title: Use of posttreatment imaging and biomarkers in survivors of early-stage breast cancer: Inappropriate surveillance or necessary care?
abstract: BACKGROUND
  Advanced imaging and serum biomarkers are commonly used for surveillance in patients with early-stage breast cancer, despite recommendations against this practice. Incentives to perform such low-value testing may be less prominent in integrated health care delivery systems. The purpose of the current study was to evaluate and compare the use of these services within 2 integrated systems: Kaiser Permanente (KP) and Intermountain Healthcare (IH). The authors also sought to distinguish the indication for testing: diagnostic purposes or routine surveillance.
  
  
  METHODS
  Patients with American Joint Committee on Cancer stage 0 to II breast cancer diagnosed between 2009 and 2010 were identified and the use of imaging and biomarker tests over an 18-month period were quantified, starting at 1 year after diagnosis. Chart abstraction was performed on a random sample of patients who received testing to identify the indication for testing. Multivariate regression was used to explore associations with the use of nonrecommended care.
  
  
  RESULTS
  A total of 6585 patients were identified; 22% had stage 0 disease, 44% had stage I disease, and 34% had stage II disease. Overall, 24% of patients received at least 1 imaging test (25% at KP vs 22% at IH; P = .009) and 28% of patients received at least 1 biomarker (36% at KP vs 13% at IH; P<.001). Chart abstraction revealed that 84% of imaging tests were performed to evaluate symptoms or signs. Virtually all biomarkers were ordered for routine surveillance. Stage of disease, medical center that provided the services, and provider experience were found to be significantly associated with the use of biomarkers.
  
  
  CONCLUSIONS
  Advanced imaging was most often performed for appropriate indications, but biomarkers were used for nonrecommended surveillance. Distinguishing between inappropriate use for surveillance and appropriate diagnostic testing is essential when evaluating adherence to recommendations.
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Erin E
authors.initials: EE
authors.lastname: Hahn
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Tania
authors.initials: T
authors.lastname: Tang
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Janet S
authors.initials: JS
authors.lastname: Lee
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Corrine E
authors.initials: CE
authors.lastname: Munoz-Plaza
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Ernest
authors.initials: E
authors.lastname: Shen
authors.affiliation: Intermountain Healthcare, Salt Lake City, Utah.
authors.forename: Braden
authors.initials: B
authors.lastname: Rowley
authors.affiliation: Mid-Atlantic Permanente Research Institute, Rockville, Maryland.
authors.forename: Jared L
authors.initials: JL
authors.lastname: Maeda
authors.affiliation: Research Response Team, Kaiser Permanente Center for Health Research, Portland, Oregon.
authors.forename: David M
authors.initials: DM
authors.lastname: Mosen
authors.affiliation: Intermountain Healthcare, Salt Lake City, Utah.
authors.forename: John C
authors.initials: JC
authors.lastname: Ruckdeschel
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
mesh_terms: D000328:Adult; D000368:Aged; D014408:Biomarkers, Tumor / Q000097:blood*; D001859:Bone Neoplasms / Q000000981:diagnostic imaging / Q000556:secondary; D001943:Breast Neoplasms / Q000097:blood* / Q000175:diagnosis* / Q000208:ethnology / Q000473:pathology / Q000517:prevention & control; D002140:California / Q000453:epidemiology; D019033:Delivery of Health Care, Integrated / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008327:Mammography / Q000706:statistics & numerical data; D008499:Medical Records; D008873:Mid-Atlantic Region / Q000453:epidemiology; D008875:Middle Aged; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D015205:Northwestern United States / Q000453:epidemiology; D016017:Odds Ratio; D011159:Population Surveillance / Q000379:methods*; D049268:Positron-Emission Tomography / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012494:Sampling Studies; D017741:Survivors; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*
chemical_list: D014408:Biomarkers, Tumor
keywords: Choosing Wisely; breast cancer surveillance; guideline adherence; imaging; serum biomarkers