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Staging of Breast Cancer: It Is Time to Break With Tradition and Initiate the Evidence-Based-Medicine Age

City HospitalRimini, Italy
L. Pierantoni HospitalForlì, Italy

To the Editor:Recently, Chen et al¹ reported that routine chest roentgenography is unnecessary in the work-up of stage I and II breast cancer, suggesting that it should be limited to symptomatic patients in whom metastatic disease is suspected. We presented similar data at the 25th Congress of the European Society of Medical Oncology (Hamburg, Germany, October 2000) and proposed that breast cancer patients could be divided into two different classes, with each of them needing different staging procedures.² We reviewed retrospectively the records of 1,220 patients with operable breast cancer, analyzing the detection rate of bone scans, chest x-rays, and liver ultrasonography carried out in 1,190, 1,206, and 1,206 patients, respectively. Bone scans were positive in 78 cases (6.4%), chest x-rays were positive in 11 cases (0.9%), and liver ultrasonography was positive in 15 cases (1.2%), but only 59 patients (4.8%) had metastatic disease at the time of diagnosis, with 37 (3%), eight (0.6%), and 10 (0.2%) having true positive bone scans, chest X-rays, and liver ultrasonography, respectively. A significant correlation was observed between true positive bone scan and serum alkaline phosphatase (P < .05), carcinoembryonic antigen (P < .05), and CA 15.3 (P < .05) and between true positive liver ultrasonography and AST/ALT or gamma-glutamyl transferase (P < .05) using the Fisher’s exact test. Considering the low detection rate of bone scans, chest x-rays, and liver ultrasonography, we calculated that we would have to perform 333 bone scans, 500 chest x-rays, and 200 liver ultrasonograms to detect one true positive examination. In our review, we also correlated the true positive examinations with the pathologic staging of the disease, detecting two different classes of patients in whom different staging procedures could be performed: a low-risk class, including the patients with pT1N0, pT1N1 with less than three nodes involved, pT2N0, pT2N1 with less than three nodes involved, pT3N0, and pT3N1 with less than three nodes involved; and a high-risk class, including the patients with pT4 and any pN disease, any pT and pN1 with more than three nodes involved, and any pT and pN2 disease. We observed an overall detection rate for metastatic disease of 2% (95% confidence interval, 1.02% to 2.98%) in the low-risk class and 8.85% (95% confidence interval, 7.22% to 10.48%) in the high-risk class, and suggested different staging procedures for the two groups. In our opinion, clinical and biochemical evaluation could be enough to stage low-risk patients; the complete staging procedure, with bone scans, chest x-rays, and liver ultrasonography, should be reserved for high-risk patients.

Our data agree with those of Chen et al as well as with those reported in literature in the last 20 years.^3-6 Unfortunately, although a lot of evidence suggests that a complete staging procedure is often unnecessary and uselessly expensive, bone scans, chest x-rays, and liver ultrasonography are still recommended either in daily clinical practice or in clinical trials. We believe that it is probably time to break with such a tradition and to initiate the age of evidence-based medicine.

REFERENCES

1. Chen EA, Carlson GA, Coughlin BF, et al: Routine chest roentgenography is unnecessary in the work-up of stage I and II breast cancer. J Clin Oncol 18: 3503-3506, 2000[Abstract/Free Full Text]

2. Ravaioli A, Tassinari D: Staging of breast cancer: Recommended standards. Ann Oncol 11: 3-6, 2000 (suppl 3)[Free Full Text]

3. Lee YN: Bone scanning in patients with early breast carcinoma: Should it be a routine staging procedure? Cancer 47: 486-495, 1981[Medline]

4. Ciatto S, Pacini P, Azzini V, et al: Preoperative staging of primary breast cancer: A multicenter study. Cancer 61: 1038-1040, 1988[Medline]

5. Bruneton JN, Balu-Maestro C, Raffaelli C, et al: Indications for hepatic ultrasonography in breast cancer staging and follow up. Breast Cancer Res Treat 37: 115-121, 1996[Medline]

6. Samant R, Ganguly P, Israel PZ: Staging investigations in patients with breast cancer: The role of bone scans and liver imaging. Arch Surg 134: 551-554, 1999[Abstract/Free Full Text]

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ravaioli, A. Articles by Amadori, D. Search for Related Content PubMed PubMed Citation Articles by Ravaioli, A. Articles by Amadori, D. Social Bookmarking                            What's this?