Examining Breast Cancer Recurrence Detection Methods in a Community Oncology Setting

Ali Duffens, MD

Data from a large study showed that the majority of breast cancer recurrences were self-detected, with only 6.8% found by physician exams, suggesting the need for better screening methods to detect metastatic recurrences earlier.

The study analyzed a cohort of patients from the Kaiser Permanente Northern California Health System. This consisted of 4431 women diagnosed with stages I to III invasive breast cancer who were enrolled from 2006 and 2013, with follow-up through December 2021. The detection methods utilized included patient-reported symptoms, surveillance mammogram, diagnostic testing, routine clinical breast exam, or incidental findings.

Findings showed that there was a high incidence of distant metastatic recurrences. A total of 617 women (13.9%) experienced breast cancer recurrence and in these patients, the median age was 59.2 years and a median body mass index (BMI) of 28.2 kg/m². Additionally, 63% of these patients were White, 13% were Hispanic, 12% were Asian, and 10% were Black.

For these recurrences, 69.4% were detected by patient-reported symptoms, 8.1% by routine mammograms, 10.9% by other diagnostic tests, 4.5% incidentally, and 6.8% by routine physician exams. Seventy percent of patients had distant metastatic disease, 17.7% had recurrence localized in the ipsilateral breast, 2.8% in both the breast and locoregional nodes, and 9.3% in locoregional nodes only.

Looking at overall survival, for those with recurrence, the rate was 31.1%, and 89% of deaths were attributed to breast cancer.

In an interview with Targeted Oncology^TM, Ali Duffens, MD, San Francisco Medical Center, Kaiser Permanente Northern California, San Francisco, CA, further discussed findings from this study.

Targeted Oncology: Can you provide an overview of your presentation from ASCO 2024, including the methods and design?

Duffens: My presentation was titled “Assessing mode of detection of breast cancer recurrence in invasive breast cancer survivors undergoing surveillance after initial treatment.” This was a prospective cohort study, and it utilized data from the PATHWAY study, which is a comprehensive cohort study of women diagnosed with invasive breast cancer within the Kaiser Permanente Northern California Health System.

Breast Cancer Image: © Giovanni Cancemi- stock.adobe.com

Enrollment for the study was from 2006 to 2013, and [patients] were followed until December 31, 2021, so for 10 years. Participants are selected from adult women diagnosed with stages I through III invasive breast cancer. Inclusion criteria mandated that [patients] were over 21 years old, current Kaiser members diagnosed recently, and able to communicate in English, Spanish, Cantonese, or Mandarin.

What modalities of detection were utilized in the study?

The study included several modalities for detecting breast cancer recurrence, including patient-driven symptoms, so recurrences reported by patients based on their symptoms; surveillance mammograms; diagnostic testing, including PET CT, MRI, and other advanced imaging techniques, routine clinical breast exams conducted by oncologists and OB-GYNs; and then an incidental finding.

What were the primary and secondary outcomes of the study and how effective were the routine survivorship exams in detecting breast cancer recurrence?

The primary outcomes of the study are focused on assessing the mode of detection of breast cancer recurrence among this cohort of asymptomatic patients who are undergoing surveillance following the initial treatment of invasive breast cancer. Secondary outcomes involve comparing the demographic clinical tumor and treatment care risk characteristics of Kaiser patients who experienced recurrent breast cancer compared to those who did not. And then the study found that routine survivorship clinical breast exams had a low detection rate for recurrences, with only 6.8% of recurrences being detected this way.

Can you discuss the relative effectiveness of the different detection modalities and identifying recurrences?

The study revealed that patient-reported symptoms were the most common modality for detecting recurrence, accounting for 69.4% of cases. Routine mammograms detected 8.1% of recurrences, diagnostic testing identified 10.9%, and physician exams were only 6.8%. Incidental findings accounted for 4.5% of recurrences. This low yield of clinical breast exams and surveillance suggests that it might not be the most effective method for detecting asymptomatic recurrence, and the limitations of clinical breast exams are attributed to factors such as the clinician skill, the patient's body habitus, and the tumor's location and characteristics.

Were there any notable differences in detection rates or outcomes based on patient demographics or initial cancer characteristics?

The differences in detection rates were observed based on patient demographics and cancer characteristics. Younger patients and those with higher BMI had slightly higher recurrence rates. Additionally, although it was not published in this abstract, we plan to publish in the upcoming paper that recurrences were more common in patients with positive nodal status than diagnosis and higher tumor grade. These factors highlight the need for more research to explore tailored surveillance strategies based on initial tumor and staging characteristics.

How did the findings of this study compare with current practice for monitoring survivors of breast cancer?

The [National Comprehensive Cancer Network (NCCN)] surveillance guidelines for invasive breast cancer recommend a history and physical exam every 3 to 12 months for the 5 five years after initial breast cancer diagnosis, followed by an annual annually followed along with a mammogram every 12 months. Compared with current practices, the study highlighted the limitations of routine clinical exams and detecting recurrences, and the findings suggested that more emphasis should be placed on patient education about symptoms of metastases and more focused on advanced imaging techniques which could lead to earlier detection and improved outcomes in certain patients. Previous older studies have not shown a mortality benefit when surveilling for metastatic disease. However, with new therapies emerging for oligometastatic and certain hormone-responsive cancers, these should be reconsidered.

The study [also] found that most recurrences were distant, so most recurrences were metastatic, emphasizing the need for alternative screening modalities to detect metastatic recurrences earlier since the current surveillance strategies do not recommend any sort of surveillance to detect metastatic cancer.

What are the potential advantages and disadvantages of routine survivorship exams compared with more targeted or symptom driven follow-up care?

Routine survivorship exams provide structured follow-up and early detection of recurrences. But frequent in-office visits also have disadvantages such as time toxicity for breast cancer survivors, low utility and recurrence detection, and potential false reassurance. Our study suggests that a more targeted approach combining routine exams with risk base may optimize patient outcomes and resource use.

What are the long-term follow-up plans for this patient cohort? How will you use these plans in helping to understand the impact of routine survivorship exams on long-term outcomes?

Mortality rates at the end of the 10-year follow-up period were reported providing crucial data on survival outcomes and the impact of routine survivorship exams. Additionally, the study plans to report on the detection of contralateral breast cancer in the forthcoming manuscript. This extended follow-up will help in understanding the survival periods and risks not only for recurrence, but also for developing contralateral new primary breast cancer. By analyzing these long-term outcomes, this study aims to provide deeper insights into the effectiveness of routine survivorship exams and improving survival rates and overall patient outcomes.

How do you anticipate the results of the study will influence clinical practice guidelines for the follow-up care of survivors of breast cancer?

In light of these results, the NCCN guidelines should consider adopting a more tailored approach to surveillance, potentially reducing the frequency of clinical breast exams or redefining the role within the follow-up care regimen. This reevaluation could advocate for the selective use of clinical exams based on individual risk factors including the patient's initial tumor characteristics, genetic predisposition, and personal and family history of breast cancer. By incorporating these personalized risk assessments, the updated guidelines can ensure more effective and efficient follow-up care, ultimately improving outcomes for breast cancer survivors.

REFERENCE:

Duffens A, Laurent C, Roh JM, et al. Evaluating the utility of routine survivorship exams in breast cancer: Modality of detection of recurrence in a prospective cohort study. J Clin Oncol. 2024;42 (suppl 16):1629. doi:10.1200/JCO.2024.42.16_suppl.1629