I had a chance to present on an important topic today at the Breast Tumor Board at @AKUGlobal.

The topic was: Screening for distant metastasis in newly diagnosed #breastcancer patients.

I thought it would be nice to share key points with a #tweetorial. https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧵" title="Thread" aria-label="Emoji: Thread"> #bcsm #bctalk

A 50 y/o woman presents with biopsy-proven breast cancer which revealed ER https://abs.twimg.com/emoji/v2/... draggable="false" alt="➕" title="Heavy plus sign" aria-label="Emoji: Heavy plus sign"> PR https://abs.twimg.com/emoji/v2/... draggable="false" alt="➕" title="Heavy plus sign" aria-label="Emoji: Heavy plus sign"> HER2 https://abs.twimg.com/emoji/v2/... draggable="false" alt="➖" title="Heavy minus sign" aria-label="Emoji: Heavy minus sign"> infiltrating ductal carcinoma. On exam and breast imaging, found to have a 4x3cm lump in the right breast and no suspicious/palpable lymph nodes. How do you proceed?

The patient reports no symptoms concerning for distant metastasis and physical exam is otherwise unremarkable too. What do you want to do next?

Based on the exam and imaging, this patient has T2N0 (Stage IIA) disease. She does not require a metastatic workup as the chances of her having distant mets are very low.

The correct answer is to proceed with appropriate treatment without a metastatic workup!

The @NCCN recommends that radiological imaging for distant metastasis in breast cancer (like CT scans and bone scintigraphy) should be reserved for those with Stage III disease or overt symptoms of distant metastasis.

The Choosing Wisely campaign by @ABIMFoundation and @ASCO specifically states that mets workup of early stage breast cancer is one of the 10 things we regularly do in cancer care that is not evidence-based.

https://www.choosingwisely.org/societies/american-society-of-clinical-oncology/">https://www.choosingwisely.org/societies...

A 2011 systematic review showed the following (median) stage-specific rates of distant mets in breast cancer at diagnosis with conventional imaging:

Stage 1: 0.2%
Stage 2: 1.1%
Stage 3: 8%

https://pubmed.ncbi.nlm.nih.gov/22094116/ 

Excellent">https://pubmed.ncbi.nlm.nih.gov/22094116/... review of evidence from https://abs.twimg.com/emoji/v2/... draggable="false" alt="🇨🇦" title="Flag of Canada" aria-label="Emoji: Flag of Canada">: https://www.cancercareontario.ca/en/content/baseline-staging-imaging-distant-metastasis-women-stage-i-ii-and-iii-breast-cancer">https://www.cancercareontario.ca/en/conten...

Despite clear guidelines and good quality evidence, a study by @AneesChagpar showed that there continues to be variability in when we choose to order metastatic workup in patients with breast cancer. https://pubmed.ncbi.nlm.nih.gov/26518161/ ">https://pubmed.ncbi.nlm.nih.gov/26518161/...

Unnecessary testing leads to: added costs https://abs.twimg.com/emoji/v2/... draggable="false" alt="💰" title="Money bag" aria-label="Emoji: Money bag">, a burden on health care resources https://abs.twimg.com/emoji/v2/... draggable="false" alt="⚕️" title="Staff of aesculapius" aria-label="Emoji: Staff of aesculapius">, false positives leading to even more testing https://abs.twimg.com/emoji/v2/... draggable="false" alt="🚨" title="Police cars revolving light" aria-label="Emoji: Police cars revolving light">, unnecessary radiation exposure https://abs.twimg.com/emoji/v2/... draggable="false" alt="☠️" title="Skull and crossbones" aria-label="Emoji: Skull and crossbones">, delays in care https://abs.twimg.com/emoji/v2/... draggable="false" alt="⏲️" title="Timer clock" aria-label="Emoji: Timer clock"> and patient anxiety https://abs.twimg.com/emoji/v2/... draggable="false" alt="😟" title="Worried face" aria-label="Emoji: Worried face">

In the words of Sir William Osler https://abs.twimg.com/emoji/v2/... draggable="false" alt="👨" title="Man" aria-label="Emoji: Man">: & #39;Listen to your patient, he (/she) is telling you the diagnosis.& #39;

Lets pledge to avoid reflexively ordering tests that don& #39;t always benefit patients, and can sometimes harm them.

Less https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow"> is More https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow">

Would love to hear your feedback and comments below! https://abs.twimg.com/emoji/v2/... draggable="false" alt="👇" title="Down pointing backhand index" aria-label="Emoji: Down pointing backhand index">