‘Extreme’ monitoring fails to boost survival in breast cancer patients

“I agree in general with the results and conclusions from this manuscript. It makes sense,” said Dr. Charles Loprinzi, Regis Professor of Breast Cancer Research at the Mayo Clinic, in an interview. “More tests do not necessarily mean more benefit. More frequent testing may help to determine early progression of disease, and then this may lead to earlier treatment changes.”

“There is a spectrum of clinicians who are more frequent testers versus infrequent testers,” Dr. Loprinzi explained. “I am on the side of not getting a lot of tests, as sometimes they provide too much information. For example, if I have a patient with metastatic breast cancer and a lump that I can feel on her chest wall or a pathologically palpable lymph node and also had a couple lung nodules, I would tend to follow this patient primarily by history and physical examination. Other physicians might order imaging tests every 3 months. I am less likely to order frequent imaging tests as long as the patient is feeling well and has responded to their anticancer therapy as per repeat physical examinations,” he said.

Shirley Mertz, president of the Metastatic Breast Cancer Network, a national, independent, nonprofit all-volunteer patient advocacy group, took issue with the generalized conclusions investigators drew. “The title of the article and the paragraph describing [the] purpose of the article infer that the authors studied the community of women living with metastatic breast cancer,” Ms. Mertz said in an interview.

“In reality, the authors looked at data from a very small proportion of women living with metastatic breast cancer – those who received a de novo diagnosis and were 65 and older. The authors then drew a broad conclusion about all elderly women based on their selected small proportion of patients. … How can the authors accurately state, ‘One-third of all elderly patients are extreme users of disease-monitoring tests?’ ”

“The selection by the authors of the word ‘extreme users’ is curious,” Ms. Mertz continued. “ ‘Extreme’ has a negative connotation and implies someone is doing something to excess. So, are readers expected to draw the conclusions of the authors? Did the authors consider a less emotional term such as ‘frequent’ or ‘heavy?’ Or does their choice of extreme help support the conclusions that ‘women with metastatic breast cancer are driving up health care costs?’ ”

When asked about the definition of extreme users, Dr. Loprinzi said, “I don’t think that there is a clinical definition of an extreme user. The authors came up with an innovative study idea and thus had to define an endpoint, which I think it is quite reasonable.”

Ms. Mertz also pointed out that while the investigators reported demographics of the study population, there was no analysis of the demographic of the medical oncologists who wrote the orders for disease-monitoring tests. “Such information is important and could be informative of issues underlying heavy use of diagnostic tests,” Ms. Mertz suggested.

Dr. Loprinzi agreed. “Is the frequent testing doctor driven or patient driven, or are they both? I suspect they are both,” he said. “That would be an interesting topic for an investigator to explore. Potentially, records could demonstrate a pattern for individual practitioners.”

What about the authors’ assertion that frequent testing is associated with emotional harm? “For some patients for whom STMs [serum tumor markers] do reflect their relative burden of metastasis, the STMs in conjunction with imaging can offer some measure of reassurance that a particular treatment is working,” Ms. Mertz said.

“What is needed is more research to develop blood markers that can be used with imaging with confidence in the clinic to monitor metastatic disease and response to treatment. We need to add to or improve upon the oncologists’ diagnostic tools, not curb their use as the authors suggest,” she added.

Dr. Loprinzi and Ms. Mertz made these comments during interviews.