ACS/ASCO issue guideline on caring for breast cancer survivors; study looks at association between screen-detected DCIS, invasive breast cancer

The American Cancer Society (ACS) and the American Society of Clinical Oncology (ASCO) released a guideline last week on caring for survivors of breast cancer.

The guideline, which is intended for primary care and other clinicians, was based on a systematic review of the literature through April 2015 and was developed by a multidisciplinary expert work group. The work group assigned the highest priority to articles that were published in a peer-reviewed journal in English since 2004 (except in cases where a seminal article published before 2004 still carried the most weight), those that analyzed more than 100 cancer cases and used high-quality assessment of covariates and analytic methods, and those that controlled for important confounders. The guideline was published jointly by CA: A Cancer Journal for Clinicians and the Journal of Clinical Oncology on Dec. 7.

The 5 areas covered by the guideline are surveillance for breast cancer recurrence, screening for second primary cancer, assessment and management of physical and psychosocial long-term and late effects of breast cancer and treatment, health promotion, and care coordination and practice implications. Some of the recommendations are as follows:

• Primary care clinicians a) should individualize clinical follow-up care provided to breast cancer survivors based on age, specific diagnosis, and treatment protocol as recommended by the treating oncology team (level of evidence [LOE] = 2A; based on National Comprehensive Cancer Network [NCCN] Clinical Practice Guidelines in Oncology); and b) should make sure the patient receives a detailed cancer-related history and physical examination every 3 to 6 months for the first 3 years after primary therapy, every 6 to 12 months for the next 2 years, and annually thereafter by the treating oncology team (LOE = 2A).
• Primary care clinicians a) should screen for other cancers, as they would for patients in the general population; and b) should provide an annual gynecologic assessment for postmenopausal women on selective estrogen-receptor modulator therapies (SERMs).
• Primary care clinicians a) should counsel survivors on how to prevent/reduce risk of lymphedema, including weight loss for those who are overweight or obese (LOE = 0; based on expert opinion, observational study [excluding case-control and prospective cohort studies], clinical practice, literature review, or pilot study); and b) should refer patients with clinical symptoms or swelling suggestive of lymphedema to a therapist knowledgeable about the diagnosis and treatment of lymphedema, such as a physical therapist, occupational therapist, or lymphedema specialist (LOE = 0).
• Primary care clinicians a) should assess the information needs of the patient related to breast cancer and its treatment, adverse effects, other health concerns, and available support services (LOE = 0); and b) should provide or refer survivors to appropriate resources to meet these needs (LOE = 0).
• Primary care clinicians should maintain communication with the oncology team throughout the patient's diagnosis, treatment, and post-treatment care to ensure care is evidence based and well coordinated (LOE = 0).

The work group noted that randomized, controlled trials of interventions in breast cancer survivors are lacking and said that the recommendations “should be largely seen as possible management strategies given the current limited evidence base.” They also reminded clinicians to pay attention to health disparities and multiple chronic conditions when applying the guideline recommendations.

In other breast cancer news, a retrospective study published last week in Lancet Oncology looked at whether ductal carcinoma in situ (DCIS) detected on mammography was associated with diagnosis of invasive interval cancer before the next screening. Researchers in the United Kingdom obtained data on DCIS diagnoses in women age 50 to 64 years who underwent screening mammography from April 1, 2003, to March 31, 2007, as well as patient-level data on interval cancer diagnosed in the 36 months after each screening. Among 5,243,658 women, the average frequency of DCIS detected on screening was 1.60 per 1,000 women screened, and a negative association was found between screening-detected DCIS and rate of invasive interval cancers (Poisson regression coefficient, −0.084; 95% CI, −0.13 to −0.03; P=0.002). The authors noted that they did not adjust for age and could not link DCIS cases found on screening mammography to individual cases of invasive cancer. However, they concluded, “The association between screen-detected DCIS and subsequent invasive interval cancers suggests that detection and treatment of DCIS is worthwhile in prevention of future invasive disease.”

The author of an accompanying editorial noted the relatively short time frame of the study and said it “suggests that high-grade DCIS (which represents most screen-detected DCIS) has the potential to become invasive and symptomatic in a shorter time period than previously thought.” He also pointed out, however, that the study's results “do not mitigate the harms due to overdiagnosis caused by the detection of low-grade DCIS” and called for additional studies on the frequency with which screening-detected DCIS prevents cases of invasive breast cancer that are “biologically important.”