Overuse of Chest CT in Patients With Stage I and II Breast Cancer: An Opportunity to Increase Guidelines Compliance at an NCCN Member Institution

Abstract

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) recommend that patients with clinical stage I/II breast cancer undergo advanced imaging for staging only when symptomatic. Regardless, many asymptomatic patients undergo chest CT. The goal of this study was to assess the use and results of chest CT in these patients at an NCCN Member Institution. Patients with breast cancer diagnosed between 1998 and 2012 were identified in a prospectively maintained database. All patients with clinical stage I/II disease who did not receive neoadjuvant chemotherapy were included. Data collected included demographics, tumor size, node status, chest CT within 6 months of diagnosis, imaging findings, need for additional workup, and identification of metastatic disease. Appropriate statistical tests were used for analysis. From 1998 to 2012, 3,321 patients were diagnosed with early-stage breast cancer. Of these, 2,062 (62.1%) had clinical stage I breast cancer at diagnosis and 1,259 (37.9%) had stage II; 227 patients (11%) with stage I and 456 (36.2%) with stage II breast cancer received staging chest CT. Of patients undergoing CT, 184 (26.9%) were found to have pulmonary nodules, which measured ≤5 mm for 128 patients (69.6%), 5 to 10 mm for 46 patients (25.0%), 11 to 20 mm for 6 patients (3.2%), and ≥20 mm for 4 patients (2.2%). Patients undergoing chest CT for staging subsequently underwent a mean of 2.34 (range, 0-16) additional CTs in follow-up. Of all patients undergoing chest CT for staging, only 9 (1.3%) were ultimately diagnosed with pulmonary metastases at an average of 25 months (range, 0-97) after initial staging chest CT. A significant percentage of patients with stage I/II breast cancer underwent unnecessary chest CT as part of their initial workup. Nearly one-third of these patients were found to have pulmonary nodules, but only 1.3% were ever diagnosed with pulmonary metastases. Adherence to NCCN Guidelines will reduce the excessive use of CT chest imaging.

Outcome of CT staging prior to neo‐adjuvant chemotherapy in patients with early breast cancer

“…In another study, 43% required additional imaging, and in common with our study, a chest CT was the most common additional scan requested 9 . Regarding CT thorax findings, a study in keeping with ours found that stage I and II breast cancer patients required on average 2.34 additional scans to exclude metastases following a staging chest CT, with just 1.3% subsequently being diagnosed with pulmonary metastases 10 . In conclusion, in patients with T1‐3 breast cancer and clinically negative lymph nodes we report a very low rate of metastases at not inconsiderable financial cost.…”

Usefulness of staging chest-CT in patients with operable breast cancer

“…The incidence of distant metastasis in patients with early breast cancer has been reported to be low [3,7,8,11]. Furthermore, there was no added survival value of additional staging studies [24].…”

“…After bone, the lung is the second most common distant metastatic site in patients with breast cancer, followed by the brain and liver [6]. However, the prevalence of radiologicallyevident distant lung metastasis in early stage breast cancer is low, approximately 0.2% and 1.2% for stage I and II disease, respectively [3,[7][8][9][10][11]. Most of the existing guidelines, including the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), and American Society of Clinical Oncology (ASCO), recommend staging chest-CT only for advanced disease [12][13][14].…”

“…Most of the existing guidelines, including the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), and American Society of Clinical Oncology (ASCO), recommend staging chest-CT only for advanced disease [12][13][14]. Despite these recommendations, many patients diagnosed with early stage breast cancer often undergo chest-CT as a part of initial staging evaluation [11,15,16]. The majority of physicians are aware of the published guidelines, but they do not change their staging imaging practices; moreover, the majority of patients also prefer to undergo chest-CT [17,18].…”

Opportunistic use of chest CT for screening osteoporosis and predicting the risk of incidental fracture in breast cancer patients: A retrospective longitudinal study

“…Chest CT is an imaging modality widely used in breast cancer patients to evaluate pulmonary symptoms or cancer spread. Regardless of the cancer stage, many clinical institutions currently perform chest CT in patients with breast cancer as a baseline and follow-up imaging modality [ 7 ]. More recently, feasibility studies have supported that CT measurement of vertebral attenuation during abdomen or chest CT performed for other indications can be used for opportunistic osteoporosis screening or evaluation of bone density loss [ 8 – 10 ].…”