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CC BY-NC-ND 4.0 · Indian J Med Paediatr Oncol 2012; 33(02): 112-122
DOI: 10.4103/0971-5851.99748
ORIGINAL ARTICLE

Guidelines for locoregional therapy in primary breast cancer in developing countries: The results of an expert panel at the 8 th Annual Women′s Cancer Initiative - Tata Memorial Hospital (WCI-TMH) Conference

Anusheel Munshi
Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
Sudeep Gupta
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
Benjamin Anderson
Director, Breast Health Clinic University of Washington/Seattle Cancer Care Alliance, Chair and Director, Breast Health Global Initiative, Surrey, UK
,
John Yarnold
Department of Clinical Oncology, Institute of Cancer Research and The Royal Marsden Hospital, Surrey, UK
,
Vani Parmar
Department of Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
Rakesh Jalali
Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
Suresh Sharma
Department of Radiation Oncology, PGI, Chandigarh, Punjab, India
,
Sangeeta Desai
Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, India
,
Meenakshi Thakur
Department of Radiology, Tata Memorial Hospital, Parel, Mumbai, India
,
Gunjan Baijal
Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
Rajiv Sarin
Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
Indraneel Mittra
Department of Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
Jaya Ghosh
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
Rajendra Badwe
Department of Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai, India
,
other Locoregional Panel Members › Author Affiliations
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Abstract

Background: Limited guidelines exist for breast cancer management in developing countries. In this context, the Women′s Cancer Initiative - Tata Memorial Hospital (WCI-TMH) organised its 8 th Annual Conference to update guidelines in breast cancer. Materials and Methods: Appropriately formulated guideline questions on each topic and subtopic in the surgical, radiation and systemic management of primary breast cancer were developed by the scientific committee and shared with the guest faculty of the Conference. Majority of the questions had multiple choice answers. The opinion of the audience, comprising academic and community oncologists, was electronically cumulated, followed by focussed presentations by eminent national and international experts on each topic. The guidelines were finally developed through an expert panel that voted on each guideline question after all talks had been delivered and audience opinion elicited. Separate panels were constituted for locoregional and systemic therapy in primary breast cancer. Results: Based on the voting results of the expert panel, guidelines for locoregional therapy of breast cancer have been formulated. Voting patterns for each question are reported. Conclusions: The updated guidelines on locoregional management of primary breast cancer in the context of developing countries are presented in this article. These recommendations have been designed to allow centers in the developing world to improve the quality of care for breast cancer patients.

Keywords

Breast cancer - developing countries - guidelines - locoregional therapy


Publication History

Article published online:
13 April 2022

© 2012. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/.)

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  • References

  • 1 Carlson RW, Allred DC, Anderson BO, Burstein HJ, Carter WB, Edge SB, et al. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2009;7:122-92.
  • 2 Aebi S, Davidson T, Gruber G, Castiglione M. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21(Supplement 5): V9-14.
  • 3 Goldhirsch A, Ingle JN, Gelber RD, Coates AS, Thürlimann B, Senn HJ. Thresholds for therapies: Highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2009. Ann Oncol 2009;20:1319-29.
  • 4 Harnett A, Smallwood J, Titshall V, Champion A. Diagnosis and treatment of early breast cancer, including locally advanced disease--summary of NICE guidance. BMJ 2009;338:b438.
  • 5 Slamon DJ, Clark GM, Wong SG, Levin WJ, Ullrich A, McGuire WL. Human breast cancer: Correlation of relapse and survival with amplification of the HER2/neu oncogene. Science 1987;235:177-82.
  • 6 Paik S, Bryant J, Tan-Chiu E, Yothers G, Park C, Wickerham DL, et al. HER2 and choice of adjuvant chemotherapy for invasive breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-15. J Natl Cancer Inst 2000;92:1991-8.
  • 7 Pritchard KI, Shepherd LE, O′Malley FP, Andrulis IL, Tu D, Bramwell VH, et al. HER2 and responsiveness of breast cancer to adjuvant chemotherapy. N Engl J Med 2006;354:2103-11.
  • 8 Wolff AC, Hammond ME, Schwartz JN, Hagerty KL, Allred DC, Cote RJ, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol 2007;25:118-45.
  • 9 Paik S, Shak S, Tang G, Kim C, Baker J, Cronin M, et al. A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med 2004;351:2817-26.
  • 10 Paik S, Tang G, Shak S, Kim C, Baker J, Kim W, et al. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol 2006;24:3726-34.
  • 11 Albain KS, Barlow WE, Shak S, Hortobagyi GN, Livingston RB, Yeh IT, et al. Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal women with node-positive, oestrogen-receptor-positive breast cancer on chemotherapy: A retrospective analysis of a randomised trial. Lancet Oncol 2010;11:55-65.
  • 12 Harris JR, Lippman ME, Morrow M, Osborne CK. Diseases of the breast. Philadelphia: Lippincott Williams and Wilkins; 2004.
  • 13 Turnbull L, Brown S, Harvey I, Olivier C, Drew P, Napp V, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: A randomised controlled trial. Lancet 2010;13;375:563-71.
  • 14 Gundry KR. The application of breast MRI in staging and screening of breast cancer. Oncology 2005;19;159-69.
  • 15 Esserman L. Integration of imaging in breast cancer. J Clin Oncol 2005;23;1601-2.
  • 16 Houssami N, Ciatto S, Macaskill P, Lord SJ, Warren RM, Dixon JM, et al. Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: Systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol 2008;26;3248-58.
  • 17 Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus radiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233-41.
  • 18 Veronesi U, Zucali R, Luini A. Local control and survival in early breast cancer: The Milan trial. Int J Radiat Oncol Biol Phys 1986;12:717-20.
  • 19 Leong SP, Shen ZZ, Liu TJ, Agarwal G, Tajima T, Paik NS,et al. Is breast cancer the same disease in Asian and Western Countries? World J Surg 2010;34:2308-24.
  • 20 Sarin R, Dinshaw KA, Shrivastava SK, Sharma V, Deore SM. Therapeutic factors influencing the cosmetic outcome and late complications in the conservative management of early breast cancer. Int J Radiat Oncol Biol Phys 1993;27:285-92.
  • 21 Munshi A, Kakkar S, Bhutani R, Jalali R, Budrukkar A, Dinshaw KA. Factors influencing cosmetic outcome in breast conservation. Clin Oncol 2009;21:285-93.
  • 22 Taylor ME, Perez CA, Halverson KJ, Kuske RR, Philpott GW, Garcia DM, et al. Factors influencing cosmetic results after conservation therapy for breast cancer. Int J Radiat Oncol Biol Phys 1995;31:753-64.
  • 23 Nicholson RM, Leinster S, Sassoon EM. A comparison of the cosmetic andpsychological outcome of breast reconstruction, breast conserving surgery and mastectomy without reconstruction. Breast 2007;16:396-410.
  • 24 Fischbacher C. Immediate versus delayed breast reconstruction. STEER.2002;2:4-18.
  • 25 Drucker-Zertuche M, Robles-Vidal C. A 7 year experience with immediate breast reconstruction after skin sparing mastectomy for cancer. Eur J Surg Oncol 2007;33:140-6.
  • 26 Heimann R, Powers C, Halpem HJ, Michel AG, Ewing CA, Wyman B, et al. Breast preservation in stage I and II carcinoma of the breast. The University of Chicago experience. Cancer 1996;78:1722-30.
  • 27 Peterson ME, Schultz DJ, Reynolds C, Solin LJ. Outcomes in breast cancer patients relative to margin status after treatment with breast-conserving surgery and radiation therapy: The University of Pennsylvania experience. Int J Radiat Oncol Biol Phys 1999;43:1029-35.
  • 28 Obedian E, Haffty BG. Negative margin status improves local control in conservatively managed breast cancer patients. Cancer J Sci Am 2000;6:28-33
  • 29 Vicini FA, Goldstein NS, Pass H, Kestin LL. Use of pathologic factors to assist in establishing adequacy of excision before radiotherapy in patients treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 2004;60:86-94.
  • 30 Arriagada R, Lê MG, Rochard F, Contesso G. Conservative treatment versus mastectomy in early breast cancer: Patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Group. J Clin Oncol. 1996;14:1558-64.
  • 31 Fisher ER, Anderson S, Redmond C, Fisher B. Pathologic findings from the National Surgical Adjuvant Breast Project protocol B-06. 10-year pathologic and clinical prognostic discriminants. Cancer. 1993;71:2507-14.
  • 32 Skripenova S, Layfield LJ. Initial margin status for invasive ductal carcinoma of the breast and subsequent identification of carcinoma in reexcision specimens. Arch Pathol Lab Med 2010;134:109-14
  • 33 Freedman GM, Fowble BL, Hanlon AL, Myint MA, Hoffman JP, Sigurdson ER, et al. A close or positive margin after mastectomy is not an indication for chest wall radiation except in women aged fifty or younger. Int J Radiat Oncol Biol Phys 1998;41:599-605.
  • 34 Katz A, Strom EA, Buchholz TA, Thames HD, Smith CD, Jhingran A, et al. Loco-regional recurrence patterns following mastectomy and doxorubicin-based chemotherapy: Implications for postoperative radiation. J Clin Oncol 2000;18:2817-27.
  • 35 Oh JL, Nguyen G, Whitman GJ, Hunt KK, Yu TK, Woodward WA, et al. Placement of radiopaque clips for tumor localization in patients undergoing neoadjuvant chemotherapy and breast conservation therapy. Cancer 2007;110:2420-7.
  • 36 Lannin DR, Grube B, Black DS, Ponn T. Breast tattoos for planning surgery following neoadjuvant chemotherapy. Am J Surg 2007;194:518-20.
  • 37 Parmar V, Krishnamurthy A, Hawaldar R, Nadkarni MS, Sarin R, Chinoy R, et al. Breast conservation treatment in women with locally advanced breast cancer - Experience from a single centre. Int J Surg 2006;4:106-14.
  • 38 Fisher ER, Wang J, Bryant J, Fisher B, Mamounas E, Wolmark N. Pathobiology of preoperative chemotherapy: Findings from the National Surgical Adjuvant Breast and Bowel (NSABP) protocol B-18. Cancer 2002;95:681-95.
  • 39 Buchholz TA, Hunt KK, Whitman GJ, Sahin AA, Hortobagyi GN. Neoadjuvant chemotherapy for breast carcinoma: Multidisciplinary considerations of benefits and risks. Cancer 2003;98:1150-60.
  • 40 Chen AM, Meric-Bernstam F, Hunt KK, Thames HD, Oswald MJ, Outlaw ED, et al. Breast-conserving therapy after neoadjuvant chemotherapy: The M.D. Anderson Cancer Center experience. J Clin Oncol 2004;22:2303-12.
  • 41 Greco M, Crippa F, Agresti R, Seregni E, Gerali A, Giovanazzi R, et al. Axillary lymph node staging in breast cancer by 2-fluoro-2-deoxy-D-glucose-positron emission tomography: clinical evaluation and alternative management. J Natl Cancer Inst 2001;93:630-5.
  • 42 Orr RK. The impact of prophylactic axillary node dissection on breast cancer survival--A Bayesian meta-analysis. Ann Surg Oncol 1999;6:109-16.
  • 43 Vinh-Hung V, Verschraegen C. Breast-conserving surgery with or without radiotherapy: Pooled-analysis for risks of ipsilateral breast tumor recurrence and mortality. J Natl Cancer Inst 2004;96:115-21.
  • 44 Clarke D, Martinez A, Cox RS, Goffinet DR. Breast edema following staging axillary node dissection in patients with breast carcinoma treated by radical radiotherapy. Cancer 1982;49:2295-9.
  • 45 Krag DN, Anderson SJ, Julian TB, Brown A, Harlow SP, Costantino JP, et al. Primary outcome results of NSABP B-32, a randomized phase III clinical trial to compare sentinel node resection (SNR) to conventional axillary dissection (AD) in clinically node-negative breast cancer patients. J Clin Oncol 2010;28:18s,(suppl; abstr LBA505).
  • 46 Mansel RE, Fallowfield L, Kissin M, Goyal A, Newcombe RG, Dixon JM, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: The ALMANAC Trial. J Natl Cancer Inst 2006;98:599-09.
  • 47 Forrest AP, Everington D, McDonald CC, Steele RJ, Chetty U, Stewart HJ. The Edinburgh randomized trial of axillary sampling or clearance after mastectomy. Br J Surg 1995;82:1504-8.
  • 48 Parmar V, Hawaldar R, Nadkarni MS, Badwe RA. Low axillary sampling in clinically node-negative operable breast cancer. Natl Med J India 2009;22:234-6.
  • 49 Badwe R, Hawaldar R, Parmar V, Nadkarni M, Shet T, Desai S, et al. Single-injection depot progesterone before surgery and survival in women with operable breast cancer: A randomized controlled trial. J Clin Oncol 2011;29:2845-51.
  • 50 Senie RT, Rosen PP, Rhodes P, Lesser ML. Timing of breast cancer excision during the menstrual cycle influences duration of disease-free survival. Ann Intern Med. 1991;115:337-42.
  • 51 Veronesi U, Luini A, Mariani L, Del Vecchio M, Alvez D, Andreoli C,. Effect of menstrual phase on surgical treatment of breast cancer. Lancet 1994;343:1545-7.
  • 52 Grant CS, Ingle JN, Suman VJ, Dumesic DA, Wickerham DL, Gelber RD, et al. Menstrual cycle and surgical treatment of breast cancer: Findings from the NCCTG N9431 study. J Clin Oncol. 2009;27:3620-66.
  • 53 Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy: Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 1997;337:949-55.
  • 54 Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Jackson SM, Wilson KS, et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst 2005;97:116-26.
  • 55 Truong PT, Olivotto IA, Kader HA, Panades M, Speers CH, Berthelet E, Selecting breast cancer patients with T1-T2 tumors and one to three positive axillary nodes at high post mastectomy locoregional recurrence risk for adjuvant radiotherapy. Int. J Radiat Oncol Biol Phys 2005;61:1337-47.
  • 56 Overgaard M, Nielsen HM, Overgaard J. Is the benefit of postmastectomy radiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 bandc randomized trials. Radiother Oncol 2007;82:247-53.
  • 57 Pignol JP, Olivotto I, Rakovitch E, Gardner S, Sixel K, Beckham W, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008;26:2085-92.
  • 58 Donovan E, Bleakley N, Denholm E, Evans P, Gothard L, Hanson J, et al. Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy.Breast Technology Group. Radiother Oncol 2007;82:254-64.
  • 59 Harsolia A, Kestin L, Grills I, Wallace M, Jolly S, Jones C, et al. Intensity-modulated radiotherapy results in significant decrease in clinical toxicities compared with conventional wedge-based breast radiotherapy. Int J Radiat Oncol Biol Phys 2007;68:1375-80.
  • 60 Clarke M, Collins R, Darby S, Davies C, Elphinstone P, Evans E, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: An overview of the randomised trials. Lancet 2005;366:2087-106.
  • 61 Munshi A, Pai RH, Phurailatpam R, Budrukkar A, Jalali R, Sarin R, et al. Do all patients of breast carcinoma need 3-dimensional CT-based planning? A dosimetric study comparing different breast sizes. Med Dosim. 2009;34:140-4.
  • 62 START Trialists′ Group, Bentzen SM, Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ, et al. The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: A randomised trial. Lancet Oncol 2008;9:331-41.
  • 63 START Trialists′ Group, Bentzen SM, Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ, et al. The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: A randomised trial. Lancet 2008;371:1098-107.
  • 64 Bartelink H, Horiot JC, Poortmans P, Struikmans H, Van den Bogaert W, Barillot I, et al. Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation. N Engl J Med 2001;345:1378-87.
  • 65 Poortmans P, Bartelink H, Horiot JC, Struikmans H, Van den Bogaert W, Fourquet A, et al. The influence of the boost technique on local control in breast conserving treatment in the EORTC ′boost versus no boost′ randomised trial. Radiother Oncol 2004;72:25-33.
  • 66 Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy: Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 1997;337:949-55.
  • 67 Ragaz J, Jackson SM, Le N, Plenderleith IH, Spinelli JJ, Basco VE, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997;337:956-62.
  • 68 Mehta K, Haffty BG. Long-term outcome in patients with four or more positive lymph nodes treated with conservative surgery and radiation therapy. Int J Radiat Oncol Biol Phys 1996;35:679-85.
  • 69 Taghian A, Jeong JH, Manounas E, Anderson S, Bryant J, Deutsch M, et al. Patterns of locoregional failure in patients with operable breast cancer treated by mastectomy and adjuvant chemotherapy with or without tamoxifen and without radiotherapy: Results from 5 National Surgical Adjuvant Breast and Bowel Project randomized clinical trials. J Clin Oncol 2004;22:4247-54.
  • 70 Chang DT, Feigenberg SJ, Indelicato DJ, Morris CG, Lightsey J, Grobmyer SR, et al. Long-term outcomes in breast cancer patients with ten or more positive axillary nodes treated with combined-modality therapy: The importance of radiation field selection. Int J Radiat Oncol Biol Phys 2007;67:1043-51.
  • 71 Beese SN, Munshi A, Buddrukar A, Elzawawy A, Perez CA. Breast radiation therapy guideline implementation in low and middle income countries. Cancer(suppl) 2008;113;2305-14.
  • 72 Matzinger O, Heimsoth I, Poortmans P, Collette L, Struikmans H, Van Den Bogaert W, et al. Toxicity at three years with and without radiation of the internal mammary and medial supraclavicular lymph node chain in stage I to III breast cancer (EORTC trial 22922/10925). Acta Oncol 2010;49:24-34.
  • 73 Orecchia R, Ciocca M, Lazzari R, Garibaldi C, Leonardi MC, Luini A, et al. Intraoperative radiation therapy with electrons (ELIOT) in early-stage breast cancer. Breast 2003;12:483-90
  • 74 Vaidya JS, Baum M, Tobias JS, Houghton J. Lancet. Targeted intraoperative radiotherapy;1999. Available from:http://www.thelancet.com/journals/lancet/misc/protocol/99PRT-47.[Last accessed on 2011 Apr 10].
  • 75 Wolmark N, Curran WJ. On behalf of NSABP and RTOG of the American College of Radiology (ACR). NSABP Protocol B-39. RTOG Protocol 0413. A randomized phase III study of conventional whole breast radiation versus partial breast radiation for women with stage 0, I, or II breast cancer. National surgical adjuvant breast and bowel project (NSABP). Trial protocol 2007. p. 1-132.
  • 76 OCOG. Ontario Clinical Oncology Group (OCOG), Canadian Institutes of Health Research (CIHR), Canadian Breast Cancer Research Alliance. RAPID: Randomized Trial of Accelerated Partial Breast Radiation; 2008.
  • 77 Yarnold J, Coles C. On behalf of the IMPORT LOW Trial Management Group: Intensity Modulated and Partial Organ Radiotherapy. Randomised trial testing intensity modulated and partial organ radiotherapy following breast conservation surgery for early breast cancer. Trial Protocol, version 4. Sutton, Surrey, UK: The Institute of Cancer Research, Royal Cancer Hospital; 2008. p. 1-74.
  • 78 Nag S, Kuske RR, Vicini FA, Arthur DW, Zwicker RD. The American Brachytherapy Society recommendations for brachytherapy for carcinoma of the breast. Oncology 2001;15:195-207.
  • 79 Smith BD, Arthur DW, Buchholz TA, Haffty BG, Hahn CA, Hardenbergh PH, et al. Accelerated Partial Breast Radiation consensus statement from The American Society For Radiation Oncology (ASTRO). Int J Radiation Oncology Biol Phys 2009;74;987-1001.
  • 80 Aebi S, Davidson T, Gruber G, Castiglione M. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. ESMO Guidelines Working Group. Ann Oncol 2010;21 Suppl 5:v9-14.
  • 81 Grunfeld E, Hodgson DC, Del Giudice ME, Moineddin R. Population-based longitudinal study of follow-up care for breast cancer survivors. J Oncol Pract 2010;6:174-81.
  • 82 Grunfeld E, Mant D, Yudkin P, Adewuyi-Dalton R, Cole D, Stewart J, et al. Routine follow up of breast cancer in primary care: Randomised trial. BMJ 1996;313:665-9.
  • 83 Palli D, Russo A, Saieva C, Ciatto S, Rosselli Del Turco M, Distante V, et al. Intensive vs clinical follow-up after treatment of primary breast cancer: 10-year update of a randomized trial. National Research Council Project on Breast Cancer Follow-up. JAMA 1999;281:1586