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Many women with early-stage breast cancer receive imaging, despite practice guidelines
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A large number of women with early-stage breast cancer underwent imaging for distant metastases, despite multiple international practice guideline recommendations against imaging in this population, according to study results.
Breast imaging to detect distant metastatic disease is not recommended for asymptomatic women with early-stage breast cancer, according to study background. The ASCO Choosing Wisely campaign recommends against imaging for patients with stage I or II disease, and the Cancer Care Ontario guidelines recommend no imaging for women with stage I disease and a bone scan for those with stage II disease.
Mark Clemons, MD, head of breast medical oncology at Princess Margaret Cancer Centre in Toronto, and colleagues conducted a population-based cohort study to determine whether physician practices for women diagnosed with early-stage breast cancer generally followed practice guidelines regarding breast imaging.
Clemons and colleagues evaluated data from 26,547 Ontario women diagnosed with early-stage, operable breast cancer (stage I = 51.7%) between 2007 and 2012. They determined whether women received imaging of the skeleton, thorax, abdomen or pelvis within 3 months of their initial tissue diagnosis.
Overall, 85.9% of women (n = 22,811) underwent at least one imaging test following a diagnosis of early-stage breast cancer, with a total of 83,249 tests performed (mean per patient imaged, 3.7).
A greater proportion of women with stage II breast cancer underwent imaging compared with women diagnosed with stage I disease (92.7% vs. 79.6%).
Researchers classified 76.2% of imaging as initial imaging and 23.8% as confirmatory. Confirmatory imaging primarily occurred postoperatively (79.1%), whereas 48% of initial imaging occurred preoperatively.
Surgeons ordered the highest number of preoperative imaging (73.9%), followed by primary care physicians (19.9%), medical oncologists (1.1%) and radiation oncologists (0.3%). Surgeons also ordered the highest number of postoperative imaging (42.6%), followed by medical oncologists (35%), PCPs (11.4%) and radiation oncologists (6.2%).
Patients who underwent imaging tended to be younger; have more comorbidities; have higher-grade tumors; and were more likely to have underwent preoperative breast ultrasonography, mastectomy or surgery in the community setting.
The researchers acknowledged limitations of their study, including their inability to identify symptomatic patients or to ascertain whether patients became symptomatic in the 3-month period following diagnosis.
“The use of this imaging for women with stage I and II breast cancer — for whom evidence suggests that it is unnecessary — may be due in part to the lack of consensus among clinicians about the guidelines themselves,” Perkins and colleagues concluded. “Further discussions about the appropriateness of guidelines in light of modern imaging techniques may be needed … However, if guideline recommendations are to be implemented in practice, additional knowledge translation strategies are needed, as dissemination of clinical practice guidelines alone is not an effective method of changing physician practice behaviors.”
Because patients are unlikely to be familiar with imaging guidelines, the responsibility falls to clinicians to utilize imaging only when necessary, Daniel Rayson, MD, and Geoff Porter, MD, of the departments of medical oncology and surgery at the Queen Elizabeth II Health Sciences Centre and Dalhousie University in Halifax, Nova Scotia, wrote in an accompanying editorial.
“Like prescribing antibiotics for a viral upper respiratory tract infection, ordering staging investigations for most asymptomatic patients with stage I and II breast cancer is easy, even though it is usually wrong,” they wrote. “Surgeons and oncologists need to take the time and do the hard work involved in helping patients adapt to, and cope with, the multifactorial stresses that come with a cancer diagnosis. … For most patients with newly diagnosed stage I and II breast cancer, reflexively ordering staging investigations does not help relieve stress, nor does it detect disease.” – by Cameron Kelsall
Disclosure: The researchers report no relevant financial disclosures. Rayson and Porter report no relevant financial disclosures.
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