrence. Data were merged with each patient's National Cancer Database record. RESULTS: Surveillance imaging detected 23.3% (284 of 1220) of distant recurrences (76.7%, 936 of 1220 by signs and/or symptoms). Based on propensity-weighted multivariable Cox proportional hazards models, patients with asymptomatic imaging compared with sign and/or symptom detected recurrences had a lower risk of death if estrogen receptor (ER) and progesterone receptor (PR) negative, HER2 negative (triple negative; hazard ratio [HR] = 0.73, 95% confidence interval [CI] = 0.54 to 0.99), or HER2 positive (HR = 0.51, 95% CI = 0.33 to 0.80). No association was observed for ER- or PR-positive, HER2-negative (HR = 1.14, 95% CI = 0.91 to 1.44) cancers. CONCLUSIONS: Recurrence detection by asymptomatic imaging compared with signs and/or symptoms was associated with lower risk of death for triple-negative and HER2-positive, but not ER- or PR-positive, HER2-negative cancers. A randomized trial is warranted to evaluate imaging surveillance for metastases results in these subgroups.
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