Improving Appropriate Care for Breast Cancer Patients

The American Society of Clinical Oncology (ASCO) recommends in Choosing Wisely against serum tumor marker tests and advanced imaging for breast cancer survivors who are asymptomatic for recurrence. Researchers from Seattle’s Fred Hutchinson Cancer Research Center evaluated baseline adherence to this recommendation in a cohort of non-metastatic breast cancer survivors from multiple cancer clinics, and prospectively tested two educational interventions: one aimed at oncologists and a second designed for patients.

“Breast cancer is the most common cancer in women and one of the most common cancers of all,” said Scott Ramsey, MD, PhD, Director of the Cancer Outcomes Research Program at the center. “Most women in early stages require monitoring over time. But excess monitoring can have a very big impact on costs while not providing additional benefits to patients.”

Study participants included patients with one or more follow-up visits within three months of the end of treatment. The interventions included academic detailing for oncologists and a brief video that provided information to patients about appropriate care following the end of their active treatment.

Results indicated:

• High baseline adherence for advanced imaging.
• Wide range in tumor marker adherence among providers.
• Tumor marker use can be both patient- and provider-driven.
• Population characteristics may impact variation in adherence.
• Higher adherence to the recommendation to avoid tumor marker testing among patients who viewed the video.

The investigators concluded that interventions targeting surveillance testing following treatment of early and regional breast cancer may wish to focus primarily on tumor markers and provider outreach. “We implemented this project in community clinics that were associated with Seattle Cancer Alliance,” Ramsey said. “These were all free-standing practices with extremely variable practice models and size. The challenge for those clinics was working on interventions focused on both physicians and patients into a very busy practice with little room for things other than their direct patient-care mission. We listened to the practices about what would and would not work. As a result of those discussions (which we started before we even did the intervention), we opted for a routine educational program that looped into clinics’ routine monthly meetings. We built videos that patients could view in the clinic while they were waiting, or at home; with no impact on clinic flow. Overall, the key to success was understanding how the clinics operate.”

The project has remained strong. “The videos are still available,” Ramsey said. “In follow-up, we have a monitoring system to track adherence to tumor marker and advanced imaging use; we report on this every year as part of the community cancer report. Individual clinics are able to look at their adherence to Choosing Wisely relative to others in the area, and see where they rank relative to the averages for the region.”

Readers can learn more about the project here.