Low adherence to annual surveillance breast imaging recommendations by women treated for cancer

By Liz Meszaros, MDLinx
Published October 20, 2016

Key Takeaways

Nearly one-third of women who have been treated for breast cancer do not go for the annual surveillance breast imaging—via mammogram or MRI—that recommendations call for, according to results of a study presented at the 2016 Annual Clinical Congress of the American College of Surgeons.

“Most of what we know about breast imaging comes from small studies or from Medicare data, a population that is 65 years old and older,” said Caprice C. Greenberg, MD, MPH, FACS, of the University of Wisconsin School of Medicine and Public Health, professor of surgery and Morgridge Distinguished Chair in Health Services Research, of the University of Wisconsin School of Medicine and Public Health, Madison, and director of the Wisconsin Surgical Outcomes Research Program (WiSOR). “This study is the first to look at a large, multi-institutional population of patients across all age groups.”

Using data from the National Cancer Database (NCBD), Dr. Greenberg and colleagues assessed the incidence of surveillance breast MRI and mammography in 9,622 women who all had a surgical procedure to treat Stage II/III breast cancer between 2006 and 2007. From the time of treatment until 5 years after diagnosis, they assessed imaging, cancer recurrence, new cancer, and death, as well as collected data on the indication for the imaging, including whether it was for diagnostic evaluation of a new sign or symptom or surveillance imaging in the absence of signs and symptoms.

“The most striking finding is that over 30% of women don’t even get surveillance breast imaging in the first place,” Dr. Greenberg said. “For some reason, we are not plugging them into follow-up surveillance from the outset. We also see that there are some disparities in the use of mammograms after the treatment of breast cancer.”

The annual incidence of surveillance breast imaging declined by 8% from the first year to the fourth year from 66% vs 58%, respectively. Researchers also found that among women who did receive surveillance breast imaging, only approximately 10% received breast MRIs. 

Factors associated with failing to undergo follow up breast imaging included younger age, black race, public or no insurance, worse health, more advanced cancers, receipt of excision alone or mastectomy (versus lumpectomy with radiation), and lack of systemic therapy.

When comparing the use of both MRI and mammography, Dr. Greenberg and colleagues found that receipt of mammography was not influenced by where a woman received her care, while MRI was.

“This finding shows that the problem is probably at the patient population level, as opposed to what we often see, which is that there is great variation in utilization of care across hospitals,” Dr. Greenberg noted. “MRI is a discretionary modality and not currently recommended in guidelines for routine surveillance following breast cancer treatment, but helpful and appropriate in certain patients. Therefore, it’s much more vulnerable to local practice patterns, whereas mammogram is something we all know is effective and, in general, the likelihood of getting it doesn’t matter where you receive your care.”

“The critical story here is that if women start off their follow-up care receiving guideline-recommended imaging, they’re likely to continue to receive that imaging over time. Women who don’t receive imaging in that first follow-up year are not likely to receive recommended surveillance breast imaging longer-term,” said study co-author Jessica R. Schumacher, PhD, an associate scientist at WiSOR.

“The bulk of the disparity seems to occur in that first year of follow up, so it’s really important to think about what we might be able to do in that timeframe to make sure women get guideline-recommended breast imaging,” she added. 

Dr. Greenberg highlighted the importance of understanding why cancer survivors aren’t receiving surveillance breast imaging and the consequences.

“We need to recognize the fact that, right now we are putting out more and more guidelines to help standardize care and to ensure patients get high quality care, but the guidelines that are already out there have been available for a long time. So I think it’s important for health care practitioners to realize that it’s not enough to just put information out there. Instead, we have to be more thoughtful about how we implement what we recommend into the actual care process,” Dr. Greenberg said.

Other study participants include Taiwo Adesoye, MD, MPH; Heather B. Neuman, MD, FACS; Stephen B. Edge, MD, FACS; Daniel P. McKellar, MD, FACS; David P. Winchester, MD, FACS; and Amanda B. Francescatti, MS.

This research was fully funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (CE-1304-6543). Publication was further made possible by CTSA Grant Numbers UL1 TR000135 and KL2TR000136-09 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH); the National Cancer Institute (NCI) of the NIH under award numbers U10CA031946, U10CA033601, U10CA180821, and U10CA180882 (to the Alliance for Clinical Trials in Oncology), U10CA076001 (to the American College of Surgeons Oncology Group), and U10CA025224 (to the North Central Cancer Oncology Group).

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