Educational initiatives regarding the American Society of Clinical Oncology (ASCO) Choosing Wisely recommendations for the use of biomarker testing in surveillance of nonmetastatic breast cancer survivors had limited influence on oncology care providers and patients, according to findings from a pilot study presented at the 2020 ASCO Quality Care Symposium, a virtual conference.1

One of the recommendations of the ASCO Choosing Wisely initiative is that neither advanced imaging tests, such as positron emission tomography (PET), computed tomography (CT), or radionuclide bone scans, nor tests to evaluate circulating tumor markers, should be part of the follow-up for survivors of stage I-III breast cancer who are asymptomatic for disease recurrence following curative-intent therapy.2

The aim of this pilot study was to evaluate baseline adherence to this recommendation in a cohort of nonmetastatic breast cancer survivors from multiple participating cancer clinics, as well as to assess the impact of an educational intervention for oncologists and patients on adherence to this recommendation.

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Adherence was defined as the absence of advanced imaging and/or circulating tumor marker testing within the first 13 months of surveillance for those patients without symptoms of recurrence. Assessments of adherence were made prior to and following separate educational interventions tailored specifically for oncologists or patients, which included a 15-minute peer-to-peer discussion for oncologists or a 4-minute video for patients.

Of the patients evaluated for adherence to the recommendation against use of advanced imaging in surveillance preintervention (802) and postintervention (724), adherence was very high at 0.99 and 1.00, respectively.

However, among the 626 patients assessed for biomarker testing prior to the educational intervention, adherence was only 0.77. Following the educational intervention, adherence increased to 0.84 among 609 patients evaluated, and this change was statistically significant (P <.05).

Of note, a wide range of adherence to the tumor marker testing recommendation was observed among the 27 providers in the evaluation. Four providers with medium/low adherence at baseline showed improvements in adherence following the intervention, although low postintervention adherence was observed for 6 providers with low adherence at baseline. 

Furthermore, patients in the postintervention population who did (130) or did not (452) participate in the educational intervention had tumor marker recommendation adherence rates of 0.90 and 0.81, respectively (P <.05).

“The higher [tumor marker] adherence among patients who viewed the video and the wide range in adherence among providers suggest that tumor marker use may be both patient- and provider-driven,” the researchers concluded.

They further added that the findings from this study suggest that “interventions targeting surveillance testing may wish to focus primarily on tumor markers and provider outreach.”


1. Kreizenbeck KL, Wong T, Jagels B, et al. A pilot study to increase adherence to ASCO Choosing Wisely recommendations for breast cancer surveillance at community clinics. J Clin Oncol. 2020;38(29_suppl);Abstr 18. doi:10.1200/JCO.2020.38.29_suppl.18

2. Rocque GB, Williams CP, Jackson BE, et al. Choosing Wisely: opportunities for improving value in cancer care delivery? J Oncol Pract. 2017;13(1):e11-e21. doi:10.1200/JOP.2016.015396