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Follow-up imaging for low-risk breast cancer varies widely across US
Geographic location may play a role in the type of follow-up imaging women with nonmetastatic breast cancer receive, according to study findings.
“[Among] patients with breast cancer treated for low-risk disease, geography has effects on the rates of posttreatment imaging, suggesting that some patients are not receiving beneficial dedicated breast imaging, and high-cost nonbreast imaging may not be targeted to those groups most likely to benefit,” Benjamin L. Franc, MD, MS, MBA, nuclear medicine specialist and professor in the department of radiology and biomedical imaging at University of California, San Francisco, and colleagues wrote.
The investigators used the Truven Health MarketScan Commercial Database to conduct a descriptive analysis of geographic variation in annual rates of dedicated breast imaging and high-cost body imaging among 36,045 women aged 18 to 64 years who underwent surgery for invasive unilateral breast cancer between 2010 and 2012.
Results showed wide geographic variation in rates of imaging use and intensity within metropolitan statistical area regions, irrespective of treatment type or age.
HemOnc Today spoke with Franc about why he and colleagues chose to study this trend, how they conducted their investigation, what they found and the potential implications of their findings.
Question : Why did you choose to conduct this study?
Answer: I noticed a trend toward greater utilization of high-cost imaging among some oncology providers and not others. There was a discrepancy between patients’ anticipated risk for recurrence and the level of surveillance/imaging taking place. Families and friends have asked what they should do in terms of surveillance testing and I did not have a firm answer for them, as it was hard to discern a community standard of care.
Q: How did you conduct the study?
A: We used a claims database from more than 100 private insurers across the U.S. We measured the magnitude of geographic variation around the U.S. in receipt of the recommended test — either mammography or other dedicated breast imaging — and other imaging tests that were not necessarily recommended during the months after surgical treatment.
Q: What did you find?
A: Among more than 36,000 women, approximately 70% had received a recommended dedicated breast imaging test for the diagnosis of breast cancer. However, more than 30% had at least one high-cost imaging study that would be typically used for an indicated reason, investigating a specific symptom or surveillance. It was unlikely that 30% of those patients at low-risk for metastatic disease would present with a symptom shortly after surgery. In addition, we found that the probability that a woman would receive an indicated or recommended test varied by a factor of 1.4 between two geographic regions, and the probability of whether she received PET imaging varied by a factor of 1.8.
Q: What are the reasons for the wide variation in follow-up imaging?
A: From a physician standpoint, imaging is not a tool that comes with a ‘user manual.’ In practice, some institutions have guidelines, but others leave complete control to the physician.
Q: What are t he implications of the findings?
A: We need to make sure that we as physicians do not forget about the fundamentals. We may be susceptible to chasing the unlikely scenario just because we have the technology to do so, while neglecting lower-tech opportunities such as mammography to catch a second cancer earlier.
Q: What can or should be done to increase the percentage of patients who receive the follow-up imaging that experts recommend?
A: Physicians should make sure their standard follow-up plan for oncology patients adheres to the most recent available data and guidelines. Patients should understand the overall goals of any testing. One imaging test is not the issue. It is the cumulative effects of radiation and financial costs of high-cost imaging modalities that is of concern.
Q: What can members of the oncology care team do or say to their patients to make sure they are adhering to expert recommendations?
A:Physicians need to address the internet upfront. Our patients receive a lot of information from the internet, as well as from social media networks. We need to emphasize that each patient’s experience will be shaped by the stage and aggressiveness of the tumor, other health conditions, etc, and they should not take other patients’ experiences with the health care system and apply them to their cases. There are wonderful resources on the internet, but patients need to understand that their physician understands their risk level and that their friends or contacts on social networks are not necessarily like them, nor do they have the same risk for recurrence.
Q: Is there anything else that you would like to mention?
A: Imaging is critical to decision-making at many junctures in the diagnosis and treatment of cancer. Imaging is a great tool and it should be used judiciously for the patients’ best interest. The long-term goal of our research is to better understand when imaging and other types of tests make a difference in a patient’s medical management, which makes a difference in a patient’s well-being. We want to apply the right tests to the right patients every time. – by Jennifer Southall
Reference:Franc BL, et al. J Natl Compr Canc Netw. 2018;doi:10.6004/jnccn.2018.7024.
For more information:
Benjamin L. Franc, MD, MS, MBA, can be reached at Center for Healthcare Value, University of California, San Francisco, 3333 California St., Suite 265, San Francisco, CA 94118; email: benjamin.franc@ucsf.edu.
Disclosure: Franc reports no relevant financial disclosures.