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. #bcsm #bctalk

A 50 y/o woman presents with biopsy-proven breast cancer which revealed ER PR HER2 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/

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 review of evidence from : https://www.cancercareontario.ca/en/content/baseline-staging-imaging-distant-metastasis-women-stage-i-ii-and-iii-breast-cancer

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/ 

Unnecessary testing leads to: added costs , a burden on health care resources , false positives leading to even more testing , unnecessary radiation exposure , delays in care and patient anxiety

In the words of Sir William Osler : 'Listen to your patient, he (/she) is telling you the diagnosis.'

Lets pledge to avoid reflexively ordering tests that don't always benefit patients, and can sometimes harm them.

Less is More

Would love to hear your feedback and comments below!