Breast cancer patients frequently undergo imaging tests such as mammograms or ultrasound scanning between their first breast cancer-related physician visit and surgery to remove the tumor.

Assessments of these scans help physicians better understand an individual’s disease and determine the best course of treatment. In recent years, however, imaging has increased in dramatic and substantial ways.

More patients have repeat visits for imaging more than they had 20 years ago, and single imaging appointments increasingly include multiple types of imaging. The researchers, led by Richard Bleicher, MD, a surgical oncologist from Fox Chase Cancer Center (Philadelphia, PA, USA), discovered that between 1992 and 2005, the percentage of patients who had multiple (2+) imaging visits nearly quadrupled. Dr. Bleicher reported that additional visits present a burden to patients, many of whom are elderly, but the stress may be alleviated through better coordination and evaluation by physicians. Dr. Bleicher presented his group’s findings at the 2011 CTRC-AACR San Antonio (TX, USA) Breast Cancer Symposium, in December 2011.

“The burden to the patient is increasing substantially,” Dr. Bleicher said. “The number of days patients are having mammograms, MRIs [magnetic resonance imaging], and ultrasounds is going up steadily year by year. They’re having imaging done more frequently on separate dates during the preoperative interval than ever before. It’s surprising.”

The preoperative interval starts when a patient first reports to a physician with a breast complaint and ends when the patient undergoes therapeutic surgery to resect a tumor. For the more than 65,000 patients involved in the study, the preoperative interval lasted 37 days on average. The Fox Chase researchers found that in 1992, about one in 20 cancer patients (4.9%) diagnosed with invasive, nonmetastatic cancer underwent imaging twice or more during the preoperative interval. By 2005, that portion had climbed to about one in five (19.4%). In the extreme instance, a small subset of 20 patients underwent mammograms on five or more visits during the preoperative interval.

The researchers also found that only one imaging visit increasingly includes multiple imaging types. In 1992, 4.3% of patients underwent multiple types of imaging; in 2005, that rate increased to 27.1%. With the increased use of imaging, Dr. Bleicher stated that for physicians, “the question becomes, ‘How are we affecting patients overall with what we’re ordering nowadays?’”

Earlier research has assessed patient burden in terms of cost, however, Dr. Bleicher noted that he has not seen studies that focus on the patient burden in terms of the patient’s time. “I wanted to take a look at how things have been changing for patients and how many times they have to travel back and forth to get more imaging,” he said. “Physicians need to keep in mind that it’s hard enough for working people to take off from work and trek back and forth to appointments, but older people have infirmities, and it’s harder to get around. The coordination of care is very important. We need to focus more on the burden to the patient.”

Other studies have shown an increase in the cost of breast cancer care--but the cost of imaging is rising even faster. “We know the costs are going up, but we don’t know why,” Dr. Bleicher remarked. “One reason might be the frequency and amount of imaging.” He pointed out that when more than one set of imaging is done on the same day, “There are perversities of the reimbursement system that may foster these separate visits, although I don’t know if that’s why we're seeing this phenomenon.”

The researchers discovered the rising trend after studying data on US Medicare patients from the US National Cancer Institute’s (Bethesda, MD, USA) Surveillance Epidemiology and End Results (SEER) program. Their findings came from the records of 67,751 women who were treated for invasive, nonmetastatic breast cancer with surgery and lymph node staging. The researchers omitted patients diagnosed with either metastatic disease or ductal carcinoma in situ (DCIS because those types of breast cancer require different approaches to imaging and treatment. The average age of the study participants was 75.

Dr. Bleicher noted that the patient’s worry might be reduced if patients ask their providers the reason why imaging is being performed, and work together to make the process smoother. “If they do need imaging, then they might ask their physician, especially if they're of an older age, whether or not they think they’re going to need additional types of imaging and if those can be scheduled together,” he said.

The researchers are now going deeper into their data to understand the trend and look for a better way to help breast cancer patients with imaging, according to Dr. Bleicher. “We want to see whether or not there is a more efficient method of imaging the patients so that we’re improving outcomes without increasing costs.”

 

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