Annals of Surgical Oncology

, Volume 26, Issue 10, pp 3289–3294 | Cite as

Overuse of Preoperative Staging of Patients Undergoing Neoadjuvant Chemotherapy for Breast Cancer

  • Marissa K. Srour
  • Minna Lee
  • Sarah Walcott-Sapp
  • Michael Luu
  • Alice Chung
  • Armando E. Giuliano
  • Farin AmersiEmail author
Breast Oncology



Guidelines of the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the European Society for Medical Oncology (ESMO) discourage the use of imaging to stage newly diagnosed early breast cancer (stages 1 and 2). This study aimed to evaluate preoperative staging imaging rates among patients with stage 1 or 2 breast cancer treated with neoadjuvant chemotherapy (NAC).


From a prospectively maintained database, 303 patients with stage 1 or 2 breast cancer who had NAC from 2008 to 2016 were identified. The main outcome measures were the rate and outcomes of staging imaging performed.


The mean age of the 303 patients with stage 1 or 2 breast cancer was 51 years (range, 26–87 years). Of these 303 patients, 278 (92.4%) had invasive ductal cancer. 90 (30.2%) had estrogen receptor (ER)-positive disease, 79 (26.5%) had triple-negative disease, and 127 (42.6%) had human epidermal growth factor receptor 2 (HER2)-positive disease. Staging positron emission tomography (PET) or computed tomography (CT) scan was performed for 258 patients (85.2%), brain imaging for 94 patients (31%), bone scans for 117 patients (38.6%), and all three for 48 patients (15.8%). As a result, 15 patients (4.9%) with a positive PET/CT scan were upstaged to stage 4 breast cancer. No difference was observed among the ER-positive (p = 1.000), HER2-positive (p = 0.259), or triple-negative (p = 0.369) receptor profiles of the patients upstaged to stage 4 disease. One patient (1.1%) had positive brain imaging. Five patients (4.3%) had a positive bone scan, and three of these patients (60%) had bone metastasis also shown on the PET/CT scan.


Despite guideline recommendations, a high rate of preoperative staging imaging is completed for patients with clinical stage 1 or 2 breast cancer who receive NAC, with few positive results.



The authors thank The Fashion Footwear Charitable Foundation of New York, Inc.; The Margie and Robert E. Petersen Foundation; Associates for Breast and Prostate Cancer Studies; and Linda and Jim Lippman for their contributions to this study.


There are no conflicts of interest.


  1. 1.
    ASCO/ABIM choosing wisely. Cancer tests and treatments. 2012. Retrieved 1 March 2019 at
  2. 2.
    NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 3. 2015. Retrieved 1 March 2019 at
  3. 3.
    Senkus E, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, Rutgers E, et al. Primary breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015;26:8–30.CrossRefGoogle Scholar
  4. 4.
    Lin NU, Thomssen C, Cardoso F, Cameron D, Cufer T, Fallowfield L, et al. International guidelines for management of metastatic breast cancer (MBC) from the European School of Oncology (ESO)–MBC task force: surveillance, staging, and evaluation of patients with early-stage and metastatic breast cancer. Breast. 2013;22(3):203–10.CrossRefGoogle Scholar
  5. 5.
    Simos D, Hutton B, Clemons M. Are physicians choosing wisely when imaging for distant metastases in women with operable breast cancer? J Oncol Pract. 2014;11:62–71.CrossRefGoogle Scholar
  6. 6.
    Crivello ML, Ruth K, Sigurdson ER, Egleston BL, Evers K, Wong Y, et al. Advanced imaging modalities in early-stage breast cancer: preoperative use in the United States medicare population. Ann Surg Oncol. 2013;20:102–10.CrossRefGoogle Scholar
  7. 7.
    Simos D, Catley C, van Walraven C, Arnaout A, Booth C, McInnes M, et al. Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study. Can Med Assoc J. 2015;187:387–97.CrossRefGoogle Scholar
  8. 8.
    Linkugel A, Margenthaler J, Dull B, Cyr A. Staging studies have limited utility for newly diagnosed stage I–II breast cancer. J Surg Res. 2015;196:33–8.CrossRefGoogle Scholar
  9. 9.
    Bychkovsky BL, Lin NU. Imaging in the evaluation and follow-up of early and advanced breast cancer: when, why, and how often? Breast. 2017;31:318–24.CrossRefGoogle Scholar
  10. 10.
    Barrett T, Bowden DJ, Greenberg DC, Brown CH, Wishart GC, Britton PD. Radiological staging in breast cancer: which asymptomatic patients to image and how. Br J Cancer. 2009;101:1522–8.CrossRefGoogle Scholar
  11. 11.
    Brennan ME, Houssami N. Evaluation of the evidence on staging imaging for detection of asymptomatic distant metastases in newly diagnosed breast cancer. Breast. 2012;21(2):112–23.CrossRefGoogle Scholar
  12. 12.
    Kim H, Han W, Moon HG, Min J, Ahn SK, Kim TY, et al. The value of preoperative staging chest computed tomography to detect asymptomatic lung and liver metastasis in patients with primary breast carcinoma. Breast Cancer Res Treat. 2011;126:637–41.CrossRefGoogle Scholar
  13. 13.
    Segaert I, Mottaghy F, Ceyssens S, De Wever W, Stroobants S, Van Ongeval C, et al. Additional value of PET-CT in staging of clinical stage IIB and III breast cancer. Breast J. 2010;16:617–24.CrossRefGoogle Scholar
  14. 14.
    Puglisi F, Fallador A, Minisini AM, Cardellino GG, Russo S, Andreetta C, et al. Baseline staging tests after a new diagnosis of breast cancer: further evidence of their limited indications. Ann Oncol. 2005;16:263–6.CrossRefGoogle Scholar
  15. 15.
    Chen X, Sun L, Cong Y, Zhang T, Lin Q, Meng Q, et al. Baseline staging tests based on molecular subtype is necessary for newly diagnosed breast cancer. J Exper Clin Cancer Res. 2014;33:1–6.CrossRefGoogle Scholar
  16. 16.
    Rosen EL, Eubank WB, Mankoff DA. FDG PET, PET/CT, and breast cancer imaging. RadioGraphics. 2007;27:215–29.CrossRefGoogle Scholar
  17. 17.
    Wahl RL, Siegel BA, Coleman E, Gatsonis CG. 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. 2004;22:277–85.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Marissa K. Srour
    • 1
  • Minna Lee
    • 1
  • Sarah Walcott-Sapp
    • 1
  • Michael Luu
    • 2
  • Alice Chung
    • 1
  • Armando E. Giuliano
    • 1
  • Farin Amersi
    • 1
    Email author
  1. 1.Division of Surgical Oncology, Department of SurgeryCedars-Sinai Medical CenterLos AngelesUSA
  2. 2.Department of Biostatistics and BioinformaticsCedars-Sinai Medical CenterLos AngelesUSA

Personalised recommendations