Baseline staging tests in primary breast cancer: a practice guideline

Background: Breast cancer develops in over 7000 women-each year in Ontario. These patients will all undergo some staging work-up at diagnosis. The Bre ast Cancer Disease Site Group of the Cancer Care Ontario Practice Guideline s Initiative reviewed the evidence and indications for routine bone scannin g, liver ultrasonography and chest radiography in asymptomatic women who ha ve undergone surgery for breast cancer. Methods: A systematic review of the published literature was combined with a consensus interpretation of the evidence in the context of conventional p ractice. Results: There were 11 studies of bone scanning reported between 1972 and 1 980, involving a total of 1307 women; bone scans detected skeletal metastas es in 6.8% of those with stage I breast cancer, 8.8% with stage II and 24.5 % with stage III. A total of 5407 women participated in 9 studies of bone s canning reported between 1985 and 1995; in these studies, bone scans detect ed skeletal metastases in only 0.5% of women with stage I disease, 2.4% wit h stage II and 8.3% with stage III. Among 1625 women in 4 studies of liver ultrasonography reported between 1988 and 1993, hepatic metastases were det ected in 0% of patients with stage I disease, 0.4% with stage II and 2.0% w ith stage III. Among 3884 patients in 2 studies of chest radiography publis hed in 1988 and 1991, lung metastases were detected in 0.1% of those with s tage 1, 0.2% with stage II and 1.7% with stage III. False-positive rates ra nged from 10% to 22% for bone scanning, 33% to 66% for liver ultrasonograph y and 0% to 23% for chest radiography. The false-negative rate for bone sca nning was about 10%. Recommendations: The following recommendations apply to women with newly di agnosed breast cancer-who have undergone surgical resection and who have no symptoms, physical signs or biochemical evidence of metastases. Routine bone scanning, liver ultrasonography and chest radiography are not indicated before surgery. In women with intraductal and pathological stage I tumours, routine bone sc anning, liver ultrasonography and chest radiography are not indicated as pa rt of baseline staging. In women who have pathological stage II tumours, a postoperative bone scan is recommended as part of baseline staging. Routine liver ultrasonography a nd chest radiography are not indicated in this group but could be considere d for patients with 4 or more positive lymph nodes. In women with pathological stage III tumours, bone scanning, liver ultrason ography and chest radiography are recommended postoperatively as part of ba seline staging. In women for whom treatment options are restricted to tamoxifen or hormone therapy, or for whom no further treatment is indicated because of age or ot her factors, routine bone scanning, liver ultrasonography and chest radiogr aphy are not indicated as part of baseline staging.