Clinicians Not 'Choosing Wisely' for Breast Cancer Imaging

Roxanne Nelson, BSN, RN

October 08, 2018

Despite guidelines from the American Society of Clinical Oncology (ASCO) "Choosing Wisely" initiative, many clinicians are not choosing wisely — at least when it comes to breast cancer imaging.

While guidelines recommend against routine imaging in patients with early-stage breast cancer (ESBC) who are at low risk for metastasis, two new studies have found that these guidelines are not being consistently followed.

In the first study, the authors report that 30% of patients with ESBC underwent staging imaging, despite guidelines recommending against it. The prevalence of inappropriate imaging varied from 26% to 68% among oncologists.

The second study found that unnecessary scanning occurred in up to 19% of patients with stage I to II breast cancer, adding almost $5000 in costs.

Both papers were presented at the ASCO Quality Care Symposium (QCS), held recently in Phoenix, Arizona.

The Choose Wisely campaign, organized by the American Board of Internal Medicine, set out to identify various tests and procedures that could be dropped without affecting medical care. For oncology, ASCO then identified five common cancer procedures and tests that are not supported by evidence and should no longer be used, including the use of advanced imaging technologies for staging of early breast and prostate cancers.

Imaging Higher in Certain Groups

One of the studies presented at QCS evaluated local adherence to imaging recommendations for staging in women with ESBC and looked at factors associated with inappropriate use for staging, explained lead author Brett Barlow, MD, a medical resident at the University of Alabama in Birmingham.

This retrospective cohort study included 872 patients with American Joint Committee on Cancer stage 0 to II disease who were diagnosed from 2013 to 2015 at a single-site, academic medical center. Of this group, 262 (30%) underwent staging imaging.

The median age at diagnosis for those who received imaging was 55 years vs 60 years for those with no or appropriate imaging. The risk for inappropriate screening imaging was higher in certain subgroups, including patients who were younger (relative risk [RR], 0.98), had triple-negative disease vs any hormone receptor–positive (RR, 2.98), had higher-stage disease (stage I vs stage 0: RR, 3.58; stage II vs stage 0: RR, 10.86), and were not covered by Medicare (RR, 1.52). The rates of imaging did not vary by race (nonwhite vs. white: RR, 0.98).

While the study did not examine the reasons for inappropriate imaging, Barlow offered some hypotheses.

"The period of time we measured was from 2013 to 2015, which was the immediate 3-year period after the guidelines were published," he told Medscape Medical News. "There may have been some lag in both dissemination and adoption of these guidelines. This particular recommendation was practice changing for many oncologists who were accustomed to routine surveillance, and it is difficult to change a well-established practice."

Second, he explained that their research showed a clear trend toward increased rates of unnecessary imaging in patients with characteristics associated with more aggressive cancers, such as younger patients, higher-stage cancers, and triple-negative receptor status. "This suggests there is a perception that these patients will have worse long-term outcomes, even though they were included in the scope of the guideline," Barlow said. 

He pointed out that patients may be requesting imaging, so that can be a factor as well. "Finally, some physicians may not believe these guidelines," Barlow added. "The degree of variability amongst our oncologists suggests that some of them are either unaware of the guidelines, or simply don't trust them for the higher-risk patients."

Increased Costs and False-Positives

In the second paper, Ana I. Velazquez Manana, MD, from Mount Sinai Beth Israel Medical Center, New York City, and colleagues examined the adherence rate and factors associated with nonadherence to imaging guidelines in 733 patients with early-stage breast cancer who were treated within a large healthcare system.

The median age at diagnosis was 58 years (range, 26 to 98 years), and 139 patients (19%) had routine imaging with a mean number of 1.53 initial scans, while 59 (42%) patients had at least 1 subsequent scan in the 1-year follow-up period (range, 1 to 4 scans/year).

The most frequent scanning modality was positron emission tomography/CT, followed by CT. A medical oncologist was the ordering provider in more than half (52%) of the cases and a surgical oncologist in 44.6% of cases. While routine scanning did not identify any cases of metastatic disease, false-positive findings were identified in 43% of patients and incidental findings in 8% of cases.

The authors pointed out that this routine imaging resulted in increased radiation exposure and additional cost of $4480 per patient. The presence of T2 tumor, positive lymph node, TN disease and young age were associated with increased staging scans.

Why Aren't Guidelines Followed?

These data are not new, and other papers have shown similar results that despite guidelines, these tests are still being ordered, commented Michael Sabel, MD, an associate professor of surgery and chief of surgical oncology at the University of Michigan, Ann Arbor.

"It's not just the cost of the scan that's detrimental," he told Medscape Medical News. "Scans lead to additional tests and biopsies — for instance, maybe show a tiny little nodule that turns out to be nothing."

In the Mt. Sinai study, Sabel pointed out, none of the scans showed any unexpected metastatic disease. "So even though we've known for a while that we shouldn't be doing these tests, why do we continue to see this?" he noted. "These are questions we need to answer."

Sabel speculated that some of the continued use of inappropriate scanning may be driven by patients. "We can't tell from these studies how much of it is patient driven, but physicians need to be educated on how to have these conversations with patients," he said. "And to better communicate that having these tests can lead to unnecessary invasive procedures and anxiety and does not improves outcomes."

He also pointed out that there might be better ways to communicate guidelines with physicians and "get the information out there."

"We discuss them at meetings, and publish them in journals, but is this really the most effective way to disseminate these guidelines? Do we need to do a better job making sure that physicians are aware of them?" Sabel added.

No funding source was disclosed for Barlow and colleagues' study. Velazquez Manana and colleagues' study was funded from Medical Student Rotation for Underrepresented Populations  2013. Barlow has disclosed no relevant financial relationships. A coauthor on that study, Gabrielle Betty Rocque, MD, disclosed consulting or advisory role with Genentech/Roche and Pfizer; travel, accommodation, and expenses from Genentech and Pfizer; and research funding from Carevive Systems, Genentech, Medscape, Pack Health, and Pfizer. Velazquez Manana and colleagues have disclosed no relevant financial relationships.

Quality Care Symposium. Abstract 269. Presented September 28, 2018.

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