Advanced Imaging and Receipt of Guideline Concordant Care in Women with Early Stage Breast Cancer

Abstract

Objective. It is unknown whether advanced imaging (AI) is associated with higher quality breast cancer (BC) care. Materials and Methods. Claims and Surveillance Epidemiology and End Results data were linked for women diagnosed with incident stage I-III BC between 2002 and 2008 in western Washington State. We examined receipt of preoperative breast magnetic resonance imaging (MRI) or AI (defined as computed tomography [CT]/positron emission tomography [PET]/PET/CT) versus mammogram and/or ultrasound (M-US) alone and receipt of guideline concordant care (GCC) using multivariable logistic regression. Results. Of 5247 women, 67% received M-US, 23% MRI, 8% CT, and 3% PET/PET-CT. In 2002, 5% received MRI and 5% AI compared to 45% and 12%, respectively, in 2008. 79% received GCC, but GCC declined over time and was associated with younger age, urban residence, less comorbidity, shorter time from diagnosis to surgery, and earlier year of diagnosis. Breast MRI was associated with GCC for lumpectomy plus radiation therapy (RT) (OR 1.55, 95% CI 1.08–2.26, and p = 0.02) and AI was associated with GCC for adjuvant chemotherapy for estrogen-receptor positive (ER+) BC (OR 1.74, 95% CI 1.17–2.59, and p = 0.01). Conclusion. GCC was associated with prior receipt of breast MRI and AI for lumpectomy plus RT and adjuvant chemotherapy for ER+ BC, respectively.

Patterns of Surveillance Advanced Imaging and Serum Tumor Biomarker Testing Following Launch of the Choosing Wisely Initiative

“…Variation in regional practice patterns and guideline adherence may also influence clinical decision-making when considering surveillance imaging. 28 Although oncologists have been shown to make guideline-concordant decisions in most clinical scenarios, 29 higher instances of guideline-discordant care have been reported regarding the diagnostic use of PET imaging and serum tumor biomarker tests in early-stage breast cancer survivors, 15,21,29 similar to our findings. Although clinician unfamiliarity with Choosing Wisely guidelines may play a partial role, anecdotal experience with perceived benefits of nonrecommended tests and reliance on smaller studies may also contribute to guideline-discordant surveillance care.…”

“…27 Patient age, family history, and tumor characteristics represent additional factors that may influence perception of recurrence risk in breast cancer survivors. 15,19 Of these previously studied factors, however, only increasing disease stage was associated with surveillance advanced imaging use in our study.…”

“…Detailed information on preauthorization policies and pathways was also limited in our dataset. 15 Lastly, because our study focused on women receiving guideline-concordant surgical therapy, we did not include those receiving lumpectomy without RT, who are at greater risk of local recurrence. As a result, our study results may not be generalizable to this small subpopulation of women.…”

“…Censoring occurred during surveillance at death or restart of treatment, defined as claims data documenting surgery, chemotherapy, or RT during surveillance, an end point that was used as a proxy for disease recurrence. 10,14,15 Clinical and tumor characteristic data were compared between women who completed their surveillance period without further treatment and those who ended surveillance early due to restart of treatment. Use of advanced imaging and serum tumor biomarker testing was compared between women with less advanced versus more advanced disease (stage 0-IIa vs stage $IIb, respectively) during both the peridiagnostic and surveillance periods.…”

Age Is Important for the Early-Stage Detection of Breast Cancer on Both Transcriptomic and Methylomic Biomarkers

“…Early-stage breast cancer was usually diagnosed by radiological imaging technologies (Simos et al, 2014) or molecular biomarkers (Duffy et al, 2015). X–ray-based mammogram (Kashyap et al, 2017; Sinthia and Malathi, 2018) and breast magnetic resonance imaging (MRI) were the predominant choices for detecting the candidate lesion sites of breast cancer (Wang et al, 2013; Loggers et al, 2016). Serum microRNA and urine DNA damage were also recently observed to have strong associations with early-stage breast cancer (Guo et al, 2017; An et al, 2018).…”