EVALUATION OF AN INTENSIVE STRATEGY FOR FOLLOW-UP AND SURVEILLANCE OFPRIMARY BREAST-CANCER

Background: Controversies over the frequency and intensity of the foll ow-up care of breast cancer patients exist. Some physicians have adopt ed an intensive approach to follow-up care that consists of frequent l aboratory tests and routine imaging studies, including chest radiograp hs, bone scans, and CT scans, whereas others have established a minima list approach consisting of only history, physical examinations, and m ammograms. Objectives: Our objective was to evaluate the role of inten sive follow-up on detection of breast cancer recurrence and to examine the impact of follow-up on overall survival. Methods: During a 10-yea r period (1986-1996), 129 patients with recurrent disease were identif ied from a prospective database of 1898 breast cancer patients. The pa tients with recurrent disease were divided into minimalist or intensiv e groups according to method of detection. Results: Twenty-seven of 12 6 (21%) patients were assigned to the intensive method of detection gr oup (LFT, CEA, CA 15-3, chest radiograph, CT scan, and bone scan); 99 of 126 (79%) patients were assigned to the minimal detection group (hi story, physical examination, and mammography). Distant disease to the bone was the most common initial tumor recurrence, at 27%. History, ph ysical examination, and mammography detected recurrent cancer in appro ximately the same amount of time as LFTs, tumor markers, CT scans, and chest radiographs (P = .960). When the recurrent patients were divide d into intensive and minimalist groups and analyzed by time to detecti on of recurrence, there was no significant difference between the time to detection in those recurrences detected by intensive methods and t hose recurrences detected by minimalist methods (P = .95). The indepen dent variables age, tumor size, type of surgery, number of positive no des, time to recurrence, method of detection, and site of recurrence ( regional or distant) were subject to univariate and multivariate analy sis by the Cox proportional hazards model. Only two variables had an i mpact on survival by multivariate analysis: early timing of the recurr ence (P = .0011) and the site of the recurrence (P = .02). Timing was defined as early (less than or equal to 365 days from the time of diag nosis to recurrence) or late (greater than or equal to 365 days from t he time of diagnosis to recurrence). Early recurrence was the first va riable found to be significant on stepwise forward regression analysis . The primary site of recurrence was significant at step two. The meth od of detection-intensive or minimal-did not significantly affect surv ival (P = .18). Conclusions: There is no survival benefit to routine i ntensive follow-up regimens in detecting recurrent breast cancer. Expe nsive diagnostic tests such as bone scans, CT scans, and serial tumor markers are best used for detection of metastasis in symptomatic patie nts.