Advanced Imaging Modalities in Early Stage Breast Cancer: Preoperative Use in the United States Medicare Population

Abstract

INTRODUCTION Guidelines for breast cancer staging exist, but adherence remains unknown. This study evaluates patterns of imaging in early-stage breast cancer usually reserved for advanced disease. METHODS Surveillance Epidemiology and End Results data linked to Medicare claims from 1992–2005 were reviewed for stage I/II breast cancer patients. Claims were searched for preoperative performance of CT, PET, and bone scans, and brain MRIs (“advanced imaging”). RESULTS There were 67,874 stage I/II breast cancer patients; 18.8% (n=12,740) had preoperative advanced imaging. The proportion of patients having CTs, PET scans and brain MRIs increased from 5.7% to 12.4% (p<0.0001), 0.8% to 3.4% (p<0.0001) and 0.2% to 1.1% (p=0.008), respectively, from 1992–2005. Bone scans declined from 20.1% to 10.7% (p<0.0001). “Breast cancer” (174.x) was the only diagnosis code associated with 62.1% of PET scans, 37.7% of bone scans, 24.2% of CTs, and 5.1% of brain MRIs. ≥1 symptom or metastatic site was suggested for 19.6% of bone scans, 13.0% of CTs, 13.0% of PET scans and 6.2% of brain MRIs. Factors associated (p<0.05) with use of all modalities were urban setting, breast MRI and ultrasound. Breast MRI was the strongest predictor (p<0.0001) of bone scan (OR1.63, 95%CI 1.44–1.86), Brain MRI (OR1.74, 95%CI 1.15–2.63), CT (OR2.42, 95%CI 2.12–2.76), and PET (OR5.71, 95%CI 4.52–7.22). CONCLUSION Aside from bone scans, performance of advanced imaging is increasing in early-stage Medicare breast cancer patients, with limited rationale provided by coded diagnoses. In light of existing guidelines and increasing scrutiny about healthcare costs, greater reinforcement of current indications is warranted.

Assessment of multifocality and axillary nodal involvement in early-stage breast cancer patients using 18F-FDG PET/CT compared to contrast-enhanced and diffusion-weighted magnetic resonance imaging and sentinel node biopsy

“…Advanced imaging methods including 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and brain magnetic resonance imaging (MRI), have traditionally not been used to assess such patients, because the frequency of distant metastases in ESBC is very low. However, the latter techniques have become increasingly applied in recent years (1).…”

Use of Preoperative Magnetic Resonance Imaging for Breast Cancer

“…described rapid expansion of breast pMRI use in the United States, 4,5,[19][20][21] ranging from a 3-4 to 20-fold 5 increase in the past 10 years. To our knowledge, there are no large-scale studies demonstrating the potential associated downstream negative consequences associated with pMRI in routine clinical practice.…”

Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study

“…2 This low frequency has not changed significantly, even with the increasing use of magnetic resonance imaging (MRI) and positron emission tomography. 2,3 For this reason, most provincial, national and international guidelines do not recommend imaging for all patients with earlystage breast cancer who are asymptomatic. [4][5][6][7][8] Despite these evidence-based guidelines, imaging for distant metastases in patients with a new diagnosis of breast cancer remains common.…”