ETF, Calico:

It is important to first establish once and for all that the recent arguments about potentially adverse impact of radiological monitoring (scans) is about excess or superfluous imaging, not well-grounded and motivated imaging: the early detection of cancer recurrence or metastasis cannot by any stretch be viewed as excess, or superfluous.

The benefit of the scan, in effectively diagnosing early malignant development, metastasis or recurrence, as well as in assisting to modulate cancer care more effectively, typically outweighs any potential risk from the radiation.  So for well-motivated radiological monitoring, an individual tends to derive much greater benefit than adverse risk, and it is highly probable that there are higher risks associated with not conducting appropriate and motivated radiological disease monitoring, which can compromise critical treatment decisions, or miss them altogether, significantly adversely effecting patient outcome and QoL.  Furthermore delayed detection can not only compromise outcome, but also likelihood of recurrence: risk of recurrence is influenced by the timeliness of detection, so detection delays are associated with a greater chance of relapsed or recurrent disease, minimized if the disease (primary, relapsed/recurrent, or metastatic) is detected earlier, with earlier therapy being associated with better patient outcome. 

And even if one argues, as does recently Mohammad Jahanzeb from the University of Tennessee that "finding metastatic disease early does not increase survival" (NCCN 2008 Annual Conference in the Use of Imaging in the Management of Patients with Cancer) - even if true, and Dr. Jahanzeb has not shown it to be so - it comes down to the easy dilemma of whether, assuming that survival is not increased according to this view, you want to live the same say 5 or 10 years with a significantly higher chance of one or more recurrences, or a  significantly lower one.  I cannot believe, and have never encountered, any women who would not opt for lowering recurrence risk. Numerous studies have consistently showed that there is virtually nothing a cancer patient fears more than a disease recurrence. 

This is what is profoundly missed by many oncologists who weigh oncotherapy regimens based predominantly as to whether they effect a significant benefit to overall survival (OS), deprecating regimens which only improve progression-free survival (PFS) but do not alter OS, and arguing against bothering to deploy those since no survival benefit accrues.  But this is disconnected from patient reality: if the no-therapy option is known to provide a median of 5 year survival, while regimen X yields the same, the correct response is not "why bother to subject the patient to therapy that fails to gain any survival benefit?", but rather that if regimen X still fails to improve OS, but does improve PFS, then there is indeed a large benefit that matters greatly to the patient, since an improvement in PFS entails a lower risk of recurrence, and even though you may statistically live the same 5 years whether treated or not, as I always say, the quality of the journey matters quite a deal - most patient would prefer to live out their 5 years without recurrence than with it, and with the associated trials and tribulations of another round or more of cancer treatment and treatment-related adverse effects and compromise to QoL. 

So yes the regimen may not gain you any extra years of survival, but the same journey is certain to be "more easy passing".  In parallel, late or missed detection of relapsed/recurrent disease or metastatic spread maximizes the likelihood that the journey will not be easy passing, so interval scanning, whether yearly, bi-annually, or every quarter matters a great deal indeed.   As the always wise David Ettinger at Johns Hopkins recently observed, "If a patient 20 years from now is suffering the consequences of radiation, I think that patient should be pretty happy. They didn't die of cancer",  a sentiment in agreement with that of the eminent John Boone, Chairman of the Science Council of the AAPM (American Association of Physicists in Medicine (AAPM) who noted that "CT scans are critical for guiding the treatment of people . . . diagnosed with cancer", and with former AAPM president Richard Morin who also noted that "For an appropriately ordered CT examination, an individual derives much greater benefit than risk . . . There are likely higher risks associated with failing to have [such] a needed medical test, as the correct diagnosis or treatment decision could be delayed or missed."

Now, from my point of view, what can be done positively, is to optimize and personalize the interval: so for me, if I am dealing with an indolent, low-grade, strongly endocrine-positive tumor burden in an otherwise prognostically favorable context, I would consider a longer imaging interval (every 6 months or yearly), while if I am dealing with a high-grade aggressive tumor in a prognostically compromised advanced disease setting, say of triple negative breast cancer, IBC, or HER2-positive disease, I would favor a short interval (3 months to no more than six months).  The judgment of optimal interval therefore should be tailored to the disease setting, weighing in histopathology, clinical treatment history, tumor biology, and other known or knowable risk and prognostic factors.  Similarly, the time-stage of the interval would matter to me: if a triple negative patient were 6 or 7 years out post-diagnosis, I might entertain 6 month scanning intervals, while if disease free at over 8 years out, I would consider yearly but I would be riveted to the progress of tumor markers to compensate for the longer interval, while in still another case of triple negative disease within the first 3 years post-Dx, I would favor aggressive dual-monitoring of both tumor biomarkers and radiological monitoring at short 3 month bursts.

We serve the patient best by optimizing as well as individualizing disease monitoring, and ultimately (1) it is always a risk/benefit weighing that must critically inform the decision as I sketched out above, and (2) the final decision is the patient's, whether alone or in consultation with their oncology professionals.  These are always deeply personal decisions and much that is not science, or beyond or above science, necessarily plays a role and cannot be discounted or dismissed.

Constantine Kaniklidis

Breast Cancer Watch

edge@evidencewatch.com 

Thank you, Constantine, Calico, and ETF.

This is a double-trouble topic regarding anyone who has experienced Radiation Treatments for Cancer.  I was never given a list of "bewares", or told to avoid CAT Scans, PET Scans, MRI'S, X-rays, or the sunshine between 10 a.m. and 2 p.m.   Are we  supposed to figure this nonsense out for ourselves?  Are "all physicians" aware of the dangers?  I always ask, jokingly, "Will I glow in the dark after having radio-active crud injected, along with being exposed to high levels of radiation...Geiger counter, please?"  I think I may purchase one, just to see if my hunch is right.  Has anyone ever taken a Geiger Counter into a Radiation or X-ray Department, usually located in a basement or an area (seems like),  miles away? 

The generic response from the Radiation Technicians is always..."perfectly safe"...what about people with asthma, broken bones, head injuries?  This stuff, radiation, is it permanently "there", in our tissues, organs, etc.? 

I am uncertain about my current Oncologist's negligence in providing scans of any kind.  He knows more than he's saying, and perhaps agrees with Dr. Mohammad Jahanzeb, why bother with anyone who is likely going to drop dead, anyway?  Sometimes, after all, the tests, treatment, and amateur foolery in giving hope & treatments while realistically knowing there is nothing ... is truly worse than the disease...Cancer, Breast Cancer...

Personally, at this moment, I think the cancer is everywhere, but no tests have been performed to determine if it "is or isn't"; not even a blood test...makes me feel a little suspicious, that this world-renowned Oncologist in Triple Negative Disease, particularly, definitely knows a heck of a lot more than he is willing to tell...me, his patient, who is currently annoyed and impatient...at first thinking, maybe he was protecting me from radio-active rays...ha, ha, ha!  If I die, it won't affect the ratio or data on the Clinical Trials...it's all about configuring the end results of these so-called Clinical Trials...isn't it?  "so-what? " regarding the uncensored idiots like me, and "why bother?" giving hope or testing for metastasis, when a patient is technically "doomed"?