Seguimento pós-tratamento de pacientes com câncer da mama
quando e como orientar?
Palavras-chave:
neoplasias mamarias, seguimentosResumo
A necessidade e a forma de seguimento de pacientes com câncer da mama é assunto controverso. Há enorme variação, entre profissionais, sobre quais exames solicitar e periodicidade das consultas. Alguns procedimentos, hoje feitos de rotina, não têm o suporte da evidência científica. Do ponto de vista de controle loco-regional, orientar a paciente para autoexame das mamas e consultas a cada 4 a 6 meses com mamografia anual, formam um conjunto de orientações bastante consensual e eficiente. O aspecto menos definido refere-se à pesquisa, de rotina, de metástases hematogênicas em pacientes assintomáticas e tratadas com intenção curativa. Este assunto tem sido recentemente discutido com opiniões bem antagónicas. Aparentemente a solicitação de vários exames de laboratório e radiológicos, de rotina, possibilita fazer diagnóstico de falha a distância um pouco mais precocemente, mas não há evidências que isso mude a sobrevida global. Pelo enorme número de pacientes, a solicitação de exames de rotina tem um alto custo. Além disso, em geral, estes exames deixam as pessoas ansiosas. Pelo menos dois estudos prospectivos e randomizados europeus, comparando a sobrevida de pacientes assintomáticas seguidas com exames usuais de rotina, versus seguimento mais orientado por queixas, mostram igualdade de sobrevida. O mesmo cabe para os atuais marcadores inespecíficos. Para pacientes que não participam de estudos prospectivos, o que significa a maioria dos casos, seguimento com exame clínico e solicitação de exames basicamente quando os sintomas exigirem, é uma boa alternativa quando se considera custo/benefício.
Downloads
Referências
ABERIZK, W.J. et ai. The use of radiotherapy for treatment of isolated locoregional recurrence of breast carcinoma after mastectomy. Câncer, New York, v.58,p.1212-1218, 1986.
ABNER, A.L. et al. Prognosis following salvage mastectomy for recurrence in the breast after conservative surgery and radiation therapy for early-stage breast cancer. J Clin Oncol, Baltimore, v. 11, n. 1, p.44-48, 1993.
ABRAMS, J.s., PHILLIPS, P.H., FRIEDMAN, M.A. Meeting highlights: a reappraisal of research results for the local treatment of early-stage breast cancer. J Nat Cancer Inst, Bethesda, v.87, n.24,p.1837-1845, 1995.
ASCO Special Article. Recommended breast cancer surveillance guidelines.J Clin Oncol, Baltimore, v.15, p.2149-2156, 1997.
BAKEMEIER, R.F. Principles of medical oncology and cancer chemotherapy. ln: RUBIN, P. Clinical oncology for medical students and physicians. RochesterNY : ACS, 1978. p.43.
BRASIL. Ministério da Saúde. O problema do câncer no Brasil. 4.ed. Rio de Janeiro: INCa, 1997.
CIATTO, S. Aula sobre seguimento das pacientes com câncer da mama (European School of Oncology). Curso de atualização. Florianopolis, junho, 1996.
CIATTO, S.et al. Chest X ray survey in the follow up of breast cancer patients. Br J Cancer, London, v.60, p.102-5, 1989.
COLOMER, R. et al. Circulating CA 15-3 serum levels in the post-surgical follow up of breast cancer patients and in non-malignant diseases. Breast CancerRes Treat, Hague, v. 13, n.2, p. 123-133, 1989.
DUARTE, D.L. Rastreamento de câncer no Brasil. Radiol Bras, São Paulo, v.29, p.5-6, 1996. (Editorial).
ESKELINEN, M. et al. Serum tumor markers CEA, AFP, CA 15-3, TPS in diagnosis of breast cancer. Anticancer Res, New York, v. 17-2B, p. 1231-1234, 1997.
ESTEBAN, J.M. al. Prognostic relevance of CEA and estrogen receptor status in breast cancer patients. Cancer, New York, v.74, p. 1575-1583, 1994.
GADELHA,M.I.P. Validade dos marcadores tumorais. Rev Bras Cancerol, Rio de Janeiro, v.44, n.3, p.211-224, 1998.
GALINDO, E.G., BUZDAR, A.U. Avaliação de pacientes em seguimento ap6s tratamento. ln: FARIA, s.L., LEME, L.H.S., OLIVEIRA FILHO, J.A. Câncer da mama, diagnóstico de tratamento. Rio de Janeiro: Medsi, 1994. pl 97.
GIAI, M. et al. TPS and CA 15-3 serum values as a guide for treating and monitoring breast cancer patients. Anticancer Res, New York, v. 1 6, n.2, p.875-881, 1996.
GIVIO Investigators: impact of follow-up testing on survival and health-related quality of life in breast cancer patients: a multicenter randomized controlled trial. JAMA, Chicago, v.271, p.1587-1592, 1994.
GRUNFELD, E., MANT, D. etal. Routine follow up of breast cancer in primary care: a randomised trial. Br Med J, London, v.313, p. 665-669, 1996.
GULLIFORD, J. et al. Popularity of less frequent follow up for breast cancer in randomised study. BrMedJ, London, v.314, p. 174-177, 1997.
HAFFTY, B.G. et al. Prognosis following local recurrence in the conservatively treated breast cancer patient. Int J Rad Oncol Biol Phys, New York, v.21, n.2, p.293-298, 1991.
HALVERSON, K.J. et al. Isolated local-regional recurrence of breast cancer following mastectomy: radiotherapeutic management. Int J Rad Oncol Biol Phys, New York, v. 19, n.4, p.851-858, 1990.
HANNISDAL, E., GUNDERSEN, S., KVALOY, S. et al. Follow up of breast cancer patients’ stage I - Il: a baseline strategy. EurJ Cancer, London, v.29A,p.992-997, 1993.
HARRIS, J.R., MORROW, M., NORTON, L. Malignant tumors of the breast. In: DEVITTA, v.T., HELLMANN, S., ROSEMBERG, S.A. Cancer, principles and practice of oncology. 5.ed. Philadelphia: Lippincott-Raven, 1997. p.1557.
HOLLI, K., HAKAMA, M. Effectiveness of routine and spontaneous follow up visits for breast cancer. EurJ Cancer Clin Oncol, London, v.25, p.251-254, 1989.
KENNEDY,M.,ABELOFF,M., Managementof locally recurrent breast cancer. Cancer, New York, v. 71, p.2395-2401, 1993.
LEE, Y.T.N. Biochemical and hematological tests in patients with breast carcinoma. Correlations with extent of disease, sites of release prognosis. J surg Oncol, New York, v.29, p.242-248, 1985.
LICHTER, A.S. et al. Mastectomy versus breast-conserving therapy in the treatment of stage I and Il carcinoma of the breast: a randomized trial at the National Cancer Institute. J Clini Oncol, Baltimore, v. 10, p.976-983, 1992.
LOPRINZI C. It is now the age to define the appropriate follow up of primary breast cancer patients. J Clin Oncol, Baltimore, v. 12, p.881-887, 1994.
NATIONAL COMPREHENSIVE CANCER NETWORK Guidelines for Treatment of Breast Cancer. NCCN Oncology Practice. Oncol, New York, v.11, p. 199-222, 1997.
O'HANLON, D.M. et al. A prospective evaluation of CA 15-3 in stage I carcinoma of the breast. J Am Coil Surgicol, New York, p.210-212, 1995.
OJEDA, M.B. et al. Follow up of breast cancer stages I and Il. An analysis of some common methods. Eur J Cancer Clin Oncol, London, v.23,p.419-423, 1987.
PANDYA, K.J. et al. A retrospective study of earliest indicators of recurrence in patients on Eastern Cooperative Oncology Group Advuant Chemotherapy Trials for Breast Cancer. Cancer, New York, v55, p.202-205, 1985.
PEDRAZZINI, A. et al. First repeated bone scan in the observation of patients with operable brest cancer.JClin Oncol, New York, v.4, p.389-394, 1986.
ROSSELLI DEL TURCO, M. et al. Intensive diagnostic follow up after treatment of primary breast cancer. A randomized trial. JAMA, Chicago, v.276, p. 1593-1600, 1994.
SCHAPIRA,D.V., URBAN,N.Aminimalistp01icy for breast cancer surveyllance. JAMA, Chicago, v.265, p.380-382, 1991.
SCHWAIBOLD, F. et al. The results of radiation therapy for isolated local regional recurrence after mastectomy. Int J Rad Oncol Biol Phys, New York, v.21, p.299-310, 1991.
TAMPELLINI, M. al. Relationship between CA 15-3 levels and disease extent in predicting overall survival of breast cancer patients with newly diagnosed metastatic disease. Br J Cancer, London, v. 75, n.5, p.698-702, 1997.
VERONESI, U. et al. Breast conservation is a safe method in patients with small cancer of the breast: long-term results of three randomised trials on 1,973 patients. Eur J Cancer, London, v.3 IA, n.10,p.1574-1579, 1995.
WERTHEIMER, M.D. Against minimalism in breast cancer follow-up. JAMA, Chicago, v.265, p.396-397, 1991.
