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Benjamin L. Franc, Timothy P. Copeland, Robert Thombley, Miran Park, Ben Marafino, Mitzi L. Dean, W. John Boscardin, Hope S. Rugo, David Seidenwurm, Bhupinder Sharma, Stephen R. Johnston, and R. Adams Dudley

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.

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Benjamin L. Franc, Kesav Raghavan, Timothy P. Copeland, Maya Ladenheim, Angela Marks, Steven Z. Pantilat, David O’Riordan, David Seidenwurm, and Michael Rabow

Purpose: For patients with advanced cancer, palliative care (PC) referral itself results in improved quality of life and lower total health care costs. While our earlier research suggests that PC referral alone does not appear to affect imaging utilization, the effect of the intensity of services for PC symptom management on utilization of imaging services is unknown. We sought to evaluate whether an association exists between the intensity of PC symptom management services and utilization of high-cost imaging at the end-of-life. Methods/Materials: Adult cancer patients who died between January 1, 2012–May 31, 2015 were identified. A PC symptom management intensity score was determined for each patient during the last year of life based upon the number of inpatient and outpatient PC service visits and the number of problems addressed within the 8 defined domains for palliative care. Frequency of utilization of nonemergent oncologic imaging was determined for the last 3 months and the last month of life. Using chi-square and Wilcoxon-rank sum tests, effects of low (<20th percentile) and high (>80th percentile) PC symptom management intensity score on the proportion of patients imaged and mean number of studies per patient (mean imaging intensity [MII]) were compared for the last 3 months and last month of life. Results: 3,772 decedents were included, with 3,523 (93.4%) never referred to PC and 249 (6.6%) referred to PC, largely before the last month of life (70.3%). Within the last 3 months and last month of life, the proportion of patients imaged was significantly greater (P<.001) in patients with high PC symptom management intensity scores when compared to those with low PC symptom management intensity scores. There was no significant difference in the mean number of imaging studies received by either group in the last 1 month or 3 months of life. (P>.05). Conclusions: The intensity of PC symptom management in end-of-life oncologic care was not associated with decreased use of nonemergent, high-cost cancer imaging in our cohort. This may suggest an opportunity for reduced high-cost imaging through further clarification of the goals of care with both patients and oncologists, although the role of imaging in the setting of PC during the end-of-life period warrants further study as well.