Younger, Just Diagnosed Breast Cancer Patients Often Undergo Unnecessary Imaging, Staging Procedures

More than a third of younger, early-stage breast cancer patients undergo unnecessary imaging procedures, including position emission tomography (PET), computed tomography (CT), nuclear medicine bone scans (NMBS), and tumor markers (TMs) at the time of staging and diagnosis, according to new findings.

The new research was presented at the 2013 CTRC-AACR San Antonio (TX, USA) Breast Cancer Symposium, by Carlos Barcenas, MD, assistant professor at the University of Texas MD Anderson Cancer Center (Houston, TX, USA) breast medical oncology department. The study is the first to examine the issue of overuse of staging procedures, including imaging and tumor markers in the diagnosis setting, specifically in younger, early-stage breast cancer patients.

Over-testing and unnecessary procedures extends beyond cancer care across the healthcare continuum. To help tackle the issue, the American Board of Internal Medicine began “Choosing Wisely,” an initiative encouraging physicians and patients to have conversations that encourage its reduction.

In 2012, the American Society of Clinical Oncology (ASCO) generated a “top five list,” which recommended against the use of CT, PET, TM, and NMBS in the diagnosis and staging of early-stage breast cancer at low risk for metastasis. Instead, treatment guidelines clearly state that for women with early-stage breast cancer, the proper procedures for diagnosis include mammogram, ultrasound, clinical exam, and blood work, according to Dr. Barcenas.

“We’ve known that overuse of staging procedures is a problem as well it may affect the cost-effectiveness in diagnosing women with early breast cancer,” said Dr. Barcenas. “With ASCO’s inclusion of this issue in its top five recommendations last year as part of its ‘Choosing Wisely’ campaign, this gave us the idea for the study: to investigate and understand just how pervasive the problem really is.”

For the retrospective study, Dr. Barcenas and coworkers analyzed claims from a national employer-based database of 42,651 women between 2005 and 2010 with an initial diagnosis of breast cancer. All were younger than 65 years old and had undergone a mastectomy, lumpectomy and sentinel lymph node biopsy. Patients who underwent axillary lymph node dissection were excluded from the study because this is considered a surrogate for node-positive disease. Claims for imaging and tumor markers were analyzed between the specific period of three months prior to surgery and one month post-surgery. Researchers stratified for age, geographic location, treatment, and insurance coverage.

The researchers found that 37% of early stage breast-cancer patients had at least one claim for an unnecessary staging test, with minimal change in rate of that average over the five-year period. Of significance, according to Dr. Barcenas, 18% of the woman had tumor markers performed, which is a staging procedure with no role in the nonmetastatic diagnosis setting. Undergoing chemotherapy had the highest link to overuse of staging procedures, with hormone and radiation therapy also associated with overuse.

The investigators also found regional differences in overuse trends, as well a higher rate of unnecessary procedures in women with PPO (preferred provider organization) insurance coverage compared to those with HMO (health maintenance organization). Moreover, women with breast cancer under 35 years old were at higher changes of having one of these tests, they explained. However, when diagnosed at such a young age, this patient population is perceived by the physician to be at higher risk of metastatic and/or aggressive disease.

“While hypothesis-generating, our study is not without limitations. For example, we don't know the receptor status of the tumor, or if the patients had a more aggressive pathology, such as triple negative disease, or if they presented with specific clinical characteristics such as back pain or an elevated blood level of a liver function test that called for more investigation. In some instances, there will be justification for the additional imaging procedures,” said Dr. Barcenas.

The researchers plan to track this trend to see if the rate of unnecessary imaging decreases with the continued propagation of the “Choosing Wisely” campaign. They also plan to evaluate for cost effectiveness.

Sharon Giordano, MD, professor and chair, health services research at MD Anderson believes the findings plainly support the need for the ASCO recommendations. She said the research shed some light on the issue of over-use and over-care and offers confirmation to physicians so that they have consent not to order unnecessary tests. “Often, doctors think they’re not being good to their patients if they don’t do all they can. Yet there’s been a shift in focus to doing what matters for the patient and what’s proven to improve outcomes, rather than testing for the sake of testing,” said Dr. Giordano, also a professor of breast medical oncology and the study’s senior author. “Ultimately, our goal is to bring the best care and value care to our patients.”

Related Links:
University of Texas MD Anderson Cancer Center