STAGING IN EARLY BREAST CANCER HELP OR HINDRANCE?

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Julianna Richardson
7 years ago
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1 STAGING IN EARLY BREAST CANCER HELP OR HINDRANCE? Naera Waters Department of Medical Oncology Auckland City Hospital

3 AIMS 1. To assess the frequency of radiological staging in women with early breast cancer at low risk of metastasis, and the frequency of asymptomatic metastatic disease detected on these scans 2. To explore the implications of radiological staging on clinical management decisions 3. To determine the number of repeat scans required following the initial scan 4. To establish whether staging scans are available at the time of commencement of chemotherapy to aid clinical decision making.

4 POPULATION EXCLUSIONS 217 new patients with breast cancer Auckland Regional Cancer and Blood Service November 10 October patients Metastatic disease at presentation Symptomatic Neoadjuvant treatment Locally recurrent disease 138 women

5 METHODS Patient Characteristics Radiology Information Review of new patient letters Patient age Tumour characteristics Size Grade Hormone receptor status Her-2 status Nodal involvement Timing and type of radiology Who requested the scans Time from request to first scan Presence/absence of indeterminate findings Further scans generated Time to investigate indeterminate findings Any cases of radiologically confirmed metastatic disease Were scan results available by the time of first treatment

6 217 women 79 excluded 113 women (82%) N<4 nodes(n0/1) 25 women (18%) N4+ nodes (N2+) 29/113 (26%) had staging scans requested 24/25 (96%) had staging scans requested

7 STAGING REQUESTED <4 nodes (N0/1) 4+ nodes (N2+) 52 women were staged

8 POPULATION CHARACTERISTICS

9 NODAL DISEASE BURDEN <4 nodes (N0/1) 4+ nodes (N2+) Number of Nodes Involved Number of Nodes Involved

10 RESULTS: PATIENT CHARACTERISTICS

11 N<4 No staging requested (n=84) in % Age <40 6% 24% Her-2 Positive Her-2 Negative Grade 1 tumour 31 7 Grade 3 tumour Hormone Receptor Positive, Her 2 Negative Hormone Receptor Negative, Her 2 Negative Age <50, Hormone Receptor Negative, Her 2 Positive positive nodes positive node positive nodes positive nodes 2 7 N<4 Staging requested (n=29) in %

12 RESULTS: RADIOLOGY

13 RADIOLOGY TYPE <4 nodes (N0/1) 4+ nodes (N2+)

14 28/52 women undergoing staging had indeterminate findings on their scans

16 Range of lesions 4-21mm lesions Liver (CT) Lung (CT) Bone (CT/BS) Soft Tissue (CT) 2mm-spiculated RUL lesion (most 3mm) Localised abnormality femoral shaft, minor irregularities on bone scan Nodes/Thyroid/ Adrenal nodules Follow up scan recommended Suspicious for metastatic disease Follow up scan performed 7/9 4/10 7/8 6/ /7 4/4 5/7 5/6 Findings on follow up scan Cysts/ haemangiomata Stable nodules, one probable metastatic lung cancer No change in lesions with time, features not concerning for met disease Changes stable or resolved with time, biopsy negative for malignancy

17 RADIOLOGY FINDINGS CONTINUED... 50% of women in N<4 group had indeterminate findings 58% of women in N4+ group had indeterminate findings Follow up scans recommended in 23/28 with indeterminate findings, 5/23 suspicious for metastatic disease One case of metastatic disease from a separate (lung) primary No other cases of metastatic disease from 52women staged

18 NUMBER OF SCANS TO NEGATE FINDINGS Total extra scans = 19 Number of Scans

19 Time to Negate Findings Median 4.5 months, range (0.5-12) Time To Scan Median 3 weeks, range (1.5-7) Staging Scans Requested By Oncology (Radiation/Medical): 23/29 Surgical: 6/29

20 Time to first treatment Median 3 weeks ( ) Time to first treatment >3 weeks 15/41 (37%) Number of scans occurring >3wks after request 25% Number of scans not available at time of first treatment 21%

21 4. Unnecessary staging generates anxiety for patients and consumes valuable time and money in an already stretched health system IMPORTANT FINDINGS 1. 26% women with N0/1 disease were radiologically staged, in no cases did the scan findings result in a change of management 2. One case of metastatic disease from a separate primary was detected, no other cases. - Personal cost to patients of 4.5 months (median) awaiting results of follow up scans and 19 extra scans negating findings 3. 21% of scans were not available at time of first treatment

Recommendations for cross-sectional imaging in cancer management, Second edition

www.rcr.ac.uk Recommendations for cross-sectional imaging in cancer management, Second edition Breast cancer Faculty of Clinical Radiology www.rcr.ac.uk Contents Breast cancer 2 Clinical background 2 Who