Staging is overused in younger, early-stage breast cancer patients

More than one-third of younger, early-stage breast cancer patients undergo unnecessary imaging procedures—including position emission tomography (PET), computed tomography (CT), nuclear medicine bone scans (NMBS), and tumor markers (TM)—at the time of staging and diagnosis, according to research presented at the 2013 San Antonio Breast Cancer Symposium, December 10-14, 2013.

The study is the first to look at the issue of overuse of staging procedures, including imaging and tumor markers in the diagnosis setting, specifically in younger, early-stage breast cancer patients. It was presented by Carlos Barcenas, MD, assistant professor at the Department of Breast Medical Oncology at The University of Texas MD Anderson Cancer Center in Houston.

In response to the “Choosing Wisely” campaign, the American Society of Clinical Oncology (ASCO) generated a "Top 5 list" and has recommended against the use of CT, PET, TM, and NMBS in the diagnosis and staging of early-stage breast cancer at low risk for metastasis. Rather, treatment guidelines clearly state that, for women with early-stage breast cancer, the proper procedures for diagnosis include mammogram, ultrasound, clinical examination, and blood work.

"We've known that overuse of staging procedures is a problem as well it may affect the cost-effectiveness in diagnosing women with early breast cancer," said Barcenas. "ASCO's inclusion of this issue gave us the idea for the study—to investigate and understand just how pervasive the problem really is."

For the retrospective study, the researchers analyzed claims from a national employer-based database of 42,651 women from 2005 through 2010 with an initial diagnosis of breast cancer. All were younger than 65 years and had undergone a mastectomy, lumpectomy, and sentinel lymph node biopsy. Patients who underwent axillary lymph node dissection were excluded from the study because this is considered a surrogate for node-positive disease. Claims for imaging and tumor markers were analyzed between the specific period of 3 months prior to surgery and 1 month postsurgery. Researchers stratified for age, geographical location, treatment, and insurance coverage via a health maintenance organization (HMO) or preferred provider organization (PPO).

The researchers found that 37% of early-stage breast cancer patients had at least one claim for an unnecessary staging test, with minimal change in rate of that average over the 5-year period. Of note, explained Barcenas, 18% of the women had tumor markers performed, which is a staging procedure with no role in the nonmetastatic diagnosis setting. Undergoing chemotherapy had the highest association with overuse of staging procedures, with hormone and radiation therapy also associated with overuse.

Barcenas and the team also found regional differences in overuse trends, as well a higher rate of unnecessary procedures in women with PPO insurance coverage compared with those with an HMO. Also, women with breast cancer younger than 35 years were at higher odds of having one of these tests. Yet when diagnosed at such a young age, this patient population is perceived by the physician to be at higher risk of metastatic and/or aggressive disease.

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