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  • Author: Rachel A. Freedman x
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Antonio Di Meglio, Nancy U. Lin, Rachel A. Freedman, William T. Barry, Eric P. Winer and Ines Vaz-Luis

Background: When monitoring patients with metastatic breast cancer (mBC), the optimal strategies for imaging and utilization of tumor markers (TM) are uncertain. Patients and Methods: We used a retrospective cohort of 302 patients with de novo mBC treated from 2000 to 2012 at Dana-Farber Cancer Institute to describe the type and timing of imaging and TM testing during the first line of treatment (baseline, first, and subsequent testing). Results: At baseline, all patients had staging scans, with increasing use of PET/PET-CT (17.5% from 2000–2002; 40.3% from 2009–2012). PET/PET-CT was used by itself in only 12.5% of cases. Overall, 30.1% of patients, of whom 80.2% had no neurologic symptoms, underwent central nervous system (CNS) screening; 78.2% of patients had baseline TM testing. Over the course of treatment, 23.5% of patients had TM retested once a month or more. Time-to-first reimaging varied by disease site (hazard ratios for shorter time-to-first reimaging [95% CI] vs bone: brain, 4.27 [1.46–12.50]; liver, 2.19 [1.39–3.46]; lung, 2.75 [1.66–4.57]), but was not associated with tumor subtype or baseline TM testing, regardless of test results. First reimaging was prompted by an elevation in TM in only 1.4% of cases. There was weak correlation between frequency of imaging and TM tests (r=0.33; R2=0.11; P<.001). Discussion: Over time, we found an increased utilization of more sophisticated imaging staging techniques, such as PET/PET-CT scan, which was mostly requested in addition to other radiographic studies. CNS evaluations were frequently performed to screen asymptomatic patients. TM testing was often ordered, both at baseline and after treatment initiation. However, patterns of imaging utilization, although appropriately influenced by clinicopathologic factors such as disease site, did not appear to be impacted by TM testing. Conclusions: Studies focused on optimizing disease monitoring, including better integration of TM testing with imaging, are encouraged.

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Kathryn J. Ruddy, Lindsey Sangaralingham, Rachel A. Freedman, Sarah S. Mougalian, Heather Neuman, Caprice Greenberg, Ahmedin Jemal, Narjust Duma, Tufia C. Haddad, Valerie Lemaine, Karthik Ghosh, Tina J. Hieken, Katie Hunt, Celine Vachon, Cary P. Gross and Nilay D. Shah

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.