According to Seeram, patients are exposed to higher radiation levels from the use of computed tomography compared to most imaging techniques. There is a lack of awareness of the actual risks involved. The exposure to ionizing radiation in CT is emphasized in the CT versus MRI debate. MRI is safe. But MRI is more expensive and has limited availability. With health care costs already spiraling out of control, it is unlikely to supercede CT and the possible replacement has not occurred.

Therefore radiation exposure from computed tomography is still a matter of concern. The well known BMJ editorial by Rehani and Berry “Radiation doses in computed tomography. The increasing doses of radiation need to be controlled” published in the year 2000 is a discussion on the controversy. In the editorial, the authors point out the potential for increased radiation exposure from the advances in CT technology. Control of radiation burden is regarded as one of the parameters of quality control in computed tomography .
The advances in computed tomography ensure that it remains a versatile, affordable and readily available diagnostic modality more than three decades after its introduction. CT scans enjoy a pride of place in diagnostic radiology that was challenged but not usurped by MRI. The radiation risk is a disadvantage inasmuch the procedure involves exposure to relatively high levels. The issue of radiation exposure is once more the focus of current debate.

It should be admitted at the outset that there is no conclusive evidence of radiation risk. Although radiation doses are considerable, the doses are still well below acceptable limits of exposure. Expert opinion is divided on whether the increase in radiation exposure from CT scans is a matter of concern or not. Moreover, there is no doubt that the benefits outweigh the risks when there is a strong indication for a CT scan. The key issue is that there must be a valid indication for a CT scan to be performed. While this may appear to be a relatively simple matter, it is actually difficult to ensure the judicious use of CT scans in practice. With the increased dependence of modern medicine on technology, coupled with the significant contribution that CT technology continues to make to medicine, it is difficult for health care providers to forego a quick, non-invasive diagnostic tool.

An increased number of physicians and scientists agree that concerted efforts are required in order to reduce radiation doses from computed tomography. The shielding of superficial radiosensitive tissues and the optimum selection of settings are some of the technical possibilities. Manufacturers of CT scanners are capable of significant contributions in the development of low dose technology. The evaluation of acceptability of low dose techniques from a clinical perspective remains a potential challenge. Therefore, most modifications have inherent disadvantages and barriers to implementation.

Finally, CT scans are now used as a screening procedure. The full body CT scan though restricted to those can afford it has a wide appeal. The commercial potential of full body CT screening makes it an attractive commodity, but the long term benefits and risks are not clear at this time. The cost-effectiveness and large scale benefit of full body scans are still to be established.

1.Rehani MM, Berry M. Radiation doses in computed tomography. The increasing doses of radiation need to be controlled. BMJ. 2000 Mar 4;320(7235):593-4.

2. Crawley MT, Booth A, Wainwright A. A practical approach to the first iteration in the optimization of radiation dose and image quality in CT: estimates of the collective dose savings achieved. Br J Radiol 2001 Jul;74(883):607-14

3. Trigaux JP, Lacrosse M. Radiation exposure and computed tomography. Rev Mal Respir. 1999 Apr;16(2):127-36.

4. Royal College of Radiologists. Making the best use of department of clinical radiology: guidelines for doctors. 4th ed. London: Royal College of Radiologists, 1998.

5. Seeram E. Radiation dose in computed tomography. Radiol Technol 1999 Jul-Aug;70(6):534-52; quiz 553-6

6. Rockstroh G, Lieberenz S, Straubel U. [Quality control in computed tomography] Radiol Diagn (Berl) 1989;30(3):339-45

7. Nishizawa K, Maruyama T, Takayama M, et al. [Estimation of effective dose from CT examination] Nippon Igaku Hoshasen Gakkai Zasshi 1995 Sep;55(11):763-8

8. Wall BF, Hart D. Revised radiation doses for typical X-ray examinations. Report on a recent review of doses to patients from.medical X-ray examinations in the UK by NRPB. National Radiological Protection Board. Br J Radiol 1997 May;70(833):437-

9. Dhingsa R, Finlay DB, Robinson GD, et al. Assessment of agreement between general practitioners and radiologists as to whether a radiation exposure is justified. Br J Radiol. 2002 Feb;75(890):136-9.

10. Hopper KD, King SH, Lobell ME et al. The breast: in- plane x-ray protection during diagnostic thoracic CT-Shielding with bismuth radioprotective garments. Radiology 1997;205:853-858[Medline].

Diagnostic:For evaluation of suspected cancer, according to 2008 European guidelines, there must be mammographic of ultrasound findings that MRI can clarify. Most guidelines do not recommend MRI for dense breasts alone but one lukewarmly endorses this idea. BC Guideline says: “MRI can be useful in a small number of patients when there is an equivocal mammographic finding, i.e. a possible architectural distortion, or mass seen only in one view, in whom there is no ultrasound or clinical correlate. Many of these patients have heterogeneously dense breasts.” It is worth it to point out that the young women have dense breasts.

Screening: MRI is becoming widely accepted for breast cancer screening. The responsible use of MRI for the evaluation of the breast is focused primarily on patients with a high probability of breast cancer, and it includes screening in women who are known or likely carriers of a BRCA1 or BRCA2 mutation. Most of the available data are based on annual MRI screening; there is a lack of evidence regarding shorter or longer screening intervals. Further, while good data are available for the first screening exam (ie, the “prevalent screen”), considerably less data are available from subsequent screening exams (ie, “incidence screens”), and the available data include relatively short follow-up times. Most studies of annual MRI have shown few interval cancers, certainly fewer than with mammography. Given the probably shorter duration of the detectable preclinical phase, or sojourn time, in women with BRCA mutations, MRI has demonstrated superiority to mammography in this group. Therefore, to the best of our knowledge, MRI should be performed annually in appropriate patients.

The American Cancer Society published new recommendations for breast-cancer screening in women at high risk for breast cancer. In the 2003 update to its guideline for breast-cancer screening, the American Cancer Society stated that women at increased risk for breast cancer might benefit from the earlier initiation of screening, shorter screening intervals, or the addition of screening methods such as breast ultrasound or MRI. On the basis of newer evidence, as well as requests from clinicians for greater guidance in the use of breast MRI, the guideline now recommends annual breast-cancer screening by means of MRI for women with approximately 20% or greater lifetime risk of breast cancer, according to risk models that are largely dependent on a strong family history of breast or ovarian cancer. Women who have received radiation treatment to the chest, such as for Hodgkin disease, compose a well-defined group that is at high risk. Although evidence of the efficacy of MRI screening in this group is lacking, it is expected that MRI screening might offer similar benefit as for women with a strong family history, particularly at younger ages and within 30 years of treatment. Because of the high risk of secondary breast cancer in this group, MRI screening is recommended based on expert consensus opinion.
The updated guideline also states that there is insufficient evidence to make a recommendation for or against MRI screening in women with a personal history of breast cancer, carcinoma in situ, or atypical hyperplasia or in women with extremely dense breasts.

MRI is also indicated for evaluation of suspected rupture of silicone, and some experts say, saline implants.

MRI is being used more and more often and for a an increasingly wider variety of reasons. However, there have been concerns about the increasing use of breast MRI and and about maintaining their quality of the examinations.

The reports of 4,271 breast MRIs from eight large scale clinical trials were reviewed recently by CD Lehman. Overall the sensitivity ranged from 71% to 100% in these reports, however the call-back rates were low at 10% and the risk of having a benign biopsy was reported at 5%, a significant improvement over mammography.

It is unclear whether the results reported by Lehman and colleagues could be reproduced in all centers offering MRI today. Of particular concern are facilities that perform breast MRI but lack the ability to perform biopsies. Patients at such facilities who require follow-up evaluation at a center with the capacity to perform a biopsy in effect have to undergo a repeat of the entire imaging procedure. The new American Cancer Society guidelines strongly recommend that breast MRI not be performed in the absence of the capacity to perform biopsies.

Guidelines: ASCO recently issued a new set of screening guidelines published in the CA journal.

The new guideline is published the ACS journal CA: A Cancer Journal for Clinicians. It recommends MRI screening in addition to mammograms for women who meet at least one of the following conditions:

they have a BRCA1 or BRCA2 mutation
they have a first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves
their lifetime risk of breast cancer has been scored at 20%-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors
they had radiation to the chest between the ages of 10 and 30
they have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative
The recommendations are based on studies that were published after the ACS last revised its breast cancer early detection guidelines in 2002-2003. At that time, the panel concluded there was not enough evidence to recommend for or against MRI in high-risk women, so the guideline advised these women to make the decision after talking with their doctor. Now there is more solid evidence that MRI is useful for certain women.

Another way to go about determining necessity is to calculate risk using models other than Gail. NCCN 2012 in its breast cancer screening guideline specifically says that it should not be Gail, because it is not sufficiently genetic risk based. It recommends BRCA-Pro or modified Gail, see BSCR-B.

The American Cancer Society recommends against MRI screening for women whose lifetime risk of breast cancer is less than 15%.

There’s not enough evidence to make a recommendation for or against yearly MRI screening for women who have a moderately increased risk of breast cancer (a lifetime risk of 15% to 20% according to risk assessment tools that are based mainly on family history) or who may be at increased risk of breast cancer based on certain factors, such as:

Having a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
Having dense breasts (“extremely” or “heterogeneously” dense) as seen on a mammogram.

Guidelines do not recommend the use of MRI to survey patients with benign breast changes.
The American College of Radiology practice guidelines include 12 indications for the performance of breast MRI. ACR and SBI suggest that annual screening
MRI be performed in addition to annual mammography
for women with 20% lifetime risk for the development
of breast cancer.
In addition to having the BRCA1 or BRCA2 mutation, a family history that may suggest a genetic predisposition to breast cancer includes having
2 first-degree relatives with breast cancer, a first-degree relative with premenopausal breast cancer, a family history of breast and ovarian cancer, a first-degree relative with more than one independent cancer, and having a male relative with breast cancer.

http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs

American College of Radiology Practice Guidelines for the Performance of Magnetic Resonance Imaging of the Breast. Available at: http://www.acr.org. Accessed onSeptember 13, 2010.

Lehman CD (2006). “”Role of MRI in screening women at high risk for breast cancer”". Journal of Magnetic Resonance Imaging 24 (5): 964

Robert A. Smith et al, American Cancer Society Guidelines for Breast Cancer Screening: Update 2003 CA Cancer J Clin 2003; 53:141-169

Bae MS, et al.Breast Cancer Detected with Screening US: Reasons for Nondetection at Mammography. Radiology. 2014 Feb;270(2):369-77. doi: 10.1148/radiol.13130724. Epub 2013 Nov 6.

Schacht DV, et al. Importance of a personal history of breast cancer as a risk factor for the development of subsequent breast cancer: results from screening breast MRI. AJR Am J Roentgenol. 2014 Feb;202(2):289-92

R. A. Smith The Evolving Role of MRI in the Detection and Evaluation of Breast Cancer
N. Engl. J. Med., March 29, 2007; 356(13): 1362 – 1364.

R. M. Mann et al, Breast MRI: guidelines from the European Society of Breast Imaging Eur Radiol. 2008 July; 18(7): 1307–1318

http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Breast/Diagnosis/MRI.htm

Eduard A. van Bodegravenet al,  European Journal of Obstetrics & Gynecology and Reproductive Biology, Volume 218, November 2017, Pages 5-11

Revised: 11/19/08

Stage II is divided into stage IIA and stage IIB based on tumor size and whether it has spread to the axillary lymph nodes (the lymph nodes under the arm). In stage IIA, the cancer is either not larger than 2 centimeters and has spread to the axillary lymph nodes, or between 2 and 5 centimeters but has not spread to the axillary lymph nodes. In stage IIB, the cancer is either between 2 and 5 centimeters and has spread to the axillary lymph nodes, or larger than 5 centimeters but has not spread to the axillary lymph nodes. This is a situation in which common practice is against literature and guideline statements. It is common for this stage to be evaluated with CT scans to rule out distant metastastes but the literature indicates that the risk of mets is so small that such staging is not indicated. 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. Abdominal and pelvic CT is only NCCN recommended if there are specific test elevations or pulmonary symptoms.

The yield of positive results among these patients was 2% with bone scanning, and less than 1% with ultrasonography and with chest radiography. A good case could be made for retaining bone scanning and eliminating the other 2 tests in this patient group. The possibility of dividing the stage II group according to size of tumor or number of positive lymph nodes (fewer than 4 v. 4 or more) was considered in one guideline based on the assumption that risk might vary across the range of stage II disease. For example, a larger number of positive nodes could be associated with a higher likelihood of detecting metastases with the staging tests. However, data were not available to answer this question. Nonetheless, the guideline group felt it appropriate to consider the addition of liver ultrasonography and chest radiography in women with 4 or more positive lymph nodes.

Robert E. Myers et al, Baseline staging tests in primary breast cancer: a practice guideline CMAJ. 2001 May 15; 164(10): 1439–1444.

F. Cardoso, S. Kyriakides, S. Ohno, F. Penault-Llorca, P. Poortmans, I. T. Rubio, S. Zackrisson and E. Senkus, Early Breast Cancer: ESMO Clinical Practice Guidelines Ann Oncol (2019)

http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf, BINV-16, 2013

ASCO 2006 Update of the Breast Cancer Follow-Up and Management Guideline in the Adjuvant Setting, JOP November 2006 vol. 2 no. 6 317-318

Hayes DF. Clinical practice. Follow-up of patients with early breast cancer. N Engl J Med 2007; 356:2505

Wahl RL, Siegel BA, Coleman RE, et al: Prospective multicenter study of axillary nodal staging by positron emission tomography in breast cancer: A report of the Staging Breast Cancer With PET Study Group. J Clin Oncol 22:277-285, 2004

Lee JH, Rosen EL, Mankoff DA: The role of radiotracer imaging in the diagnosis and management of patients with breast cancer: Part 1–Overview, detection, and staging. J Nucl Med 50:569-581, 2009

Lovrics PJ, Chen V, Coates G, et al: A prospective evaluation of positron emission tomography scanning, sentinel lymph node biopsy, and standard axillary dissection for axillary staging in patients with early stage breast cancer. Ann Surg Oncol 11:846-853, 2004

David A. Mankoff and Jennifer M. Specht, University of Washington; Seattle Cancer Care Alliance, Seattle, WA William B. Eubank, University of Washington; Puget Sound Veterans Affairs Medical Center, Seattle, WA Larry Kessler, University of Washington, Seattle, WA [18F]Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography in Breast Cancer: When… and When Not? JCO April 20, 2012 vol. 30 no. 12 1252-1254

The National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 study reported a nearly a 57% increase in invasive cancer compared to patients without atypical hyperplasia (10.11 events per 1,000 patients vs 6.44 events per 1,000 patients) with a mean follow-up of 47.7 months.

The most extensive evaluation of chemoprevention agents has been with tamoxifen. Tamoxifen, a selective estrogen receptor modulator (SERM), inhibits the binding of estrogen to estrogen receptors and also acts as an agonist on bone, the uterus, and liver. The data from multiple, randomized studies have supported the use of tamoxifen for prevention of breast cancer in high-risk individuals. The largest of these studies, the Breast Cancer Prevention Trial (NSABP P-1), compared tamoxifen to placebo in over 13,000 women with a Gail model score ≥ 1.66%. The study was halted early due to a 49% reduction of invasive breast cancer. More specifically, tamoxifen reduced the risk of breast cancer in LCIS patients by 56% and in atypical hyperplasia patients by 86%. It is interesting that tamoxifen preferentially decreased the incidence of estrogen receptor (ER)-positive tumors, a common finding of atypical hyperplasia and LCIS.[61,62] In addition, there was a 50% reduction in the incidence of noninvasive cancers in the tamoxifen arm. Adverse outcomes due to tamoxifen, such as increased risk of endometrial cancer and thromboembolic events, were reported (risk ratio of 2.53 for endometrial cancer and 3.01 for pulmonary embolism).

A smaller reduction was noted in the International Breast Cancer Intervention Study (IBIS-I) in which a 32% risk reduction was noted after 50 months in patients with a greater than twofold relative risk of breast cancer. Two additional European studies, the Royal Marsden Hospital study and the Italian study, have failed to demonstrate a statistical benefit toward tamoxifen, but many believe that differences in patient selection, poor compliance, and insufficient power account for the differences. A further meta-analysis of these four trials produced a 38% reduction in the incidence of breast cancer and decreased ER-positive tumors by 48%.

1. Cuzick J, Forbes J, Edwards R, et al. First results from the International Breast Cancer Intervention Study (IBIS-I): a randomised prevention trial. Lancet. 2002;360:817-824.
2. Powles T, Eeles R, Ashley S, et al. Interim analysis of the incidence of breast cancer in the Royal Marsden Hospital tamoxifen randomised chemoprevention trial. Lancet. 1998;352:98-101.
3. Veronesi U, Maisonneuve P, Costa A, et al. Prevention of breast cannncer with tamoxifen: preliminary findings from the Italian randomised trial among hysterectomised women. Italian Tamoxifen Prevention Study. Lancet. 1998;352:93-97.
4. Bao T, Prowell T, Stearns V. Chemoprevention of Breast cancer: tamoxifen, raloxifene, and beyond. Am J Ther. 2006;13:337-348.
5. Cuzick, J, Powles T, Veronesi U, et al. Overview of the main outcomes in breast-cancer prevention trials. Lancet. 2003;361:296-300.
6. Cummings SR, Eckert S, Krueger KA, et al. The effect on raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Mutiple Outcomes of Raloxifene Evaluation. JAMA. 1999;281:2189-2197. Erratum in: JAMA. 1999 Dec 8;282(22):2124.
7. Martino S, Cauley JA, Barrett-Conner E, et al. Continuing outcomes relevant to Evista: breast cancer incidence in postmenopausal osteoporotic women in a randomized trial of raloxifene. J Natl Cancer Inst. 2004;96: 1751-1761.
8. 8.Banu Arun et a, High Prevalence of Preinvasive Lesions Adjacent to BRCA1/2-Associated Breast Cancers Cancer Prev Res February 2009 2; 122
9. Michael J. Hall et al, Prevalence of BRCA1 and BRCA2 Mutations in Women with Breast Carcinoma In Situ and Referred for Genetic Testing Cancer Prev Res December 1, 2010 3:12 1579-1585

There are some special groups in which screening may be reasonable. These include hereditary pancreatitism chronic pancreatitits and thos with a strong family history.

An individual’s risk of developing pancreatic cancer increases with the number of affected first-degree relatives, and it is estimated that hereditary factors account for at least 5% of pancreatic cancers.2 Familial pancreatic cancer (FPC) is inherited in an autosomal dominant manner, with variable penetrance. In order to diagnose FPC, it is necessary to obtain an accurate and thorough family history with particular emphasis on the oncologic history. While it is important to ascertain any family history of pancreatic cancer, it is also important to screen for a personal and family history of extrapancreatic malignancies, and to obtain a family cancer history beyond first-degree relatives, if possible. The family history allows the clinician to determine if prior cases of pancreatic cancer in relatives are more likely to be familial or sporadic.

If a diagnosis of FPC is made in conjunction with a family history of extrapancreatic malignancies, consideration should also be given to a syndromic FPC. Hereditary pancreatic cancer has been associated with colorectal cancer in the Lynch syndrome II variety of hereditary nonpolyposis colorectal cancer (HNPCC), with breast and ovarian cancer (breast–ovarian cancer syndrome), Peutz–Jeghers syndrome, and melanomas in the familial atypical multiple mole melanoma (FAMMM) syndrome. A family history of early pancreatitis suggestive of hereditary pancreatitis is also an important risk factor for subsequent pancreatic adenocarcinoma.

Although there are no consensus guidelines on what defines FPC, an assessment of the risk of developing pancreatic cancer according to the number of affected relatives is useful in clinical practice. Genetic testing might be a useful adjunct in the management of a patient with FPC, but should be performed only after appropriate genetic counseling. Many important genes that have at least a partial role in FPC, both syndrome-associated and nonsyndromic, have been identified. In a multicenter study, 40% of patients with a history of hereditary pancreatitis developed pancreatic adenocarcinoma by 70 years of age.6 Testing for the cationic trypsinogen gene (PRSS1), which is associated with hereditary pancreatitis, is available. The FAMMM syndrome, described in 1975, is associated with a germline mutation of the p16 tumor suppressor gene (CDKN2A). Testing for p16 mutations helps identify those patients at risk for pancreatic malignancy in families with a history of melanomas and pancreatic cancer. The majority of FPC cases, however, are nonsyndromic.

CT scanning, while critical in the management of pancreatic adenocarcinoma, has not proven to be of definitive benefit in screening for pancreatic malignancy in FPC, mainly because of a lack of adequate resolution to detect dysplasia. For CT scanning to exert a benefit in terms of mortality, it must detect either premalignant changes or early malignancy, so that curative surgery can be performed.

In conclusion, genetic counselling should precede radiological screening, an attempt to better define a familial syndrome should be made before screening, and there is no evidence that any screening is supror to another or to no screening at all. There is little evidence for CT scan based screening.

U.S. Preventive Services Task Force (USPSTF). Screening for pancreatic cancer: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2004 Feb. 3 p. [4 references]

Ulrich CD; Consensus Committees of the European Registry of Hereditary Pancreatic Diseases, Midwest Multi-Center Pancreatic Study Group, International Association of Pancreatology.Pancreatic cancer in hereditary pancreatitis: consensus guidelines for prevention, screening and treatment.Pancreatology. 2001;1(5):416-22
Ellis I, Lerch MM, Whitcomb DC; Consensus Committees of the European Registry of Hereditary Pancreatic Diseases, Midwest Multi-Center Pancreatic Study Group, International Association of Pancreatology.  Genetic testing for hereditary pancreatitis: guidelines for indications, counselling, consent and privacy issues.
Pancreatology. 2001;1(5):405-15

Rajesh N Keswani, Amy Noffsinger and Irving Waxman A family history of pancreatic cancer, Nature Clinical Practice Gastroenterology & Hepatology (2006) 3, 586-591

Kanjeekal S, Biagi J, Walker-Dilks C. PET imaging in pancreatic cancer: recommendations. Toronto (ON): Cancer Care Ontario (CCO); 2009 Jan 19. 20 p. (Recommendation report – PET; no. 5).  [34 references]

1. In lung cancer patients who have been treated with curative-intent therapy, the follow-up for complications related to the curative-intent therapy should be managed by the appropriate specialist and should probably last 3 to 6 months. At that point, the patient should be reevaluated by the multidisciplinary tumor board for entry into an appropriate surveillance program for detecting recurrences and/or metachronous tumors. Level of evidence, poor; benefit, moderate; grade of recommendation, C
2. In lung cancer patients who have been treated with curative-intent therapy, surveillance with a medical history, physical examination, and imaging study (either chest radiograph or chest computed tomography [CT] scan) is recommended every 6 months for 2 years and then annually. Patients should be counseled on symptom recognition and should be advised to contact their physician if worrisome symptoms are recognized. Level of evidence, poor; benefit, moderate; grade of recommendation, C
3. Ideally, surveillance for the recognition of a recurrence of the original lung cancer and/or the development of a metachronous tumor should be coordinated through a multidisciplinary team approach. This team should develop a lifelong surveillance plan appropriate for the individual circumstances of each patient immediately following initial curative-intent therapy. If possible, the physician who diagnosed the primary lung cancer and initiated the curative-intent therapy should remain as the health-care provider overseeing the surveillance process. Level of evidence, poor; benefit, moderate; grade of recommendation, C
4. In lung cancer patients following curative-intent therapy, the use of blood tests, positron emission tomography (PET) scanning, sputum cytology, tumor markers, and fluorescence bronchoscopy is not currently recommended for surveillance. Level of evidence, poor; benefit, negative; grade of recommendation, D
5. Lung cancer patients who smoke should be strongly encouraged to stop smoking. Level of evidence, fair; benefit, moderate; grade of recommendation, B

NCCN 2017 recommends CT every 6 months for two years and then annually, then annual low dose CT. For oligometastatic disease:

H&P and chest CT ± contrast every 3–6 mo for 3 y, then H&P and chest CT ± contrast every 6 mo for 2 y, then H&P and a low-dose non-contrast-enhanced chest CT annually.

Colice GL, Rubins J, Unger M. Follow-up and surveillance of the lung cancer patient following curative-intent therapy. Chest 2003 Jan;123(1 Suppl):272S-83S.

nccn.org, Non-small Cell Lung Cancer, 2013.

Standardized interpretation guidelines in thermal breast imaging have been utilized since the adoption of the 20 point TH interpretation and classification system in the early 1980’s. This system has been continually updated as ongoing research has dictated. Many large-scale studies performed over the last three decades, encompassing well over 300,000 women participants, confirm the objectivity and accuracy of this interpretation and classification system. This system of interpretation is the most up-to-date method for use in the qualitative and quantitative analysis of thermal breast images. The 20 point TH interpretation and classification system is the accepted standard in thermal breast imaging analysis.

Thermography has been proposed as an alternative method of breast cancer screening. Currently, the gold standard for breast cancer screening is mammography; therefore, sensitivities, specificities, and positive and negative predictive values of thermography need to be compared against those of mammography in order to evaluate whether or not thermography is equivalent or superior to mammography. There are no published studies in the peer-reviewed scientific literature comparing the two screening techniques. Furthermore, there are no national published evidence-based practice guidelines which endorse thermography as the appropriate method of screening for early detection of breast cancer.

Thermography has been approved for this purpose for many years by the US FDA (United States Food and Drug Administration). Breast thermography is very accurate, but only in the hands of trained personnel using the correct type of thermography cameras. The accuracy of the examination varies around the world but varies from 87%-96% depending on old the literature is. Over 800 peer-reviewed studies on breast thermography exist in the index medicus literature.  In this database, well over 300,000 women have been included as study participants.  The numbers of participants in many studies are very large (10,000, 37,000, 60,000, 85,000, etc.)  Some of these studies have followed patients for up to 12 years.  These studies, however, were not definitive and many were poorly designed and hard to interpret. They showed, using mammography as the gold-standard comparison, that thermography was very sensitive but had many false positives.

Unfortunately, early enthisiasm let to widepread adoption of thermography not only in breast cancer deteection but also by chropractics and non-allopathic practitioners. Many did not have the appropriate training or experience. Farther study of this new technique diminshed in the late 1980′s.

Moskowitz M. Thermography as a risk indicator of breast cancer. Results of a study and a review of the recent literature. Journal of Reproductive
Medicine 1985;30(6)):451-459.

BC guidelines -  BC Cancer Agency (http://www.bccancer.bc.ca).

http://www.nzbcf.org.nz/education/position_statements.asp

International Agency for Research on Cancer (IARC). Breast Cancer Screening. 1st ed. Lyon, France: IARC Press, 2002.

Royal Australian and New Zealand College of Radiologists Breast Imaging Reference Group policy on the use of thermography to detect breast
cancer 2001. http://www.ranzcr.edu.au/open/policies/diagnostic_imaging/pol7_3.htm

American Medical Association thermography update H-175.988: AMA Policy Finder undated.
http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-175.988.HTM

Lay Summary: I discuss the guidelines for BRCA testing.

There are two approaches to determining necessity for BRCA testing, one that focuses on specific family history and another that focuses on global risk. The USPSTF recommends against routine referral for genetic counseling or routine breast cancer susceptibility genes (BRCA) testing for women whose family history is not associated with an increased risk for deleterious mutations in breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA).

The USPSTF found fair evidence that women without certain specific family history patterns, termed here “increased risk family history” have a low risk for developing breast or ovarian cancer associated with BRCA1 or 2 mutations. Thus, any benefit to routine screening of these women for BRCA1 or 2 mutations, or routine referral for genetic counseling, would be small or zero. The USPSTF found fair evidence regarding important adverse ethical, legal, and social consequences that could result from routine referral and testing of these women. Interventions such as prophylactic surgery, chemoprevention, or intensive screening have known harms. The USPSTF estimated that the magnitude of these potential harms is small or greater. The USPSTF concluded that the potential harms of routine referral for genetic counseling or BRCA testing in these women outweigh the benefits.

The USPSTF found fair evidence that women with certain specific family history patterns (“increased risk family history”) have an increased risk for developing breast or ovarian cancer associated with BRCA1 or 2 mutations. The USPSTF determined that these women would benefit from genetic counseling that allows informed decision-making about testing and further prophylactic treatment. This counseling should be done by suitably trained health care providers. There is insufficient evidence to determine the benefits of chemoprevention or intensive screening in improving health outcomes in these women if they test positive for deleterious BRCA1 or 2 mutations. However, there is fair evidence that prophylactic surgery for these women significantly decreases breast and ovarian cancer incidence. Thus, the potential benefits of referral and discussion of testing and prophylactic treatment for these women may be substantial.

The USPSTF concluded that the benefits of referring women with an increased risk family history to suitably trained healthcare providers outweigh the harms.

This recommendation applies to women who have not been diagnosed with either breast or ovarian cancer. It does not apply to women with a family history of breast or ovarian cancer that includes a relative with a known deleterious mutation in BRCA1 or BRCA2 genes; these women should be referred for genetic counseling. This recommendation does not apply to men.
While there currently are no standardized referral criteria, women with an increased risk family history (see below) should be considered for genetic counseling to further evaluate their potential risks.
Certain specific family history patterns are associated with an increased risk for deleterious mutations in BRCA1 or 2 genes. Both maternal and paternal family histories are important. For non-Ashkenazi Jewish women, these patterns include:
Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger
A combination of 3 or more first- or second-degree relatives with breast cancer, regardless of age of diagnosis
A combination of both breast and ovarian cancer among first- and second- degree relatives
A first-degree relative with bilateral breast cancer
A combination of 2 or more first- or second-degree relatives with ovarian cancer, regardless of age of diagnosis
A first- or second-degree relative with both breast and ovarian cancer, at any age
A history of breast cancer in a male relative
For women of Ashkenazi Jewish heritage, an increased risk family history includes any first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.
About 2% of adult women in the general population have an increased risk family history as defined above. Women without one of these family history patterns have a low probability of having a deleterious mutation in BRCA1 or BRCA2 genes.
Computational tools are available to predict the risk for clinically important BRCA mutations (i.e., BRCA mutations associated with the presence of breast and/or ovarian cancer), but these tools have not been verified in the general population. There is no empirical evidence concerning what level of risk for a BRCA mutation merits referral for genetic counseling.
Not all women with a potentially deleterious BRCA mutation will develop breast or ovarian cancer. The probability of developing breast or ovarian cancer by the age of 70 in a woman who has a clinically important BRCA mutation is estimated to be 35% to 84% for breast cancer and 10% to 50% for ovarian cancer.
Appropriate genetic counseling helps women make informed decisions and can improve their knowledge and perception of absolute risk for breast and ovarian cancer and often reduce anxiety. Genetic counseling includes elements of counseling, risk assessment, pedigree analysis, and, in some cases, recommendations for testing for BRCA mutations in affected family members and/or the presenting patient. It is best delivered by a suitably trained healthcare provider.
Ordering a BRCA test typically is done by a physician. When done in concert with genetic counseling, the test assures the linkage of testing with appropriate management decisions. Genetic testing may lead to potential adverse ethical, legal, and social consequences, such as insurance and employment discrimination; these issues should be discussed in the context of genetic counseling and evaluation for testing.
Among women with BRCA1 or 2 mutations, prophylactic mastectomy or oophorectomy decreases the incidence of breast and ovarian cancer; there is inadequate evidence for mortality benefits. Chemoprevention with selective estrogen receptor modulators (SERMs) may decrease breast cancer incidence of estrogen receptor-positive cancers; however, it is also associated with adverse effects such pulmonary embolism, deep vein thrombosis, and endometrial cancer. Most breast cancers associated with BRCA1 mutations are estrogen-receptor negative and thus not prevented by tamoxifen. Intensive screening with mammography has poor sensitivity, and there is no evidence of benefit of intensive screening for women with BRCA1 or BRCA2 gene mutations; magnetic resonance imaging (MRI) may detect more cancers, but the effect on mortality is not clear.
Women with an increased risk family history are at risk not only for deleterious BRCA1 or BRCA2 mutations, but potentially for other unknown mutations as well. Women with an increased risk family history who test negative for BRCA1 and BRCA2 mutations may also benefit from surgical prophylaxis.

NCCN also advises BRCA testing for women below age 60 with a personal history of triple negative breast cancer.

The American Society of Clinical Oncology (ASCO) has recently established a policy statement on guidelines for genetic testing for cancer predisposition genes (ASCO, J Clin Oncol, 2003 Jun 15;21(12):2397-2406). ASCO recommends genetic testing be offered when:

1. an individual or the family history shows features of a cancer predisposition syndrome such as a cancer of early onset or the presence of specific and rare tumors
2. the test is known to be technically sound
3. the test results will help to clarify a diagnosis or provide management guidelines for the patient or family member.

In addition, there are guidelines by NICE, ACHG, PDQ, NCCN and other authoritative bodies.They generally require risk > 20% of brest cancer in general as measured by standard instruments to indicate BRCA testing. Using instruments, such as BRCPro, measures the overall risk of breast cancer, and if it is greater than 20%, BRCA testing is recommended. BRCAPRO is a specifically BRCA risk analysis. Gail scoring is specifically not recommended by NCCN.

In general courts have rules that the state of being a BRCA carrier is considered an illness. The Nebraska Supreme Court, for example, found that illness includes an abnormal state resulting from a genetic deviation from the norm, and so contract language dealing with illness applied to patients with a family history of cancer.
Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med 2005 Sep 6;143(5):355-61

Amanda Ewart Toland, Clinical testing of BRCA1 and BRCA2: a worldwide snapshot of technological practices. npj Genomic Medicinevolume 3, Article number: 7 (2018

PDQ® Cancer Information Summary. National Cancer Institute; Bethesda, MD. Genetics of Breast and Ovarian Cancer (PDQ®) – Health Professional. Date last modified 04/24/2009. Available at: http://www.cancer.gov/cancertopics/pdq/genetics/breast-and-ovarian/healthprofessional. Accessed 05/15/2009.

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Recurrence of breast cancer is usually symptomatic and is often first noticed by the patient rather than at routine follow-up visits to hospital clinics. Women will frequently report the symptoms first to their GP. A study that compared breast cancer follow-up in primary care with specialist care shows that patients were more satisfied with follow-up in general practice and that there was no increase in time to diagnosis of recurrence in primary care compared with specialist care.

‘Guidelines for limited (two or three years) follow-up should be agreed by each network. The aims of follow-up should be to detect and treat local recurrence and adverse effects of therapy, particularly lymphoedema. Intensive follow-up, designed to detect metastatic disease before symptoms develop, is not beneficial and should not be provided.’( NICE: Improving Outcomes in Breast Cancer: Manual Update 2002)

Eva Grunfeld, Sukhbinder Dhesy-Thind, Mark Levine, CLinical Care Guidelines: follow-up after treatment for breast cancer (summary of the 2005 update) CMAJ • May 10, 2005; 172 (10)
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Randomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care
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Yasuhiro Kodera, MD, Seiji Ito, MD, Yoshitaka Yamamura, MD, Yoshinari Mochizuki, MD, Michitaka Fujiwara, MD, Kenji Hibi, MD, Katsuki Ito, MD, Seiji Akiyama, MD and Akimasa Nakao, Follow-Up Surveillance for Recurrence After Curative Gastric Cancer Surgery Lacks Survival Benefit Annals of Surgical Oncology 10:898-902 (2003)

Kodera Y, Ito S, Yamamura Y, et al. A follow-up surveillance for recurrence after curative gastric cancer surgery lacks survival benefit. Ann Surg Oncol 2003; 10:898–902.[