Authors' Reply: To the Letter to the Editor by Groheux et al

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  • 1 University of California, San Francisco, California

Re: Groheux D, Hindié E, Espié M, Ulaner GA. Letter to the Editor: PET/CT in Locally Advanced Breast Cancer: Time for a Guideline Change? J Natl Compr Canc Netw 2021;19(8):xxx.

The recent articles by Ko et al1 and our group2 contribute to the growing consensus that 18F-FDG PET/CT adds value to the care of locally advanced breast cancer. Retrospective and prospective evidence suggests that 18F-FDG PET/CT detects unsuspected axillary and distant metastases in a sizable proportion of patients, with detection rate increasing by stage.35 18F-FDG PET/CT is both more sensitive and specific than conventional imaging (CT + bone scan) in this patient population.2,57 Identification of distant metastatic disease directly affects management, potentially preventing costs, morbidity, and emotional burden associated with inappropriate treatments. In the ECOG-ACRIN E2108 trial, no survival benefit was observed in patients with de novo stage IV breast cancer randomized to surgery for locoregional control after a course of systemic therapy.8 Although some patients still opt to proceed with surgery in the setting of stage IV disease, recognition of distant metastases may lead some to revise their surgical preferences. Furthermore, in known stage IV disease, oncologists may opt to refrain from recommending chemotherapy with the goal of cure and are more likely to recommend a hormone-based therapy regimen, particularly for older patients or those with minimal visceral disease. Conversely, data from the phase II SABR-COMET trial suggest that stereotactic ablative radiotherapy in patients with solid tumors and 1 to 5 known metastatic sites improves overall survival.9 Although the number of patients with breast cancer in this study was small, the potential of “cure” in patients with oligometastatic disease has resonated, driving a rationale for the most sensitive imaging study to ascertain stage and sites of disease, not only at diagnosis but also along the trajectory of care.

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer as well as other guidelines do not yet recommend 18F-FDG PET/CT for first-line imaging in locally advanced breast cancer.10 This is at least partly related to concerns regarding higher up-front cost of 18F-FDG PET/CT. As physicians, we have a duty to balance individual patient well-being with prudent stewardship of limited healthcare resources. For staging locally advanced breast cancer, there is mounting evidence that 18F-FDG PET/CT is not just diagnostically superior but also cost-effective. In the Ko et al1 study, overall costs of 18F-FDG PET/CT and CT plus bone scan were comparable. In the Hyland et al2 study, costs were comparable or in some cases less for 18F-FDG PET/CT, driven by decreased biopsies and follow-up imaging to resolve equivocal or suspicious findings on CT and/or bone scan. Neither study evaluated cost savings associated with avoidance of futile surgery and/or radiation in accurately upstaged patients, which may further increase the cost-effectiveness of 18F-FDG PET/CT. Further study is needed to determine overall cost effectiveness of 18F-FDG PET/CT across different practice systems and patient populations. Additionally, we must determine the impact of more sensitive up-front staging on outcomes such as disease-specific and overall survival in patients with locally advanced breast cancer. Given the increasing evidence supporting the improved accuracy of PET/CT, it is time to include PET/CT in the guidance for metastatic workup for stage II and III breast cancer, given that it is the more patient-centered option.

References

  • 1.

    Ko H, Baghdadi Y, Love C, Sparano JA. Clinical Utility of 18F-FDG PET/CT in staging localized breast cancer before initiating preoperative systemic therapy. J Natl Compr Canc Netw 2020;18:12401246.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Hyland CJ, Varghese F, Yau C, et al. Use of 18F-FDG PET/CT as an initial staging procedure for stage II-III breast cancer: a multicenter value analysis. J Natl Compr Canc Netw 2020;18:15101517.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Caresia Aroztegui AP, Garcia Vicente AM, et al. 18F-FDG PET/CT in breast cancer: evidence-based recommendations in initial staging. Tumour Biol 2017;39:1010428317728285.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Han S, Choi JY. Impact of 18F-FDG PET, PET/CT, and PET/MRI on staging and management as an initial staging modality in breast cancer: a systematic review and meta-analysis. Clin Nucl Med 2021;46:271282.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Hong S, Li J, Wang S. 18FDG PET-CT for diagnosis of distant metastases in breast cancer patients. A meta-analysis. Surg Oncol 2013;22:139143.

  • 6.

    Sun Z, Yi YL, Liu Y, et al. Comparison of whole-body PET/PET-CT and conventional imaging procedures for distant metastasis staging in patients with breast cancer: a meta-analysis. Eur J Gynaecol Oncol 2015;36:672676.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Rong J, Wang S, Ding Q, et al. Comparison of 18 FDG PET-CT and bone scintigraphy for detection of bone metastases in breast cancer patients. A meta-analysis. Surg Oncol 2013;22:8691.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Zhao FM, Solin LJ, Goldstein LJ, et al. A randomized phase III trial of systemic therapy plus early local therapy versus systemic therapy alone in women with de novo stage IV breast cancer: a trial of the ECOG-ACRIN Research Group (E2108) [abstract]. J Clin Oncol 2020;38(Suppl):Abstract LBA2.

    • Search Google Scholar
    • Export Citation
  • 9.

    Palma DA, Olson R, Harrow S, et al. Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. Lancet 2019;393:20512058.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Gradisher WJ, Moran MS, Abraham J, et al. NCCN Clinical Practice Guidelines In Oncology: Breast Cancer. Version 3.2021. Accessed May 1, 2021. To view the most recent version, visit NCCN.org

  • 1.

    Ko H, Baghdadi Y, Love C, Sparano JA. Clinical Utility of 18F-FDG PET/CT in staging localized breast cancer before initiating preoperative systemic therapy. J Natl Compr Canc Netw 2020;18:12401246.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Hyland CJ, Varghese F, Yau C, et al. Use of 18F-FDG PET/CT as an initial staging procedure for stage II-III breast cancer: a multicenter value analysis. J Natl Compr Canc Netw 2020;18:15101517.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Caresia Aroztegui AP, Garcia Vicente AM, et al. 18F-FDG PET/CT in breast cancer: evidence-based recommendations in initial staging. Tumour Biol 2017;39:1010428317728285.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Han S, Choi JY. Impact of 18F-FDG PET, PET/CT, and PET/MRI on staging and management as an initial staging modality in breast cancer: a systematic review and meta-analysis. Clin Nucl Med 2021;46:271282.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Hong S, Li J, Wang S. 18FDG PET-CT for diagnosis of distant metastases in breast cancer patients. A meta-analysis. Surg Oncol 2013;22:139143.

  • 6.

    Sun Z, Yi YL, Liu Y, et al. Comparison of whole-body PET/PET-CT and conventional imaging procedures for distant metastasis staging in patients with breast cancer: a meta-analysis. Eur J Gynaecol Oncol 2015;36:672676.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Rong J, Wang S, Ding Q, et al. Comparison of 18 FDG PET-CT and bone scintigraphy for detection of bone metastases in breast cancer patients. A meta-analysis. Surg Oncol 2013;22:8691.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Zhao FM, Solin LJ, Goldstein LJ, et al. A randomized phase III trial of systemic therapy plus early local therapy versus systemic therapy alone in women with de novo stage IV breast cancer: a trial of the ECOG-ACRIN Research Group (E2108) [abstract]. J Clin Oncol 2020;38(Suppl):Abstract LBA2.

    • Search Google Scholar
    • Export Citation
  • 9.

    Palma DA, Olson R, Harrow S, et al. Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. Lancet 2019;393:20512058.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Gradisher WJ, Moran MS, Abraham J, et al. NCCN Clinical Practice Guidelines In Oncology: Breast Cancer. Version 3.2021. Accessed May 1, 2021. To view the most recent version, visit NCCN.org

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