Ein perioperatives Screening auf Metastasen ist bei Patientinnen mit einem primär operablem Mammakarzinom und fehlender klinischer Symptomatik einer Metastasierung nicht indiziert

Zusammenfassung

Fragestellung: Ist ein perioperatives Screening auf Fernmetastasen bei Patientinnen mit einem primär operablen Mammakarzinom und fehlender klinischer Symptomatik indiziert?
Patientinnen und Methoden: Bei 1 076 Mammakarzinompatientinnen ohne klinischen Metastasenverdacht wurden die Befunde der perioperativen Screeninguntersuchungen (Röntgen-Thorax, Lebersonographie, Skelettszintigraphie) auf die Prognose, adjuvante Therapie, Lebensqualität und Kosten analysiert.
Ergebnisse: Die perioperativen Staginguntersuchungen ergaben bei 30 (2,8 %) Patientinnen Fernmetastasen, 130 (12,1 %) suspekte Befunde und 916 (85,1 %) normale Befunde. Die weiterführenden Untersuchungen bei den 130 Patientinnen mit suspekten Befunden ergaben Fernmetastasen in 7 (5,4 %) und schlossen diese in 123 (94,6 %) Fällen aus. Fernmetastasen wurden häufiger mit steigender Tumorgröße (pT ≤ 2,0 cm: 1,6 %, pT 2,1-5,0 cm: 3,0 %, pT > 5,0 cm: 15,1 %; p < 0,001) und Anzahl befallener Lymphknoten (pN0: 1,4 %, pN1-3 +: 1,8 %, pN4-9 +: 4,0 %, pN > 10 +: 12,5 %; p < 0,001) nachgewiesen. Falsch positive Befunde mit der Ungewissheit über die Erkrankungssituation führten bei 123 (11,4 %) aller Patientinnen zu einer verminderten Lebensqualität. Der Verzicht auf perioperative Screeninguntersuchungen wäre ohne therapeutische Nachteile und würde Kosten von minimal € 259 366,68 sparen.
Schlussfolgerung: Bei Brustkrebspatientinnen ohne klinische Hinweise auf eine Fernmetastasierung ist ein perioperatives Metastasenscreening wegen fehlender therapeutischer Konsequenzen, häufig falsch positiver Befunde mit Verminderung der Lebensqualität und hoher Kosten nicht indiziert.

Abstract

Objective: Is a perioperative metastatic screening programme indicated in patients presenting with primary operable breast cancer and no signs of distant metastases?
Patients and methods: The impact of staging results (chest X-ray, bone scanning, liver ultrasound) for prognosis, treatment, quality of life and costs was retrospectively analysed in 1 076 patients with an operable breast cancer and no clinical signs of metastases.
Results: Staging examinations revealed 30 (2.8 %) distant metastases, 130 (12.1 %) suspect findings and excluded metastases in 916 (85.1 %) patients. Further diagnostic procedures confirmed distant metastases in 7 (5.4 %) and excluded them in 123 (94.6 %) out of 130 patients with suspect findings. Distant metastases were detected more frequently with increasing tumor size (pT ≤ 2.0 cm: 1.6 %, pT 2.1-5.0 cm: 3.0 %, respectively pT > 5.0 cm: 15.1 %; p < 0.001) and increasing number of involved axillary lymph nodes (pN0: 1.4 %, pN1-3 +: 1.8 %, pN4-9 +: 4.0 %, pN > 10 +: 12.5 %; p < 0.001). Due to false positive findings 123 (11.4 %) patients had to live for a significant period of time with the psychological distress of suspected metastatic disease. The abandonment of a perioperative screening in 1 076 patients saves costs of at least € 259 366.68.
Conclusions: In breast cancer patients without clinical signs of tumor spread perioperative screening for metastases is not warranted because of low frequency of metastases, false positive findings, missing therapeutic consequences and high costs.

Brustkrebs - Staging - Fernmetastasierung - Kosten - Behandlung

Breast cancer - staging - metastatic disease - costs - treatment

Literatur

• 1 Barry M C, Thornton F, Murphy M, Younis F, Watson R G. The value of metastatic screening in early primary breast cancer.  Ir J Med Sci. 1999;  168 248-250
• 2 Brenner H, Hakulinen T. Long-term cancer patient survival achieved by the end of the 20^th century: most up-to-date estimates from the nationwide Finnish cancer registry.  Br J Cancer. 2001;  85 367-371
• 3 Bruneton J N, Balu-Maestro C, Raffaelli C, Mourou M Y, Cambon P, Granon C. Indications for hepatic ultrasonography in breast cancer staging and follow-up.  Breast Cancer Res Treat. 1996;  37 115-121
• 4 Chen E A, Carlson G A, Coughlin B F, Reed W PJ, Garb J L, Frank J L. Routine chest roentgenography is unnecessary in the work-up of stage I and II breast cancer.  J Clin Oncol. 2000;  18 3503-3506
• 5 Cooke A L. Baseline staging tests for breast cancer.  CMAJ. 2002;  166 419
• 6 Curigliano G, Ferretti G, Colleoni M, Marrocco E, Peruzzotti G, De Cicco C, Paganelli G, Goldhirsch A. Bone scan had no role in the staging of 765 consecutive operable T(1-2)N(0-1) breast cancer patients without skeletal symptoms.  Ann Oncol. 2001;  12 724-725
• 7 Dillman R O, Chico S. Radiologic tests after a new diagnosis of breast cancer.  Eff Clin Pract. 2000;  3 1-6
• 8 Donnelly J, Mack P, Donaldson L A. Follow-up of breast cancer: time for a new approach?.  Int J Clin Pract. 2001;  55 431-433
• 9 ESMO . ESMO Minimum Clinical Recommendations for diagnosis, adjuvant treatment and follow-up of primary breast cancer.  Ann Oncol. 2001;  12 1047-1048
• 10 Gerber B, Seitz E, Krause A, Müller H, Reimer T, Küchenmeister I, Kundt G, Friese K. A perioperative staging for distant metastases in primary operable breast cancer patients is indicated only in advanced cases.  Breast Cancer Res Treat. 2003;  82 29-37
• 11 GIVIO Investigators . Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. A multicenter randomized controlled trial.  JAMA. 1994;  271 1587-1592
• 12 Goldhirsch A, Glick J H, Gelber R D, Coates A, Senn H J. Meeting highlights: International consensus panel on the treatment of primary breast cancer.  J Clin Oncol. 2003;  21 3357-3365
• 13 Hadley D, Fowble B, Torosian M H. Evidence for selective use of bone scans in early stage breast cancer.  Oncol Rep. 1998;  5 991-993
• 14 Hoffken K. The European experience.  J Clin Oncol. 2001;  19 112S-117S
• 15 Myers R E, Johnston M, Pritchard K, Levine M, Oliver T. Baseline staging tests in primary breast cancer: a practice guideline.  CMAJ. 2001;  164 1439-1444
• 16 Nabholtz J, Pienkowski T, Mackey J, Pawlicki M, Guastalla J P, Vogel C, Weaver C, Walley M. Phase III trial comparing TAC (docetaxel, doxorubicin, cyclophosphamide) with FAC (5-fluorouracil, doxorubicin, cyclophosphamide) in the adjuvant treatment of node positive breast cancer patients: interim analysis of the BCIRG 001 study.  Proc ASCO. 2002;  21 36a
• 17 NIH .National Institutes of Health Consensus Development Conference statement: adjuvant therapy for breast cancer, November 1-3, 2000. J Natl Cancer Inst Monogr 2001; 5-15
• 18 Niu Y, Fu X, Lv A, Fan Y, Wang Y. Potential markers predicting distant metastasis in axillary node-negative breast carcinoma.  Int J Cancer. 2002;  98 754-760
• 19 Norum J, Andreassen T. Screening for metastatic disease in newly diagnosed breast cancer patients. What is cost-effective?.  Anticancer Res. 2000;  20 2193-2196
• 20 Palli D, Russo A, Saieva C, Ciatto S, Rosselli D T, Distante V, Pacini P. Intensive vs clinical follow-up after treatment of primary breast cancer: 10-year-update of a randomized trial. National Research Council Project on Breast Cancer Follow-up.  JAMA. 1999;  281 1586
• 21 Ravaioli A, Pasini G, Polselli A, Papi M, Tassinari D, Arcangeli V, Milandri C, Amadori D, Bravi M, Rossi D, Fattori P P, Pasquini E, Panzini I. Staging of breast cancer: new recommended standard procedure.  Breast Cancer Res Treat. 2002;  72 53-60
• 22 Ravaioli A, Tassinari D, Panzini I, Milandri C, Amadori D. Staging of breast cancer: it is time to break with tradition and initiate the evidence-based-medicine age.  J Clin Oncol. 2001;  19 1234
• 23 Rojas M P, Telaro E, Russo A, Fossati R, Confalonieri C, Liberati A. Follow-up strategies for women treated for early breast cancer. Cochrane Database Syst Rev 2000; CD001768
• 24 Rosselli D T, Palli D, Cariddi A, Ciatto S, Pacini P, Distante V. Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up.  JAMA. 1994;  271 1593-1597
• 25 Sakorafas G H, Tsiotou A G, Pavlakis G. Follow-up after primary treatment for breast cancer.  Acta Oncol. 2000;  39 935-940
• 26 Samant R, Ganguly P. Staging investigations in patients with breast cancer: the role of bone scans and liver imaging.  Arch Surg. 1999;  134 551-553
• 27 Sant M. Differences in stage and therapy for breast cancer across Europe.  Int J Cancer. 2001;  93 894-901
• 28 Singletary S E, Allred C, Ashley P, Bassett L W, Berry D, Bland K I, Borgen P I, Clark G, Edge S B, Hayes D F, Hughes L L, Hutter R V, Morrow M, Page D L, Recht A, Theriault R L, Thor A, Weaver D L, Wieand H S, Greene F L. Revision of the American Joint Committee on Cancer staging system for breast cancer.  J Clin Oncol. 2002;  20 3628-3636
• 29 Sittek H, de Waal C, Eiermann W, Engel J, Gauwerky J F, Hellemann H P. Screening und Diagnsotik. In: Mannual Mammakarzinom (Hrsg). 9. Aufl.Tumorzentrum München 2003; 28-40
• 30 Tassinari D, Sartori S, Ravaioli A. Staging of breast cancer. Is the evidence so evident?.  Ann Oncol. 2001;  12 1653
• 31 Vacek P M, Geller B M, Weaver D L, Foster R SJ. Increased mammography use and its impact on earlier breast cancer detection in Vermont, 1975-1999.  Cancer. 2002;  94 2160-2168
• 32 Will B P, Berthelot J M, Le Petit C, Tomiak E M, Verma S, Evans W K. Estimates of the lifetime costs of breast cancer treatment in Canada.  Eur J Cancer. 2000;  36 724-735
• 33 Wingo P A, Ries L A, Giovino G A, Miller D S, Rosenberg H M, Shopland D R, Thun M J, Edwards B K. Annual report to the nation on the status of cancer, 1973-1996, with a special section on lung cancer and tobacco smoking.  J Natl Cancer Inst. 1999;  91 675-690