Who's Ordering Tests and Imaging for Breast Cancer Survivors?

Roxanne Nelson, BSN, RN

February 01, 2017

SAN DIEGO, California ― Clinicians may not be adhering to recommendations when caring for breast cancer patients following active treatment.

New study results presented here at the Cancer Survivorship Symposium (CSS) Advancing Care and Research suggest that patients may be getting tested for biomarkers and undergoing imaging inappropriately.

The Choosing Wisely initiative recommends that tumor marker tests, as well as CT, positron-emission tomography (PET), and bone scans, should not be routinely used in patients with early-stage breast cancer who have no signs or symptoms of disease recurrence.

But the current study found that 37% of patients underwent biomarker testing and that 17% underwent advanced imaging within the first 13 months after ending active treatment.

The majority of biomarker testing and the largest proportion of advanced imaging appeared to be associated with visits to oncologists rather than primary care practitioners (PCPs).

"Our working group had a hypothesis that oncologists were driving the use of testing and imaging and wanted to see if the evidence supported their beliefs," said lead author Julia Walker, MPH, regional collaborations project manager, Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, Washington.

"We did hear from some oncologists that there was a belief that maybe PCPs were driving the use, but this evidence did not support that, so now we can focus our intervention on oncologists," said Walker, who presented the findings at the meeting. "Patients frequently see oncologists and PCPs during this early period, but targeting oncologists for potentially inappropriate testing could have the largest impact with aligning practice with Choosing Wisely."

Notably, the claims data used in the study did not allow a determination as to whether a test was medically indicated, said Walker.

The new study was conducted to assess whether surveillance of patients with early-stage breast cancer varied by whether the patients obtained follow-up care with oncologists, PCPs, or both.

"Clinical guidelines are generally consistent in the recommended number of annual visits and recommended mammograms, but studies of oncologists and PCPs have shown variations regarding who is responsible for follow-ups and adherence to Choosing Wisely," Walker explained.

The authors used cancer registry records for patients in western Washington from 2007 to 2015. These were linked with claims from two regional commercial insurers.

The cohort included 2193 patients who had been diagnosed with stage I/II breast cancer and were treated with mastectomy or lumpectomy plus radiation. The surveillance period assessed in the study began at the first 4-month gap in treatment through 13 months from gap start or restart of treatment.

Evaluation and Management (E&M) codes for visits and procedure codes for biomarker and advanced imaging (PET, CT, bone scan) were identified in the claims, and specialty codes were used to determine the type of provider that was seen. The researchers matched physician visits to tests using E&M codes in the ±7 days around each specific test.

Walker explained that they looked at visits over time to see whether any patterns emerged, such as changes in the utilization of tests and imaging over time.

"Fifty percent of the patients saw an oncologist during the first month, but that began to taper off, while patients seeing a PCP stayed fairly steady at about 20%," she said.

There was an average of 13.3 physician visits per patient (median, 11; IQR, 8 - 17), with the most common treating physicians being oncologists (91%) and PCPs (83%).

With respect to testing, 74% of patients received mammography (average number of examinations, 1.6), 37% were tested for biomarkers (average, 2.8 tests per patient), and 17% underwent advanced imaging (average, 1.5 assessments per patient).

The majority of biomarker testing and the largest proportion of advanced imaging occurred near the time of an oncology visit: 38% of advanced imaging and 71% of biomarker testing.

In contrast, PCP visits were associated with a much smaller percentage: 16% of advanced imaging and 9% of biomarker testing.

When broken down by oncology specialty, the largest proportion of testing and imaging occurred around visits to medical oncologists (74% biomarker, 38% advanced imaging).

"The data raised some questions," said Walker. "Our working group did question why 9% of biomarker testing was occurring about PCP visits, since it is oncologists who generally order testing. There was also 45% with no office visit, and we hypothesized this may be due to automatic ordering."

She noted that claims data do not make it clear which providers ordered the tests.

Additional Opportunities

In a discussion of the paper, Wendy Landier, PhD, RN, from the University of Alabama School of Medicine, Birmingham, agreed that "conclusions from this paper are that oncology-provided care appears to the be primary driver of biomarker testing."

Dr Landier noted that there are ways to further analyze these data. "Investigators may want to look at their data to see if they can detect differences in biomarker testing by cancer stage as well as by patterns of practices in their region," she said.

Another way is to compare the "before and after" patterns, because the data used in this study were for the period 2007 to 2016, and the Choosing Wisely campaign was launched in 2012.

Dr Landier added that because this study was based on claims data, it is possible to analyze the cost of the testing, both to the healthcare system and to the patients.

Julia Walker has disclosed no relevant financial relationships.Several coauthors have reported relationships with industry, as noted in the abstract. Dr Landier has received research funding from Merck Sharp & Dohme (Inst).

Cancer Survivorship Symposium (CSS) Advancing Care and Research, Abstract 4, presented January 28, 2017.

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