Nick Mulcahy

June 09, 2015

CHICAGO — Only a minority (14%) of surgeons in the Untied States inappropriately order body imaging tests for early breast cancer patients between their diagnosis and date of surgery, according to an analysis of a national database.

The tests (PET scans, CT scans, and bone scans) — targeted by the 2012 ASCO Choosing Wisely campaign — are not recommended for staging because the chance of disease spread in this setting is very low, said lead study author Allison Lipitz-Snyderman, PhD, from the Memorial Sloan Kettering Cancer Center in New York City.

But it appears that, amid this small slice of surgeons, there are some big, bad habits, according to a study presented here at the American Society of Clinical Oncology (ASCO) 2015 Annual Meeting.

The researchers found that a woman was three times more likely to undergo unneeded imaging if her physician's previous patient underwent imaging than if the previous patient had not (adjusted odds ratio, 3.01; 95% confidence interval, 2.85 - 3.17).

"We observed a substantial physician-driven influence on imaging for women with early-stage breast cancer," conclude Dr Lipitz-Snyderman and her colleagues.

 
We observed a substantial physician-driven influence on imaging.
 

These findings are a surprise, said another expert.

"The supposition is that the unadvised use is spread out among doctors," said Blasé Polite, MD, from the University of Chicago, who reviewed the study during a Highlights of the Day session.

However, the results show that "this is not random variation across doctors," observed Dr Polite.

Every clinician can imagine a scenario that runs counter to a guideline, he acknowledged. But when you find a limited number of clinicians more likely to use tests that are not recommended in a certain setting, you have a problem, he pointed out.

The doctors who are racking up reimbursements with unadvised testing will have their comeuppance, he noted, as the payment system in the United States moves from being volume-based to quality-based.

 
You are going to be in trouble in the new system.
 

"I submit to you that if you are in this category [of overtesting], you are going to be in trouble in the new system; these are the folks who are going to be subject to very large [reimbursement] cuts," Dr Polite predicted.

In their study, Dr Lipitz-Snyderman and her colleagues identified 63,191 women in the SEER–Medicare database who were diagnosed with stage 0 to II breast cancer from 2004 to 2009 and who were at least 66 years of age.

The patients were treated by 3921 surgeons, all of whom had at least two patients in the database. On average, there were nine patients per doctor.

The researchers evaluated the "habit hypothesis" by looking at a physician's consecutive patients to determine if there was a pattern of imaging choices.

Notably, in defense of the doctors, patients with the lowest-risk diagnoses (i.e., stage 0 ductal carcinoma in situ) were the least tested (5%). For patients with stage I breast cancer, 13% underwent inappropriate testing; for patients with stage II breast cancer, 22% did.

Dr Lipitz-Snyderman could not say what is motivating the ill-advised imaging. "There is incomplete understanding of mechanisms through which patterns exist," she explained. In other words, she did not equate the behavior of these doctors with profit seeking.

But her team is reform-minded.

"Our findings support intervening at the physician level, specifically targeting high users, to help reduce the use of these potentially harmful and costly services," the researchers write in their abstract.

The team also looked at SEER–Medicare data to evaluate three other Choosing Wisely dictums — two more from ASCO campaigns and one from American Society of Radiation Oncology (ASTRO). And they found the same physician-driven influence on ill-advised imaging and therapy.

The study was funded by the National Institute for Health Care Management Foundation and a Cancer Center Support Grant. Dr Lipitz-Snyderman and Dr Polite have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2015 Annual Meeting: Abstract 6507. Presented May 30, 2015.

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