Geographic Variation in Postoperative Imaging for Low-Risk Breast Cancer

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  • a Department of Radiology and Biomedical Imaging, Philip R. Lee Institute for Health Policy Studies, Center for Healthcare Value, Department of Medicine, Epidemiology & Biostatistics, and Department of Medicine, University of California, San Francisco, California; Diagnostic Imaging, Sutter Medical Group, Sacramento, California; and The Royal Marsden NHS Foundation Trust, Chelsea, London, United Kingdom.

Background: The objective of this study was to examine the presence and magnitude of US geographic variation in use rates of both recommended and high-cost imaging in young patients with early-stage breast cancer during the 18 month period after surgical treatment of their primary tumor. Methods: Using the Truven Health MarketScan Commercial Database, a descriptive analysis was conducted of geographic variation in annual rates of dedicated breast imaging and high-cost body imaging of 36,045 women aged 18 to 64 years treated with surgery for invasive unilateral breast cancer between 2010 and 2012. Multivariate hierarchical analysis examined the relationship between likelihood of imaging and patient characteristics, with metropolitan statistical area (MSA) serving as a random effect. Patient characteristics included age group, BRCA1/2 carrier status, family history of breast cancer, combination of breast surgery type and radiation therapy, drug therapy, and payer type. All MSAs in the United States were included, with areas outside MSAs within a given state aggregated into a single area for analytic purposes. Results: Descriptive analysis of rates of imaging use and intensity within MSA regions revealed wide geographic variation, irrespective of treatment cohort or age group. Increased probability of recommended postoperative dedicated breast imaging was primarily associated with age and treatment including both surgery and radiation therapy, followed by MSA region (odds ratio, 1.42). Increased probability of PET use—a high-cost imaging modality for which postoperative routine use is not recommended in the absence of specific clinical findings—was primarily associated with surgery type followed by MSA region (odds ratio, 1.82). Conclusions: In patients with breast cancer treated for low-risk disease, geography has effects on the rates of posttreatment imaging, suggesting that some patients are not receiving beneficial dedicated breast imaging, and high-cost nonbreast imaging may not be targeted to those groups most likely to benefit.

Author contributions: Study design, management, analysis, and/or implementation: Franc, Dean, Rugo, Seidenwurm, Sharma, Johnston, Dudley. Data programming and guidance: Copeland, Thombley, Park, Marafino. Project coordination and agreements: Dean. Statistical analysis: Boscardin. US clinical oncology direction: Rugo. UK clinical oncology direction: Johnston. US radiologic quality and value perspective: Seidenwurm. UK radiologic quality and value perspective: Sharma. Manuscript preparation: Franc, Copeland, Thombley, Park, Marafino, Rugo, Seidenwurm, Sharma, Johnston, Dudley.

Correspondence: Benjamin L. Franc, MD, MS, MBA, Department of Radiology and Biomedical Imaging, Center for Healthcare Value, University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94118. Email:

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