Abstract
Purpose:
To assess advanced imaging (bone scan, CT, or PET-CT) and serum tumor biomarker use in asymptomatic breast cancer survivors during the surveillance period.
Patients and Methods:
Cancer registry records for 2,923 women diagnosed with primary breast cancer in Washington State from January 1, 2007 to December 31, 2014 were linked with claims data from two regional commercial insurance plans. Clinical data including demographic and tumor characteristics were collected. Evaluation and management codes from claims data were used to determine advanced imaging and serum tumor biomarker use during the peri-diagnostic and surveillance phases of care. Multivariable logistic regression models were used to identify clinical factors and patterns of imaging and biomarker test utilization associated with surveillance advanced imaging use.
Results:
Of eligible women, 16.5% (480/2,923) received surveillance advanced imaging and 31.8% (930/2,923) received surveillance serum tumor biomarker tests. Compared to women diagnosed prior to the launch of Choosing Wisely in 2012, later diagnosis was associated with lower surveillance advanced imaging use (OR=0.68, 95% CI: 0.52–0.89). Factors significantly associated with surveillance advanced imaging use included increasing stage of disease (stage III: OR=3.65, 95% CI: 2.48–5.38), peri-diagnostic advanced imaging use (OR=1.76, 95% CI: 1.33–2.31), and peri-diagnostic serum tumor biomarker use (OR=1.35, 95% CI: 1.01–1.80).
Conclusions:
While surveillance advanced imaging use in asymptomatic breast cancer survivors has declined since the launch of the Choosing Wisely campaign, frequent use of surveillance serum tumor biomarker testing remains prevalent representing a potential target for further efforts to reduce low-value breast cancer surveillance practices.
Keywords: breast cancer surveillance, serum tumor biomarkers, advanced imaging, Choosing Wisely
Background:
The Institute of Medicine estimates that nearly 30% of all medical expenses result from inappropriate or unnecessary practices, increasing strain on the US healthcare system.[1] In oncology, total healthcare expenditures are projected to reach $173 billion dollars by 2020, a $50 billion dollar increase compared to 2010.[2] Efforts to identify and improve practices by physicians, payers, and policymakers have led to the Choosing Wisely campaign by the American Board of Internal Medicine (ABIM) Foundation.
In 2012, a “Top 5” list in oncology of low-value practices that could be avoided without impacting patient care was released through this initiative in partnership with the American Society of Clinical Oncology (ASCO).[3,4] Surveillance of asymptomatic breast cancer survivors, including advanced imaging (whole body imaging with bone scan, computed tomography (CT), or positron emission tomography–computed tomography (PET-CT) and/or serum tumor biomarker (carcinoembryonic antigen, CA 15–3, and CA 27.29) tests, was one of the measures included on this list. Randomized controlled trials have demonstrated no survival benefit or decreased time to detection of disease recurrence in women receiving these advanced imaging tests.[5,6] Furthermore, numerous potential harms associated with advanced imaging use in breast cancer survivors have been reported including increased patient anxiety, exposure to ionizing radiation, and false positive results leading to further invasive testing.[7]
Current evidence-based guidelines for breast cancer follow-up and management after primary treatment by ASCO and National Comprehensive Cancer Network (NCCN) include routine history, physical examination, and mammography.[8,9] Physical examination is recommended every 3–6 months for the first 3 years, every 6–12 months for years 4 and 5, and annually thereafter. For women who have received breast-conservation therapy, a post-treatment mammogram is recommended 1 year after the initial mammogram and at least 6 months after completion of radiation therapy, followed by yearly mammography.
Despite consensus on recommendations against the use of low-value surveillance care through the Choosing Wisely initiative, variable adherence to guidelines have been observed.[10] Predictors of non-concordance with guidelines have yet to be clearly elucidated, which limit efforts to develop interventions aimed at reducing unnecessary surveillance testing. Understanding determinants of advanced surveillance testing will be key in implementing effective strategies to increase guideline concordant care. Thus, the objectives of our study were to evaluate advanced imaging use during breast cancer surveillance, and to identify drivers of potential advanced imaging overutilization, as outlined by ASCO/ABIM Choosing Wisely recommendations.
Patients and Methods:
We performed a retrospective cohort study involving 18,912 unique individuals diagnosed with breast cancer in western Washington between January 1, 2007 and December 31, 2014 from 13 counties. We linked insurance enrollment data from two major commercial insurers in the region, Premera Blue Cross and Regence Blue Shield, with cancer registry records from the Cancer Surveillance System (CSS), which includes 13 counties in western Washington state. After linking insurance enrollment and CSS data, claims for inpatient and outpatient services were extracted for eligible individuals during our study period. We received institutional review board approval for this Health Insurance Portability and Accountability Act (HIPAA) compliant study to link registry and commercial insurance data and to perform analyses.
We included women aged ≥18 years at the time of diagnosis, who had American Joint Committee on Cancer (AJCC) 7th edition stage 0-III breast cancer treated with primary therapy with curative intent. (Figure 1) Primary therapy was defined as mastectomy or lumpectomy and radiation therapy within 180 days of diagnosis.[11] Exclusion criteria included women who (1) had a prior history of breast cancer (2) had an unknown breast cancer diagnosis date or diagnosis date outside of the study period, (3) were diagnosed at autopsy, (4) had AJCC stage IV breast cancer, (5) did not have continuous insurance enrollment from 3 months prior to diagnosis through 14 months after diagnosis, (6) did not receive curative therapy (defined as mastectomy 6 months after diagnosis or lumpectomy with radiation within 180 days after surgery), and (7) did not have continuous enrollment during the surveillance period (15-month period starting 4 months after completion of primary therapy).
Figure 1.
CONSORT diagram of cohort creation
Clinical data collected included age at diagnosis, race, diagnosis year, family history of breast cancer, and breast cancer-specific genetic mutation status. Tumor characteristic data collected included AJCC stage, grade, size, estrogen receptor (ER) status, progesterone receptor (PR) status, and human epidermal growth factor receptor 2 (HER-2) receptor status. Survival information was obtained from the CSS.
Evaluation and management codes from claims data were used to determine advanced imaging (whole body imaging with bone scan, CT, and/or PET-CT) and serum tumor biomarker use during both the peri-diagnostic period (defined as 1-month prior to diagnosis until completion of primary therapy) and surveillance period (defined as the 15-month period starting 4 months after completion of primary therapy).[12, 13] Surveillance tumor biomarker utilization performed after surveillance advanced imaging was excluded. Censoring occurred during surveillance at death or restart of treatment, defined as claims data documenting surgery, chemotherapy, or radiation during surveillance, an endpoint we used as a proxy for disease recurrence. [14–16]
Clinical and tumor characteristic data of women who completed their surveillance period without further treatment were compared to women who ended surveillance early due to restart of treatment. Advanced imaging and serum tumor biomarker use in women with less advanced stage of disease (Stage 0-IIa) was compared to women with more advanced stage of disease (Stage IIb+) during both the peri-diagnostic and surveillance phases of care. Surveillance advanced imaging and serum tumor biomarker use in these two groups were then compared based on whether treatment was restarted during surveillance to assess potentially appropriate versus inappropriate surveillance testing utilization.
Multivariable logistic regression was used to identify clinical factors and patterns of care utilization (peri-diagnostic advanced imaging use and tumor biomarker use and surveillance tumor biomarker use) that were associated with surveillance advanced imaging use. For our regression model, we excluded patients with surveillance biomarker use that did not precede surveillance advanced imaging use. Specifically, we included the following covariates in the model: age, race, diagnosis year, stage, ER status, PR status, HER2 status, curative therapy, family history, genetic mutation, peri-diagnostic advanced imaging and peri-diagnostic tumor biomarker use. Patients with unknown ER/PR status were excluded from the model. There was no interaction between covariates. All statistical tests were two-sided, and p values less than 0.05 were considered statistically significant.
For the fully adjusted multivariable model, we used multiple imputation via chained equations to impute missing HER2 data in 1,123 women.[17,18] This method imputed missing variables using a regression model conditional on all the other variables in the model. Ten imputations were conducted in STATA 14 (StataCorp. 2015; College Station, TX), and estimates were combined across imputations using standard methods for multiple imputation.[19]
Results:
After applying inclusion and exclusion criteria, 2,923 women were included in the study cohort. Clinical data including demographic and tumor characteristics are shown in Table 1. The median age of women in our study was 57.2 years (interquartile range: 48–65 years). Nearly half (n=1,342; 45.9%) of all women were diagnosed with AJCC stage I disease. The majority of tumors were < 20 mm in size (n=1,836; 62.8%), ER-receptor positive (n=2,523; 86.3%), and PR-receptor positive (n=2,166; 74.1%). Most women (n=1,792, 61.3%) underwent breast conservation therapy, while 38.7% (n=1,131) underwent mastectomy. A minority of women had a family history of breast cancer (n=641; 21.9%) or breast cancer-specific genetic mutation (n=52; 1.8%). Of all women in our study, 5.5% (n=161) ended their surveillance period early due to restart of treatment. Compared to women who did not restart treatment, these women were more likely to have advanced stage of disease, larger tumor size (> 20 mm), and ER-negative receptor status at primary breast cancer diagnosis.
Table 1:
Clinical and Tumor Characteristics of Women with Primary Breast Cancer
| Characteristics | Total | Restarted Treatment During Surveillance | Completed Surveillance |
|---|---|---|---|
| N = 2,923 | N = 161 | N = 2,762 | |
| Age | |||
| < 45 | 416 (14.2%) | 25 (15.5%) | 391 (14.2%) |
| 45–54 | 856 (29.3%) | 50 (31.1%) | 806 (29.2%) |
| 55–64 | 897 (30.7%) | 52 (32.3%) | 845 (30.6%) |
| 65–74 | 503 (17.2%) | 23 (14.3%) | 480 (17.4%) |
| 75+ | 251 (8.6%) | 11 (6.8%) | 240 (8.7%) |
| Race | |||
| White | 2609 (89.3%) | 144 (89.4%) | 2465 (89.2%) |
| Other | 314 (10.7%) | 17 (10.6%) | 297 (10.8%) |
| Diagnosis Year | |||
| 2007 | 182 (6.2%) | 17 (10.6%) | 165 (6.0%) |
| 2008 | 320 (10.9%) | 20 (12.4%) | 300 (10.9%) |
| 2009 | 352 (12.0%) | 20 (12.4%) | 332 (12.0%) |
| 2010 | 351 (12.0%) | 22 (13.7%) | 329 (11.9%) |
| 2011 | 488 (16.7%) | 26 (16.1%) | 462 (16.7%) |
| 2012 | 532 (18.2%) | 24 (14.9%) | 508 (18.4%) |
| 2013 | 485 (16.6%) | 19 (11.8%) | 466 (16.9%) |
| 2014 | 213 (7.3%) | 13 (8.1%) | 200 (7.2%) |
| Stage | |||
| Stage 0 | 695 (23.8%) | 31 (19.3%) | 664 (24.0%) |
| Stage I | 1342 (45.9%) | 57 (35.4%) | 1285 (46.5%) |
| Stage II | 720 (24.6%) | 51 (31.7%) | 669 (24.2%) |
| Stage III | 166 (5.7%) | 22 (13.7%) | 144 (5.2%) |
| Stage Categories | |||
| Stage 0-IIa | 2561 (87.6%) | 123 (76.4%) | 2438 (88.3%) |
| Stage IIb+ | 362 (12.4%) | 38 (23.6%) | 324 (11.7%) |
| Tumor Grade | |||
| 1 | 698 (23.9%) | 37 (23.0%) | 661 (23.9%) |
| 2 | 1220 (41.7%) | 62 (38.5%) | 1158 (41.9%) |
| 3 | 927 (31.7%) | 55 (34.2%) | 872 (31.6%) |
| Tumor Size (mm) | |||
| < 20 | 1836 (62.8%) | 85 (52.8%) | 1751 (63.4%) |
| 20–49 | 812 (27.8%) | 56 (34.8%) | 756 (27.4%) |
| 50+ | 161 (5.5%) | 13 (8.1%) | 148 (5.4%) |
| ER | |||
| Positive | 2523 (86.3%) | 126 (78.3%) | 2397 (86.8%) |
| Negative | 354 (12.1%) | 32 (19.9%) | 322 (11.7%) |
| PR | |||
| Positive | 2166 (74.1%) | 102 (63.4%) | 2064 (74.7%) |
| Negative | 553 (18.9%) | 46 (28.6%) | 507 (18.4%) |
| HER2 | |||
| Positive | 159 (5.4%) | 10 (6.2%) | 149 (5.4%) |
| Negative | 1438 (49.2%) | 71 (44.1%) | 1367 (49.5%) |
| Curative Therapy | |||
| Lumpectomy | 1792 (61.3%) | 80 (49.7%) | 1712 (62.0%) |
| Mastectomy | 1131 (38.7%) | 81 (50.3%) | 1050 (38.0%) |
| Family History | |||
| Yes | 641 (21.9%) | 35 (21.7%) | 606 (21.9%) |
| No | 2282 (78.1%) | 126 (78.3%) | 2156 (78.1%) |
| Genetic Mutation | |||
| Yes | 52 (1.8%) | 6 (3.7%) | 46 (1.7%) |
| No | 2871 (98.2%) | 155 (96.3%) | 2716 (98.3%) |
During the peri-diagnostic phase of care, 14.2% (n=415) of women received at least one advanced imaging test (bone scan, CT, and/or PET-CT) and 13.3% (n=388) of women received serum tumor biomarker testing (Table 2). Compared to women with early stage breast cancer (Stage 0-IIa, n=2,561), a greater proportion of women with advanced stage breast cancer (Stage IIB or higher, n=362) received advanced imaging (n=160, 44.2%) and serum tumor biomarker testing (n=101, 27.9%) during the peri-diagnostic phase of care.
Table 2:
Imaging and Serum Tumor Biomarker Use During the Peri-diagnostic Period
| All Women n=2,923 |
Stage (0-IIa) n=2,561 |
Stage (IIb+) n=362 |
|
|---|---|---|---|
| No Advanced Imaging Use | 2508 (85.8%) | 2306 (90.0%) | 202 (55.8%) |
| Advanced Imaging Usea | 415 (14.2%) | 255 (10.0%) | 160 (44.2%) |
| Bone Scan | 134 (4.6%) | 77 (3.0%) | 57 (15.7%) |
| CT | 289 (9.9%) | 182 (7.1%) | 107 (29.6%) |
| PET – CT | 205 (7.0%) | 101 (3.9%) | 104 (28.7%) |
| Serum tumor biomarker Use | 388 (13.3%) | 287 (11.2%) | 101 (27.9%) |
Including any combination of Bone Scan, CT, or PET-CT and/or imaging
During the surveillance phase of care, 16.5% (n=480) of all women received advanced imaging and 31.8% (n=930) received serum tumor biomarker tests (Table 3). CT imaging (n=370) was the most frequently utilized advanced imaging test in women receiving advanced imaging surveillance, followed by bone scan (n=132) and PET-CT (n=85). Compared to women with early stage breast cancer, more women with advanced stage breast cancer received surveillance advanced imaging (n=126; 34.8%) and serum tumor biomarker testing (n=182; 50.3%). Serum tumor biomarker test utilization increased from 13.3% (388/2,923) to 31.8% (930/2,923), between the peri-diagnostic and surveillance phases of care.
Table 3:
Imaging and Serum Tumor Biomarker Use During the Surveillance Period
| All Women n=2,923 |
Stage (0-IIa) n=2,561 |
Stage (IIb+) n=362 |
|
|---|---|---|---|
| No Advanced Imaging Use | 2443 (83.5%) | 2207 (86.2%) | 236 (65.2%) |
| Advanced Imaging Usea | 480 (16.5%) | 354 (13.8%) | 126 (34.8%) |
| Bone Scan | 132 (4.5%) | 94 (3.7%) | 38 (10.5%) |
| CT | 370 (12.7%) | 266 (10.4%) | 104 (28.7%) |
| PET – CT | 85 (2.9%) | 54 (2.1%) | 31 (8.6%) |
| Serum tumor biomarker Use | 930 (31.8%) | 748 (29.2%) | 182 (50.3%) |
Including any combination of Bone Scan, CT, or PET-CT and/or imaging
Multivariable logistic regression modeling indicated that advanced imaging use during surveillance was most significantly associated with increasing stage of disease (stage III: Odds Ratio [OR] = 3.65, 95% Confidence Interval [CI]: 2.48–5.38)(Table 4). Compared to women diagnosed prior to the launch of Choosing Wisely in 2012, later diagnosis (OR = 0.68, 95% CI: 0.52–0.89) was associated with lower surveillance advanced imaging use. Additional factors significantly associated with surveillance advanced imaging use included peri-diagnostic advanced imaging use (OR = 1.76, 95% CI: 1.33–2.31) and serum tumor biomarker use (OR = 1.35, 95% CI: 1.01–1.80).
Table 4:
Association Between Clinical Characteristics and Surveillance Advanced Imaging Use
| Variable | Odds Ratio (95% Confidence Interval) | P-Value |
|---|---|---|
| Age | 0.41 | |
| < 45 | 1.18 (0.84, 1.67) | |
| 45–54 | 1.27 (0.96, 1.67) | -- |
| 55–64 (Reference) | -- -- | -- |
| 65–74 | 1.18 (0.85, 1.63) | -- |
| 75+ | 1.43 (0.97, 2.11) | -- |
| Race | 0.93 | |
| White (Reference) | -- | -- |
| Non-White | 1.02 (0.71, 1.46) | -- |
| Diagnosis Year | <0.01 | |
| 2007–2012 (Reference) | -- | -- |
| 2013–2014 | 0.68 (0.52, 0.89) | -- |
| Stage | <0.01 | |
| Stage 0 | 0.55 (0.38, 0.80) | -- |
| Stage I (Reference) | -- | -- |
| Stage II | 1.85 (1.45, 2.37) | -- |
| Stage III | 3.65 (2.48, 5.38) | -- |
| ER | 0.33 | |
| Positive | 0.82 (0.54, 1.23) | -- |
| Negative (Reference) | -- | -- |
| PR | 0.36 | |
| Positive | 0.85 (0.60, 1.20) | -- |
| Negative (Reference) | -- | -- |
| HER2 | 0.96 | |
| Positive | 0.99 (0.64, 1.52) | -- |
| Negative (Reference) | -- | -- |
| Curative Therapy | 0.86 | |
| Mastectomy (Reference) | -- | -- |
| Lumpectomy + Radiation | 0.98 (0.78, 1.23) | -- |
| Family History | 0.63 | |
| Yes | 1.07 (0.82, 1.38) | -- |
| No (Reference) | -- | -- |
| Genetic Mutation | 0.46 | |
| Yes | 1.30 (0.65, 2.60) | -- |
| No (Reference) | -- | -- |
| Tumor Marker Use (Peri-diagnostic) | 0.04 | |
| Yes | 1.35 (1.01, 1.80) | -- |
| No (Reference) | -- | -- |
| Tumor Marker Use (Surveillance) | 0.19 | |
| Yes | 0.86 (0.68, 1.08) | -- |
| No (Reference) | -- | -- |
| Advanced Imaging Use (Peri-diagnostic) | <0.01 | |
| Yes | 1.76 (1.33, 2.31) | -- |
| No (Reference) | -- | -- |
Among women who received advanced imaging during surveillance (n=480), 19.1% (24/126) of women with advanced stage breast cancer restarted treatment compared with 6.5% (23/354) of women with early stage breast cancer (Table 5). Over 90% of women with early stage breast cancer who received either advanced imaging or serum tumor biomarker testing during the surveillance phase of care did not restart treatment.
Table 5:
Treatment Restart Status by Stage among Women Receiving Surveillance Advanced Imaging and Biomarker Testing
| Treatment Restarted | Total | ||
|---|---|---|---|
| Yes | No | ||
| n (%) | n (%) | ||
| Advanced Imaging - Yes | |||
| Stage 0-IIa | 23 (6.5%) | 331 (93.5%) | 354 |
| Stage IIb+ | 24 (19.1%) | 102 (80.9%) | 126 |
| Total | 47 (9.8%) | 433 (90.2%) | 480 |
| Serum tumor biomarker - Yes | |||
| Stage 0-IIa | 33 (4.4%) | 715 (95.6%) | 748 |
| Stage IIb+ | 16 (8.8%) | 166 (91.2%) | 182 |
| Total | 49 (5.3%) | 881 (94.7%) | 930 |
Discussion:
Several studies have demonstrated limited clinical benefit from surveillance advanced imaging and serum tumor biomarker testing in asymptomatic breast cancer survivors.[5,6] In our study population of 2,923 women treated for primary breast cancer with curative intent, we found that only 16.5% of women received surveillance advanced imaging, a lower proportion compared to prior studies evaluating advanced imaging utilization among breast cancer survivors. Nearly one- third of women in our study received surveillance serum tumor biomarker testing however, reflecting care that may be discordant with Choosing Wisely guideline recommendations.[3, 4]
Of women receiving surveillance advanced imaging, 6.5% (23/354) treated for early stage disease and 19.1% (24/126) treated for advanced stage disease restarted treatment due to probable recurrent or metastatic disease. In contrast, overall low treatment restart rates were seen in women receiving surveillance serum tumor biomarker testing (5.3%; 49/930) for probable recurrent or metastatic disease, despite nearly one-third of primary breast cancer survivors in our study receiving these tests. Additionally, increased surveillance tumor biomarker use was not associated with follow-up surveillance advanced imaging, indicating biomarker use had little effect on subsequent clinical management and supporting limited clinical benefit of its use in this population.
Overall, variable surveillance advanced imaging estimates ranging from 24% to 55% have been previously reported, likely attributable to differences in study setting, patient selection, and definitions of advanced imaging surveillance.[20–24] Panageas et al. for example, who demonstrated surveillance advanced imaging use in 40% of early stage breast cancer survivors utilizing Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, included breast MRI in their analysis likely contributing to comparatively higher overall advanced imaging utilization rates.[24] Our study results were more aligned with more recent studies demonstrating lower utilization rates, supporting decreasing use of surveillance advanced imaging over time.[20, 21] Schumacher et al, in a recent analysis found that although patients were more likely to receive surveillance imaging at their first follow-up examination, lower utilization was seen in subsequent years.[21] Similar to ours, their study supported surveillance imaging use in patients at higher recurrence risk including patients diagnosed with estrogen receptor/progesterone receptor-negative tumors. Greater awareness of the Choosing Wisely initiative may influence this trend towards more evidence-based surveillance practice patterns in more recent studies, along with expansion of high-deductible health plans in the private market over time.[25, 26] This is supported in our study, as earlier date of primary breast cancer diagnosis prior to 2012 (launch year of the Choosing Wisely campaign) was a predictor of surveillance advanced imaging use. Lastly, requirements by insurance for pre- authorization for surveillance testing, as well as declining Medicare & Medicaid Services fees in women with early breast cancer may have influenced study results, although not directly evaluated in our study. [27]
Advanced imaging and tumor biomarker testing performed during the peri-diagnostic phase of care was associated with increased use of surveillance advanced imaging. Considering these tests were performed before surgery, it appears peri-diagnostic ordering patterns may significantly influence surveillance advanced imaging use, by potentially informing recurrence risk. These findings may be supported by recent data showing a positive association between surveillance PET imaging use and mastectomy with radiation treatment, indicating advanced imaging use may be utilized in higher rates in women with increased risk of recurrence.[28] Patient age, family history, and tumor characteristics represent additional factors that may influence perception of recurrence risk in breast cancer survivors.[16, 20] Of these previously studied factors, however, only increasing stage of disease was associated with surveillance advanced imaging use in our study.
Variation in regional practice patterns and guideline adherence may also influence clinical decision-making when considering surveillance imaging. [29] While oncologists have been shown to make guideline-concordant decisions in most clinical scenarios, higher instances of guideline discordant care have been previously demonstrated for the diagnostic use of PET imaging and serum tumor biomarker tests, similar to our study, in early breast cancer survivors.[16, 22, 30] While clinician unfamiliarity with Choosing Wisely guidelines may play a partial role, anecdotal experience with perceived benefits of non-recommended tests and reliance on smaller studies may also contribute to guideline discordant surveillance care.
Our study has several limitations. Claims data does not include information on clinical indication or test results which limits assessment of the appropriateness of follow-up testing based on suspicious clinical history and/or physical examination findings. Additionally, we had limited data available on number of patients per physician and clinic to analyze physician- and clinic- level variables in our study. Next, detailed information in our dataset on pre-authorization policies and pathways was limited.[16] Additionally, since we focused on women receiving guideline concordant surgical therapy, our study did not include women receiving lumpectomy without radiation therapy who are at greater risk of local recurrence. As a result, our study results may not apply be generalizable to this small subpopulation of women.
As breast cancer survivorship continues to increase, the potential negative impact of inappropriate surveillance testing on individuals, as well as the US healthcare system overall, will only be magnified.[31, 32] Prior reports demonstrating potential imaging overuse highlight the importance of evidence-based initiatives such as the ASCO/ABIM Foundation’s Choosing Wisely campaign.[33] Moreover, it is unclear how recently established guidelines by the American College of Radiology (ACR) surveillance imaging recommendations suggesting annual breast MRI in breast cancer survivors who are over the age of 50 years or who have dense breast tissue will impact messaging around appropriate use of advanced imaging in this population.[34] While our study demonstrates that guideline discordant care may be declining after the launch of Choosing Wisely, non-recommended surveillance testing remains prevalent. Continued efforts to reduce low value care is needed to reduce costly, unnecessary tests and procedures, with special focus on surveillance tumor biomarker testing.
Initiatives such as ASCO’s Quality Oncology Practice Initiative (QOPI), an oncologist-led, practice-based quality assessment and improvement program aim to promote evidence-based cancer care by encouraging constant self- inspection to reduce discordant practice patterns, while creating a platform to compare variation across diverse practices.[35] Peri- diagnostic ordering patterns that may lead to discordant surveillance testing, as seen in our study, could be documented, compared, and used to target physicians who are more likely to not adhere with Choosing Wisely guidelines. Overall, increased efforts aimed at health practitioners and patients about evidence-based breast cancer surveillance practices will be required to further increase concordant care with Choosing Wisely guidelines.
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