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Baseline staging tests in primary breast cancer: a practice guideline

Robert E. Myers^*, Mary Johnston, Kathy Pritchard, Mark Levine, Tom Oliver and The Breast Cancer Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative^¶

From *the Department of Oncology, Credit Valley Hospital, Mississauga, Ont.; the Program in Evidence-Based Care, Cancer Care Ontario, Hamilton, Ont.; the Toronto–Sunnybrook Regional Cancer Centre, Toronto, Ont.; and the Hamilton Regional Cancer Centre, Hamilton, Ont.Members of the Breast Cancer Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative [at the time of writing]: R. Michael Crump, Toronto General Hospital, Toronto, Ont.; Catherine de Metz, Windsor Regional Cancer Centre, Windsor, Ont.; Dhali Dhaliwal, Northwestern Regional Cancer Centre, Thunder Bay, Ont.; Mary Sue Douglas, community representative; Nancy Down, North York General Hospital, Toronto, Ont.; David Ginsburg, Kingston Regional Cancer Centre, Kingston, Ont.; Ian Graham, Ottawa Hospital – Civic Campus, Ottawa, Ont.; Caroline Hamm, community physician, Wheatley, Ont.; Eric Holowaty, Ontario Cancer Registry, Toronto, Ont.; Barbara Lada, Northeastern Regional Cancer Centre, Sudbury, Ont.; E. Laukkanen, Windsor Regional Cancer Centre, Windsor, Ont.; Mark Levine, Hamilton Clinical Trials Research Institute, Hamilton, Ont.; David McCready, Princess Margaret Hospital, Toronto, Ont.; Douglas Mirsky, Ottawa Regional Women's Breast Centre, Ottawa, Ont.; Robert Myers, Credit Valley Hospital, Toronto, Ont.; Tom Oliver, Program in Evidence-Based Care, Cancer Care Ontario, Hamilton, Ont.; Frances O'Malley, Mount Sinai Hospital, Toronto, Ont.; Francisco Perera, London Regional Cancer Centre, London, Ont.; Kathleen Pritchard, chair, Toronto–Sunnybrook Regional Cancer Centre, Toronto, Ont.; Carol Sawka, Toronto–Sunnybrook Regional Cancer Centre, Toronto, Ont.; Marilyn Schneider, community representative; Wendy Shelley, Kingston Regional Cancer Centre, Kingston, Ont.; Eva Tomiak, Ottawa Regional Cancer Centre, Ottawa, Ont.; Shailendra Verma, Ottawa Regional Cancer Centre, Ottawa, Ont.; David Warr, Princess Margaret Hospital, Toronto, Ont.; and Tim Whelan, Hamilton Regional Cancer Centre, Hamilton, Ont.

Background: Breast cancer develops in over 7000 women each year in Ontario. These patients will all undergo some staging work-up at diagnosis. The Breast Cancer Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative reviewed the evidence and indications for routine bone scanning, liver ultrasonography and chest radiography in asymptomatic women who have 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 practice.

Results: There were 11 studies of bone scanning reported between 1972 and 1980, involving a total of 1307 women; bone scans detected skeletal metastases 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 scanning reported between 1985 and 1995; in these studies, bone scans detected skeletal metastases in only 0.5% of women with stage I disease, 2.4% with 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 detected in 0% of patients with stage I disease, 0.4% with stage II and 2.0% with stage III. Among 3884 patients in 2 studies of chest radiography published in 1988 and 1991, lung metastases were detected in 0.1% of those with stage I, 0.2% with stage II and 1.7% with stage III. False-positive rates ranged from 10% to 22% for bone scanning, 33% to 66% for liver ultrasonography and 0% to 23% for chest radiography. The false-negative rate for bone scanning was about 10%.

Recommendations: The following recommendations apply to women with newly diagnosed 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 scanning, liver ultrasonography and chest radiography are not indicated as part 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 and chest radiography are not indicated in this group but could be considered for patients with 4 or more positive lymph nodes. · In women with pathological stage III tumours, bone scanning, liver ultrasonography and chest radiography are recommended postoperatively as part of baseline 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 other factors, routine bone scanning, liver ultrasonography and chest radiography are not indicated as part of baseline staging.

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