Guideline:
American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting
Bibliographic Source(s)
- Khatcheressian JL Wolff AC Smith TJ Grunfeld E Muss HB Vogel VG Halberg F Somerfield MR Davidson NE American Society of Clinical Oncology. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 2006 Nov 1;24(31):5091-7. [30 references] PubMed
Guideline Status
This is the current release of the guideline.
This guideline updates previous versions: American Society of Clinical Oncology. American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. J Clin Oncol 1999 Mar;17(3):1080-2.
American Society of Clinical Oncology. Recommended breast cancer surveillance guidelines. J Clin Oncol 1997 May;15(5):2149-56.
Guideline Category
Counseling
Evaluation
Management
Risk Assessment
Intended Users
Patients
Physicians
Guideline Objective(s)
To update the 1999 American Society of Clinical Oncology (ASCO) guideline on breast cancer follow-up and management in the adjuvant setting
Target Population
Women with breast cancer
Interventions and Practices Considered
- Clinical history
- Physical examination
- Patient education on symptoms of recurrence
- Referral for genetic counseling
- Breast self-examination (BSE)
- Mammography
- Coordination of care
- Pelvic examination
Note: The following interventions were considered but not recommended for routine breast cancer surveillance:
- Complete blood count (CBC) testing
- Liver function tests
- Chest x-rays
- Bone scans
- Liver ultrasound
- Computed tomography
- [18F]fluorodeoxyglucose-positron emissions tomography (FDG-PET) scanning
- Breast magnetic resonance imaging (MRI)
- Cancer antigen (CA) 15-3 or CA 27.29 testing
- Carcinoembryonic antigen testing
Major Outcomes Considered
- Overall survival
- Disease-free survival
- Quality of life
- Toxicity reduction
- Cost effectiveness
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
For the 2006 update the Expert Panel completed the review and analysis of data published since 1998. Computerized literature searches of MEDLINE and the Cochrane Collaboration Library were performed. The searches of the English-language literature from 1999 to March 2006 combined the terms "breast neoplasms" with the Medical Subject Heading [MeSH] term "follow-up studies" and the text words "surveillance" and "follow-up." The set of articles yielded from this initial search was supplemented by articles identified from searches on each of the tests or procedures addressed in the original guideline (e.g. history and physical examination carcinoembryonic antigen) in combination with "surveillance" "follow-up studies" and "follow-up." The searches were limited to human-only studies and to specific study design or publication type such as randomized clinical trial meta-analysis practice guideline systematic overview or systematic review. The literature review centered on randomized clinical trials and meta-analyses of data from randomized clinical trials.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
The Expert Panel did not complete an independent meta-analysis of the data from available randomized clinical trials given the availability of a high-quality and recent meta-analysis and a high-quality systematic literature review identified through the literature search.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The American Society of Clinical Oncology (ASCO) convened an Expert Panel to review and update evidence-based strategies for breast cancer follow-up and management in asymptomatic patients following primary curative therapy. These guidelines were originally published in 1997 and previously updated in 1998. The ASCO Panel was guided by a list of clinical outcomes published by ASCO in 1996 (see "Major Outcomes Considered" field) and recommended tests if they demonstrated a positive impact on these important clinical outcomes.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
Historically breast cancer follow-up has used a conservative approach based on clinical examination and mammography but variations in practice patterns exist and have significant cost implications. One set of researchers at Centre Regional Leon Berard studied the impact of clinical practice guidelines on follow-up of patients with localized breast cancer. Follow-up that was not guideline compliant cost 2.2 to 3.6 times more than guideline-compliant follow-up as a result of nonmammographic examinations performed in the absence of any warning signs or symptoms of recurrence. After the introduction of surveillance guidelines in 1994 there was a one-third decrease in expenditures per patient with no change in health outcomes expected. Although guideline compliance saves limited health care resources patients also understand the limitations of diagnostic tests and accept limited testing from their physicians when recommended.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
Recommended Breast Cancer Surveillance
History Physical Examination and Patient Education Regarding Symptoms of Recurrence
2006 recommendation. All women should have a careful history and physical examination every 3 to 6 months for the first 3 years after primary therapy then every 6 to 12 months for the next 2 years and then annually. Physicians should counsel patients about the symptoms of recurrence including new lumps bone pain chest pain dyspnea abdominal pain or persistent headaches. Helpful Web sites for patient education include www.plwc.org and www.cancer.org.
Women at high risk for familial breast cancer syndromes should be referred for genetic counseling in accordance with clinical guidelines recommended by the U.S. Preventive Services Task Force (USPSTF) (see the National Guideline Clearinghouse [NGC] summary of the USPSTF guideline Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement). Criteria to recommend referral include the following: Ashkenazi Jewish heritage; history of ovarian cancer at any age in the patient or any first- or second-degree relatives; any first-degree relative with a history of breast cancer diagnosed before the age of 50 years; two or more first- or second-degree relatives diagnosed with breast cancer at any age; patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative.
Breast Self-Examination
2006 recommendation. All women should be counseled to perform monthly breast self-examination (BSE).
Mammography
2006 recommendation. Women treated with breast-conserving therapy should have their first post-treatment mammogram no earlier than 6 months after definitive radiation therapy. Subsequent mammograms should be obtained every 6 to 12 months for surveillance of abnormalities. Mammography should be performed yearly if stability of mammographic findings is achieved after completion of locoregional therapy.
Coordination of Care
2006 recommendation. The risk of breast cancer recurrence continues through 15 years after primary treatment and beyond. Continuity of care for breast cancer patients is recommended and should be performed by a physician experienced in the surveillance of cancer patients and in breast examination including the examination of irradiated breasts.
Follow-up by a primary care physician (PCP) seems to lead to the same health outcomes as specialist follow-up with good patient satisfaction. If a patient with early-stage breast cancer (tumor <5 cm and < four positive nodes) desires follow-up exclusively by a PCP care may be transferred to the PCP approximately 1 year after diagnosis. If care is transferred to a PCP both the PCP and the patient should be informed of the appropriate follow-up and management strategy. This approach will necessitate referral for oncology assessment if a patient is receiving adjuvant endocrine therapy.
Pelvic Examination
2006 recommendation. Regular gynecologic follow-up is recommended for all women. Patients who receive tamoxifen therapy are at increased risk for developing endometrial cancer and should be advised to report any vaginal bleeding to their physicians. Longer follow-up intervals may be appropriate for women who have had a total hysterectomy and oophorectomy.
Breast Cancer Surveillance Testing: Not Recommended
Complete Blood Count (CBC)
2006 recommendation. CBC testing is not recommended for routine breast cancer surveillance.
Automated Chemistry Studies
2006 recommendation. Automated chemistry studies are not recommended for routine breast cancer surveillance.
Chest X-Rays
2006 recommendation. Chest x-rays are not recommended for routine breast cancer surveillance.
Bone Scan
2006 recommendation. Bone scans are not recommended for routine breast cancer surveillance.
Ultrasound of the Liver
2006 recommendation. Liver ultrasound is not recommended for routine breast cancer surveillance.
Computed Tomography (CT)
2006 recommendation. CT is not recommended for routine breast cancer surveillance.
[18F]Fluorodeoxyglucose–Positron Emission Tomography Scanning
2006 recommendation. [18F]fluorodeoxyglucose-positron emission tomography (FDG-PET) scanning is not recommended for routine breast cancer surveillance.
Breast Magnetic Resonance Imaging
2006 recommendation. Breast magnetic resonance imaging (MRI) is not recommended for routine breast cancer surveillance.
Breast Cancer Tumor Markers CA 15-3 and CA 27.29
2006 recommendation. The use of the CA 15-3 or CA 27.29 is not recommended for routine surveillance of breast cancer patients after primary therapy. The ASCO Breast Cancer Tumor Markers Panel will publish guideline recommendations for selected tumor markers.
Breast Cancer Tumor Marker Carcinoembryonic Antigen
2006 recommendation. Carcinoembryonic antigen testing is not recommended for routine surveillance of breast cancer patients after primary therapy. The ASCO Breast Cancer Tumor Markers Panel will publish guideline recommendations for selected tumor markers.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The evidence supporting each recommendation is presented in the original guideline document under "literature update and discussion" following each recommendation. In general the literature review supporting these recommendations centered on randomized clinical trials and meta-analyses of data from randomized clinical trials.
Potential Benefits
Appropriate follow-up and management of breast cancer in the adjuvant setting
Potential Harms
Women who perform regular breast self-examination (BSE) may be at increased risk of undergoing invasive procedures to diagnose benign breast lesions but there are no randomized data examining the effect of BSE in conjunction with regular screening mammograms for women who have been treated for breast cancer.
Qualifying Statements
It is important to emphasize that guidelines and technology assessments cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations and cannot be considered inclusive of all proper methods of care or exclusive of other treatments reasonably directed at obtaining the same result. Accordingly the American Society for Clinical Oncology (ASCO) considers adherence to this guideline assessment to be voluntary with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. In addition this guideline describes the use of procedures and therapies in clinical practice; it cannot be assumed to apply to the use of these interventions performed in the context of clinical trials given that clinical studies are designed to evaluate or validate innovative approaches in a disease for which improved staging and treatment is needed.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Chart Documentation/Checklists/Forms
Patient Resources
Personal Digital Assistant (PDA) Downloads
Quick Reference Guides/Physician Guides
Slide Presentation
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Timeliness
Bibliographic Source(s)
- Khatcheressian JL Wolff AC Smith TJ Grunfeld E Muss HB Vogel VG Halberg F Somerfield MR Davidson NE American Society of Clinical Oncology. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 2006 Nov 1;24(31):5091-7. [30 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Society of Clinical Oncology (ASCO)
Guideline Committee
American Society of Clinical Oncology (ASCO) Breast Cancer Tumor Markers Panel
Composition of Group that Authored the Guideline
Panel Members: Nancy E. Davidson MD (Co-Chair) Johns Hopkins Hospital Sidney Kimmel Cancer Center; James L. Khatcheressian MD (Co-Chair) Virginia Commonwealth University/Massey Cancer Center; Martha Bluming Hematology-Oncology Medical Group of the San Fernando Valley; Laura Esserman MD University of California San Francisco; Eva Grunfeld MD DPhil Dalhousie University; Francine E. Halberg MD Marin Cancer Institute Marin General Hospital; Alexander Hantel MD Loyola University Edward Hospital Cancer Center; Alexander Kennedy MD Dartmouth-Hitchcock Manchester; Hyman B. Muss MD University of Vermont; Thomas J. Smith MD Virginia Commonwealth University/Massey Cancer Center; Victor G. Vogel MD MHS Magee-Womens Hospital of the University of Pittsburgh Medical Center; Antonio C. Wolff MD Johns Hopkins Hospital Sidney Kimmel Cancer Center
Financial Disclosures/Conflicts of Interest
Although all authors completed the disclosure declaration the following author or immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories or for more information about the American Society of Clinical Oncology's (ASCO's) conflict of interest policy please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors in the original journal of publication.
| Author | Employment | Leadership | Consultant | Stock | Honoraria | Research Funds | Testimony | Other |
|---|---|---|---|---|---|---|---|---|
| Victor G. Vogel | AstraZeneca; Eli Lilly | Eli Lilly; AstraZeneca |
Guideline Status
This is the current release of the guideline.
This guideline updates previous versions: American Society of Clinical Oncology. American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. J Clin Oncol 1999 Mar;17(3):1080-2.
American Society of Clinical Oncology. Recommended breast cancer surveillance guidelines. J Clin Oncol 1997 May;15(5):2149-56.
Guideline Availability
Electronic copies: Available from the American Society of Clinical Oncology (ASCO) Web site.
Print copies: Available from American Society of Clinical Oncology Cancer Policy and Clinical Affairs 1900 Duke Street Suite 200 Alexandria VA 22314; E-mail: guidelines@asco.org.
Availability of Companion Documents
The following are available:
- ASCO 2006 update of the breast cancer follow-up and management guideline in the adjuvant setting. J Clin Oncol 2006 Nov; 2(6):317-318. Available in Portable Document Format (PDF) from the American Society of Clinical Oncology (ASCO) Web site.
- 2006 update revisions table. ASCO 2006 guideline update: breast cancer follow-up & management in the adjuvant setting. 2006. 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American Society of Clinical Oncology (ASCO) Web site.
- Breast cancer follow up & management in the adjuvant setting patient flow sheet. 2006. 1 p. Electronic copies: Available in Portable Document Format (PDF) from the American Society of Clinical Oncology (ASCO) Web site.
- Breast cancer follow up & management in the adjuvant setting: 2006 update. Slide set. 2006. 20 p. Electronic copies: Available in Portable Document Format (PDF) from the American Society of Clinical Oncology (ASCO) Web site.
Guidelines are available for Personal Digital Assistant (PDA) download from the ASCO Web site.
See the related QualityTool tool set on the Health Care Innovations Exchange Web site.
Patient Resources
The following is available:
- ASCO patient guide: follow-up care for breast cancer. 2006 Oct. 4 p.
Available in Portable Document Format (PDF) from the Cancer.Net Web site.
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
NGC STATUS
This NGC summary was completed by ECRI on September 1 1998. It was verified by the guideline developer on December 1 1998. This NGC summary was updated by ECRI on June 11 1999 and November 22 2006. The updated information was verified by the guideline developer on December 6 2006.
COPYRIGHT STATEMENT
This summary is based on the original guideline which is subject to the American Society of Clinical Oncology's copyright restrictions.
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