Breast cancer patients face increasing number of imaging visits before surgery

The researchers, led by Richard Bleicher, MD, surgical oncologist at Fox Chase, found that between 1992 and 2005, the percentage of patients who had multiple (2+) imaging visits nearly quadrupled. Bleicher says 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. Bleicher presented his group's findings Dec. 9 at the 2011 CTRC-AACR San Antonio Breast Cancer Symposium.

"The burden to the patient is increasing substantially," Bleicher says. "The number of days patients are having mammograms, MRIs, 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 begins when a patient first reports to a doctor 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, roughly one in 20 cancer patients (4.9 percent) diagnosed with invasive, non-metastatic cancer underwent imaging twice or more during the preoperative interval. By 2005, that portion had climbed to about one in 5 (19.4 percent). In the extreme case, a small subset of 20 patients underwent mammograms on five or more visits during the preoperative interval.

The researchers also found that a single imaging visit increasingly includes multiple imaging types. In 1992, 4.3 percent of patients underwent multiple types of imaging; in 2005, that rate rose to 27.1 percent.

With the increased use of imaging, Bleicher says that for physicians, "the question becomes, 'How are we affecting patients overall with what we're ordering nowadays?'"

Previous studies have examined patient burden in terms of cost, but Bleicher says he hasn't 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 says. "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," he says. "One reason might be the frequency and amount of imaging."

He points 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 climbing trend after studying data on Medicare patients from the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) program. Their results came from the records of 67,751 women who were treated for invasive, non-metastatic breast cancer with surgery and lymph node staging. The researchers omitted patients diagnosed with either metastatic disease or DCIS because those types of breast cancer require different approaches to imaging and treatment. The median age of the study participants was 75.

Bleicher says the patient's burden may be reduced if patients ask their providers why imaging is being done, 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 says.

The researchers are now diving deeper into their data to understand the trend and look for a better way to help breast cancer patients with imaging, Bleicher says. "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."

Co-authors include Karen Ruth, Elin R. Sigurdson, Kathryn Evers, Yu-Ning Wong, Marcia Boraas, and Brian L. Egleston from Fox Chase.

The study was supported, in part, by a US Public Health Services grant, an appropriation from the Commonwealth of Pennsylvania, an American Cancer Society grant, and by generous private donor support.