Are We ‘Choosing Wisely’? Use of Surveillance Advanced Imaging and Serum Tumor Biomarker Testing in Older Women with Breast Cancer

OBJECTIVES: The American Society of Clinical Oncology’s (ASCO) Choosing Wisely (CW) initiative recommends against the use of surveillance testing (ST) of asymptomatic women with breast cancer (BC) using advanced imaging or serum tumor biomarkers testing. We evaluated if CW impacted the use of ST in women with BC. Also, its predictors were identified.

METHODS: A retrospective observational cohort study using the Surveillance, Epidemiology, End Results-Medicare database was conducted. Women age >66 years diagnosed with stage 0-III BC during 2007-2014 who had completed their cancer treatment (N=62,782) were included. ST during six months post-treatment was identified. The proportion of patients who received ST procedures were determined. An interrupted time-series (ITS) analysis and segmented regression were conducted to examine if CW was associated with ST use and to estimate the magnitude of change. A multivariable logistic regression was conducted for the post-CW group to identify predictors of receipt of ST.

RESULTS: During 2007-2014, 37.2% of the study cohort received ST prior to the launch of CW in April 2012 compared to 33.1% post-CW. From the ITS analysis, there was a significant 0.21 per 100 patients per quarter decrease in the use of ST procedures pre-CW (p<0.0001). However, there was a marginal increase of 0.23 per 100 patients per quarter immediately following the implementation of CW and a significant 0.18 per 100 patients per quarter decrease in the use of ST procedures due to CW (p<0.0001). Residence in Northeast, presence of ≥2 comorbidities, having moderately or poorly differentiated tumor, regional lymph node involvement, having relatively advanced tumor stage, and having a triple negative tumor significantly increased the odds of ST.

CONCLUSIONS: A slow reduction of use of ST procedures in older women with BC who completed their treatment occurred following the ASCO’s CW recommendation, which underscores the substantial opportunity to reduce the use of this unnecessary care.