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Extreme use of testing common among older women with metastatic breast cancer
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More than one-third of older women with metastatic breast cancer were extreme users of disease-monitoring tests, according to the results of population-based analysis.
Further, higher use of these tests increased total health care costs.
“In the Medicare population, diagnostic testing, including radiographic imaging, is the most rapidly growing sector of reimbursed services and represents almost one quarter of ambulatory health care costs,” Melissa K. Accordino, MD, assistant professor of medicine at Columbia University Medical Center, and colleagues wrote. “In patients with advanced cancer, the optimal frequency and modality of disease monitoring are unknown. ... Clinical guidelines, such as those of the National Comprehensive Cancer Center Network, suggest that patients with metastatic disease should be monitored routinely while undergoing systemic therapy to continue treatments that control disease while avoiding toxicities from nonefficacious therapies.”
Research has shown that patients of specific ages, ethnicity and sociodemographic status use a disproportionately high percentage of health care services.
Accordino and colleagues identified predictors and patterns of use and “extreme use” of disease-monitoring tests, including serum tumor marker tests and radiographic imaging. They used billing dates to determine testing frequency and defined extreme use as more than 12 serum tumor marker tests or more than four radiographic tests within a 12-month period.
The analysis included data from 2,460 women in the SEER–Medicare database diagnosis with metastatic breast cancer between 2002 and 2011. Of these women, 37.6% (n = 924) qualified as extreme users of disease-monitoring tests. Nine percent were extreme users of serum tumor marker tests and 32.8% were extreme users of radiographic imaging.
A multivariate analysis showed that extreme users were more likely to have a Charlson comorbidity score of two or higher (OR = 1.43; 95% CI, 1.12-1.84), hormone receptor–negative disease (OR = 1.63; 95% CI, 1.27-2.08) and a history of at least one PET scan (OR = 2.92; 95% CI, 2.4-3.55). Extreme users also visited oncology offices more frequently (OR = 3.14; 95% CI, 2.49-3.96).
In comparison, patients were less likely to be extreme users if they were aged 80 years or older (OR = 0.58; 95% CI, 0.45-0.75) and were single (OR = 0.77; 95% CI, 0.63-0.93).
Serum tumor marker testing also was more likely among women with medium (OR = 1.53; 95% CI, 1.05-2.23) and high (OR = 1.56; 95% CI, 1.07-2.27) socioeconomic status.
Researchers observed no difference in OS among extreme testing users (HR = 0.93; 95% CI, 0.86-1.02). However, extreme users appeared more likely to use ED and hospice services at the end of life.
Among extreme users, total costs of care were 50.6% higher ($56,249 vs. $37,121) in the first year following diagnosis, 68.7% higher ($63,697 vs. $39,843) in the last year of life, and 59.2% higher overall ($54,211 vs. $35,038) than for nonextreme users (P < .001 for all).
Researchers acknowledged that findings may not be generalizable because all patients in the database were aged at least 65 years.
“Extreme use may reflect both patient and physician factors, and these should be targeted for interventions to curb spending, including potential health policy changes,” Accordino and colleagues wrote. “In addition, better evidence is needed with regard to the benefits and harms of frequent disease-monitoring testing to inform guidelines.”
Thomas J. Smith
Reducing the current level of extreme testing use may require the field to “move out of [its] comfort zone,” Karen L. Smith, MD, MPH, clinical associate of the breast cancer program and assistant professor of oncology, and Thomas J. Smith, MD, Harry J. Duffy Family professor of palliative medicine, both of Johns Hopkins University School of Medicine, wrote in an accompanying editorial.
“We should take better advantage of social media and reach out to educate our members, advocacy groups and patients about the unnecessary use of serum tumor marker or imaging tests outside our guidelines,” they wrote. “As our patients live longer, we must remain mindful of our limited resources and allocate costs across the disease trajectory from diagnostic tests to therapeutics to palliative interventions. Given the choice between spending limited dollars on extreme use of tests that do not have an impact on outcomes and spending them on newer therapies that improve health, the answer is clear.” – by Nick Andrews
Disclos ure: Accordino reports no relevant financial disclosures. One researcher reports consultant/advisory roles with EHE International, Otsuka, Pfizer, TEVA Pharmaceuticals Industries and United Biosource Corporation. Karen L. Smith reports stock or other ownership in Abbott Laboratories, AbbVie and Hospira.
Perspective
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Aditya Bardia
Accordino and colleagues present an analysis of data from the SEER–Medicare database and demonstrate that a subset (37.6%) of patients with metastatic breast cancer tend to be “extreme users” of testing. This pattern was higher among patients who had hormone receptor–negative breast cancer and a history of more frequent scans or office visits. The researchers report that the extreme users had higher medical costs, without deriving any clear clinical benefit.
This is an important study. It reminds us that we need to be mindful of the costs associated with cancer diagnostics and therapeutics. It also reminds that we should think about value related to cancer care, and the results are in line with the ASCO Value Framework.
However, although the study suggests that frequent users had higher medical costs, it does not clearly demonstrate that higher users also had worse outcomes and therefore that testing should not be done. Because this was not a prospective study, it is very much possible that the patients who had more frequent testing were the ones that were also sicker — such as those with visceral metastases, triple-negative breast cancer, etc — and hence needed more frequent testing clinically, which probably is not unjustified.
Nevertheless, the researchers do point out that some tests were ordered because they were simply carried on from the last order-set, and this is something that should clearly be avoided. It follows the old axiom that before ordering a test, we should carefully think how the results would influence clinical decision-making.
Further, the study raises a bigger issue about optimal monitoring in metastatic breast cancer. Conceptually, it makes sense to closely monitor therapeutic efficacy so that therapies, some of which can be very expensive, can be stopped at the first instance in which they cease to be effective. However, the challenge is that we do not have a sensitive marker that can accurately demonstrate early signs of tumor progression. Radiological scans are not sensitive enough to look for early progression, and tumor markers are neither highly sensitive nor specific. Thus, there is an unmet clinical need.
In this regard, tumor monitoring by circulating tumor cells or circulating tumor DNA hold a lot of promise. In lung cancer, studies have shown how these could be utilized to determine early evidence of disease progression, as well as mechanism of resistance such as development of T790M mutations in response to EGFR inhibitors.
In breast cancer, there is emerging interest in detection of ESR1 mutations, as they could potentially predict resistance to aromatase inhibitors and, thus, potentially represent an actionable finding. Clinical development of such assays would change the landscape of cancer management and potentially help improve the outcomes of patients with metastatic disease.
However, rigorous testing in clinical trials is needed. Again, those ordering the tests will have to address the basic question: How would the results influence clinical decision-making?
References:
Bardia A, et al. Oncologist. 2016;doi:10.1634/theoncologist.2016-0240.
Fribbens C, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2016.67.3061.
Maheswaran S, et al. N Engl J Med. 2008;doi:10.1056/NEJMoa0800668.
Sacher AG, et al. JAMA Oncol. 2016;doi:10.1001/jamaoncol.2016.0173.
Disclosure: Bardia reports no relevant financial disclosures.
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