Evaluating the utility of routine survivorship exams in breast cancer: Modality of detection of recurrence in a prospective cohort study.

Abstract

1629 Background: National Comprehensive Cancer Network surveillance guidelines for invasive breast cancer recommend a history and physical exam every 3-12 months for the first 5 years, followed by annually, and mammography every 12 months. However, frequent in-office visits create time toxicity for breast cancer survivors, may have low utility in recurrence detection, and can create false reassurance. This study evaluates the modality of breast cancer recurrence in an integrated health system with access to primary and specialty care. Methods: We investigated mode of detection of recurrent breast cancer in the Pathways Study, a prospective cohort study of adult women diagnosed with and treated for invasive breast cancer in Kaiser Permanente Northern California, with enrollment from 2006 to 2013, and follow-up through December 2021. In this analysis, we included 4,431 women diagnosed at Stages I-III. Cohort members were followed for recurrences, deaths, and other outcomes. Of primary interest was modality of detection of recurrence, categorized as patient-driven symptoms, surveillance mammogram, diagnostic testing (i.e., other surveillance imaging for recurrence such as PET CT or MRI), routine clinical breast exam, or incidental finding. Results: A total of 617 (13.9%) women were identified as having breast cancer recurrence. Patients with recurrence shared similar demographic characteristics to those without recurrence. The recurrence population had median age of 59.2 years, BMI of 28.2 kg/m2, and racial/ethnic composition of 63% white,13% Hispanic,12% Asian, and 10% black. The median time from diagnosis to recurrence was 4 years. Seventy percent of recurrences were found to have distant metastatic disease, of which only 6.7% had concurrent local nodal and/or breast involvement. For those without metastases, 17.7% had recurrence localized in the ipsilateral breast, 2.8% in both the breast and locoregional nodes, and 9.3% only in locoregional nodes. Most recurrences were detected by patient driven symptoms (69.4%). Among the total cases, 8.1% of patients were diagnosed by routine mammogram, 10.9% with diagnostic testing and 4.5% by incidental finding. Recurrences in 6.8% of patients were detected by routine physician exam. Overall survival for those with recurrence was 31.1% and most deaths were attributed to breast cancer (89%). Conclusions: Our study, the largest investigation of breast cancer recurrence modality of detection in a US community oncology setting with comprehensive care, revealed the majority of recurrences were identified through patient self-detection with only 6.8% detected by physician exam. Most recurrences were distant, underscoring the need for alternative screening modalities to detect metastatic recurrences earlier, especially in the context of emerging treatments and improved survival rates for oligometastatic disease.