Article Title

Use of Low-Value Surveillance Services for Early Stage Breast Cancer Survivors

Publication Date



breast cancer surveillance, low-value services


Background/Aims: Guidelines from the National Comprehensive Cancer Network and the American Society of Clinical Oncology recommend against aggressive surveillance for early stage breast cancer survivors. However, breast cancer survivors commonly receive nonrecommended services, including advanced imaging and biomarker tests. The objective of this study was to measure use of posttreatment breast cancer surveillance services including carcinogenic antigen biomarker tests and advanced imaging in two integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH), and to identify potential target areas for de-implementation of low-value services.

Methods: We identified stage 0–IIB breast cancer patients diagnosed with first primary malignancy between January 1, 2009, and December 31, 2010, from tumor registries in three KP regions and all four IH regions. Using the KP and IH electronic health records, we identified use of advanced imaging tests (positron emission tomography [PET], computerized tomography [CT], bone scan) and biomarker tests over 18 months, starting one year after diagnosis. We excluded services performed in the emergency department or inpatient setting. We performed chart abstraction on a stratified random sample of patients who received an imaging or biomarker test to identify clinical indication: diagnostic (used in response to a clinical sign or symptom) or surveillance.

Results: Of the total sample of 7,217 patients, 23% received at least one imaging test during the surveillance period, including 25% at KP and 20% at IH (P<0.05), and 27% of patients received at least one biomarker test, 36% at KP and 12% at IH (P<0.05). Chart abstraction (n=155) revealed that the majority of imaging services (90%) were diagnostic, while the majority of biomarker (96%) tests were used for surveillance in absence of documented signs or symptoms.

Discussion: There is substantial use of imaging services and biomarker tests during posttreatment care of early stage breast cancer patients. Review of health records revealed that the majority of imaging services were performed in response to clinical signs or symptoms, while the overwhelming majority of biomarker tests were performed for surveillance. Next steps include developing a tailored strategy that incorporates input from oncology clinicians to reduce use of surveillance biomarker tests as a care improvement project.




March 30th, 2015


April 28th, 2015