Adherence to Guidelines for Breast Surveillance in Breast Cancer Survivors

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Kathryn J. Ruddy Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Lindsey Sangaralingham Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Rachel A. Freedman Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Sarah S. Mougalian Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Heather Neuman Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Caprice Greenberg Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Ahmedin Jemal Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Narjust Duma Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Tufia C. Haddad Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Valerie Lemaine Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Karthik Ghosh Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Tina J. Hieken Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Katie Hunt Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Celine Vachon Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Cary P. Gross Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Nilay D. Shah Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.
Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.
Department of Oncology, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Cancer Society, Atlanta, Georgia; Departments of Surgery, Medicine, Radiology, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota; and OptumLabs, Cambridge, Massachusetts.

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Background: Guidelines recommend annual mammography after curative-intent treatment for breast cancer. The goal of this study was to assess contemporary patterns of breast imaging after breast cancer treatment. Methods: Administrative claims data were used to identify privately insured and Medicare Advantage beneficiaries with nonmetastatic breast cancer who had residual breast tissue (not bilateral mastectomy) after breast surgery between January 2005 and May 2015. We calculated the proportion of patients who had a mammogram, MRI, both, or neither during each of 5 subsequent 13-month periods. Multinomial logistic regression was used to assess associations between patient characteristics, healthcare use, and breast imaging in the first and fifth years after surgery. Results: A total of 27,212 patients were followed for a median of 2.9 years (interquartile range, 1.8–4.6) after definitive breast cancer surgery. In year 1, 78% were screened using mammography alone, 1% using MRI alone, and 8% using both tests; 13% did not undergo either. By year 5, the proportion of the remaining cohort (n=4,790) who had no breast imaging was 19%. Older age was associated with an increased likelihood of mammography and a decreased likelihood of MRI during the first and fifth years. Black race, mastectomy, chemotherapy, and no MRI at baseline were all associated with a decreased likelihood of both types of imaging. Conclusions: Even in an insured cohort, a substantial proportion of breast cancer survivors do not undergo annual surveillance breast imaging, particularly as time passes. Understanding factors associated with imaging in cancer survivors may help improve adherence to survivorship care guidelines.

Author contributions: Study concept: Ruddy. Study design: Ruddy, Sangaralingham, Freedman, Mougalian, Neuman, Greenberg, Jemal, Gross, Shah. Funding acquisition: Ruddy. Data analysis: Sangaralingham. Interpretation of results: Ruddy, Freedman, Mougalian, Neuman, Greenberg, Jemal, Duma, Haddad, Lemaine, Ghosh, Hieken, Hunt, Vachon, Gross, Shah. Manuscript preparation: Ruddy. Critical revision and final approval: All authors.

Correspondence: Kathryn J. Ruddy, MD, MPH, Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Email: Ruddy.kathryn@mayo.edu
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