Young breast cancer patients with early-stage disease may undergo unnecessary testing when diagnosed

MD Anderson Cancer Center
Date: 12/16/2013

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Lisa Garvin:  Welcome to Cancer Newsline, a podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I am your host, Lisa Garvin, and today we will be talking about a poster that will be presented at the San Antonio Breast Cancer Symposium in December of 2013 and it discusses the use of staging procedures for women with breast cancer. My guests today are both from MD Anderson's Department of Breast Medical Oncology. We have Dr. Sharon Giordano, who is also the Chair of the Health Services Research Group, and Dr. Carlos Barcenas. Welcome to you both.

Dr. Sharon Giordano: Thank you.

Dr. Carlos Barcenas: Thank you.

Lisa Garvin:  Well, let's talk about breast staging. Obviously, staging is something that is very important in deciding the right treatment for breast cancer. Correct?

Dr. Carlos Barcenas: Yes. So, staging is something that we do with all breast cancer patients. When there are early stage breast cancer, we need to determine how extensive their disease is to determine a treatment plan for them.

Lisa Garvin:  And what sorts of procedures do you use to stage breast cancer?

Dr. Carlos Barcenas:  So, that's exactly the key question here because it depends. It depends on how extensive the tumor is. So if it is an early stage breast cancer, which is small, sometimes just labs and a clinical examination and a mammogram and an ultrasound may be just enough.

Lisa Garvin:  Now, the study that you -- apparently it was an idea that came to you after the American Society of Clinical Oncology, also known as ASCO, came up with some guidelines about a year ago. Let's talk about it. It was called Choosing Wisely.

Dr. Carlos Barcenas:  So Choosing Wisely is actually a campaign from the American Board of Internal Medicine, and so ASCO participated in this and all different specialties, including ASCO, created a list and they call it the Top Five List. And these are things, procedures that are probably overused in practice, and so the recommendations are not to use. So, sometimes less can be more.

Lisa Garvin:  So that gave you the idea for this research study.

Dr. Carlos Barcenas: Yes. Well, it spiraled after that idea. Yeah. So it was specifically on one of their points. They talk about not performing certain staging scans, imaging, for early breast cancer that has a low risk for metastases. So that's how this idea came about.

Lisa Garvin:  Now, the name of your poster presentation is Overuse of Staging Procedures in Early Breast Cancer Patients Less than 65 Years of Age. And it seems like some of the results you have come up with is that overuse seems to be very common amongst younger women.

Dr. Carlos Barcenas: That's what it appears. Yes. And the reason we use less than 65 is because, this is -- the poster that we are presenting is based on claims, databases, and this is specifically on market scan, there has been a lot more, probably, information on over 65 years of age because we use the SEER-Medicare, but less than 65, there is less information. So we thought this was a great opportunity.

Lisa Garvin:   So tell me how you went about gathering this data.

Dr. Carlos Barcenas: So the information itself, we have. These are databases that we have acquired and, you know, these are huge databases with many, many data points, and we determine, based on the claims, what the circumstances of a particular patient may have happened. Of course, claims means that the first time a cat scan was performed, we assume the cat scan was actually performed on that specific patient. So we can come up with a story specifically for a patient based just on claims. Of course there is some drawbacks and there is some, you know, things that we don't know specifically for each patient, but we definitely can make a story out of the information that we have.

Dr. Sharon Giordano: Just to clarify, when we are talking about claims, this is really looking at the medical bills. So, we are able to -- we have a database that we license, where we can look at all the bills a patient has generated over the course of his or her treatment. And based on that, we are really able to backtrack and see what kind of treatment they had and what kind of tests were ordered to help work up a patient.

Lisa Garvin:  So, I guess the question at the top of my mind is, what is the basic problem with overuse of staging procedures?

Dr. Carlos Barcenas: So, the basic problem is, it's a problem of overuse and over diagnoses and also a problem of cost. What is, you know, cost effectiveness? So, it is clear that, and we've shown this multiple times, that when somebody has an early stage breast cancer that has a low risk of metastases, there is no need to perform these tests because they are just adding costs. You're probably adding false positive findings. You're adding biopsies that the patient did not need. And at the end of the day, these will not make any difference in the outcome of the patient.

Dr. Sharon Giordano: It's really a goal, too, to improve the quality and the value of the care that we deliver. The whole point of the Choosing Wisely campaign is really to focus on providing the best quality and value care for our patients. So we don't want to be bringing people in to do unnecessary tests that they don't need. We don't want to expose them to radiation if that's not necessary. As Doctor Barcenas said, we certainly don't want to do biopsies that aren't necessary because this puts patients through an enormous amount of stress, pain, cost that is not necessary. So, when none of these have proven to have any benefit, it really doesn't make sense to have patients undergo all of these tests and procedures.

Lisa Garvin:  What do you think the drivers are, Doctor Giordano? Do you think there's like an incentive on the part of insurance companies or doctors to provide these diagnostic methods?

Dr. Sharon Giordano:  I am sure there is a whole host of reasons that this happens. I mean, sometimes there are financial incentives to provide extra testing, but sometimes it is just a natural worry about the disease. I think people inherently want to be thorough and want to do a good job and want to make sure they really understand what is going on with their patients. And unfortunately, sometimes the best of intentions lead to overuse of testing that really doesn't improve patient outcomes.

Lisa Garvin: Do you find that patients are demanding certain procedures? Is that a problem that you all have seen in your practice?

Dr. Carlos Barcenas: It may be. I think it is multi-factorial, as Doctor Giordano said. That is maybe one of the reasons. Yes.

Dr. Sharon Giordano:  Often, people are quite worried about the possibility that the cancer has spread and so they hope to get some peace of mind by having additional testing done. Unfortunately, often, it can backfire and instead of getting results that are convincingly negative, often we find lots of indeterminate lesions and things we can't tell people what they are. So even though the intent is often to reduce worry, I think in the end, often, it makes people more worried.

Lisa Garvin: Is there any way to set some sort of baseline? I mean, I know we have struggled with mammograms, trying to set some sort of baselines and, you know, how often do we do it and who should do it. Are we at that point with other diagnostic imaging like PET and so forth?

Dr. Carlos Barcenas: We follow the NCCN Guidelines and the guidelines are pretty clear on what to order, depending on the clinical stage, and it is based on this information, when or when not to order a PET CT scan, when or when not to order a CT scan or a tumor marker. And so it is very clear if somebody has very early stage breast cancer, no negative disease, these imagings are not necessary to be done. Now, it can be in a situation and where a patient, for example, they order a lab and they have elevated liver function test, for example. In that particular patient, it may be okay to order a subsequent ultrasound of the liver or a subsequent CAT scan of the liver because you are focusing on a finding based on the lab. That may be a situation. But again, you have the titrate of your clinical practice, depending on what you see with the patient. But overall, we do follow the guidelines, the NCCN Guidelines, and they are pretty clear on what to order and when not to order.

Lisa Garvin: But I would think it would be difficult in a patient-doctor situation to say, mmm -- you don't need this test. That must be really hard to bring that across to the patient, I would think.

Dr. Carlos Barcenas: Well, I think if you are clear from the beginning what the plan is and you explain to the patient why you do something or why you do not do something, to be honest, I think it is something that may be done and, particularly, I've been very successful trying to tone down, sometimes, patients that are asking for tests. I think it depends a lot on the relationship that you have with the patients. But you are right, there are some patients that have strong personalities and sometimes they will demand. But to be honest, and at least in my practice, it's not that common. To be honest.

Dr. Sharon Giordano:  Most people are pretty reasonable. I mean, I think they want things that are going to help improve their health and improve their outcomes, but when they realize that this isn't something that is likely to help them or to give them a better chance of curing the cancer, often they are relieved not to have to undergo additional tests and procedures.

Lisa Garvin: But I wonder, maybe outside of a comprehensive cancer center, or maybe even in a private practice, that these might be actually foisted upon patients. Did you discover any of that in your study?

Dr. Carlos Barcenas: We didn't look at that particularly. No. We were looking at, you know, a population. We didn't focus specifically if it was an academic center or -- we don't have that information. But, yeah, that may be the case, but we don't have that information.

Lisa Garvin: Now, you did find some interesting trends. Apparently, there were some demographic trends and some regional trends. Can you elaborate on those?

Dr. Carlos Barcenas: Well, regarding the demographical trends, we did see that the younger patients, the less than 35 years old, which is pretty young for breast cancer, had higher odds of being tested. And we think that if a patient is less than 35, in particular, we think that these patients may have more of an aggressive disease inherently, so that may trigger the need for more staging, just because they are so young. The regional differences, I think that has to do a lot with the way practices are across the United States. We have seen this, and every time we do these claims based study, we always see regional differences in many things that we do. Again, it depends a lot on how things are practiced and if it is private practice, academic practice, if it's the Northeast, if it's the South, we do see these trends. And, you know, I think the campaign of ASCO's Top Five is, you know, fairly new for the last year, year and a half, and it may take some time. You know, we may repeat this in five years and we may see a trend of this going down. I think it takes some time before this poster and these use cats, you know, it's important to make sure people understand that this is important and that there is a campaign for this.

Lisa Garvin: So what is your hope with this study and this poster presentation? Is there the hope that you can maybe help hone standardized guidelines for staging, or?

Dr. Carlos Barcenas: I think awareness. I think it's important that we understand that we have the guidelines and that there is, you know, the ASCO recommendations, but I think this brings an initial idea of what we have right now and I think it opens up the eyes of the oncologist, saying, wow, this really is a problem and we are looking at 37% of the patients had at least one of these tests performed. Twenty-five percent had tumor markers performed and that is completely not indicated for any type of early stage breast cancer. So it is clearly a problem, and I think it is awareness and probably, again, it will help the campaign.

Dr. Sharon Giordano:  Yeah, I think ASCO, by identifying these areas of overuse of care and their Choosing Wisely campaign, really is trying to, as Dr. Barcenas said, to really raise awareness and give validation so people also have permission not to order these tests. I think sometimes a lot of people feel like well maybe they have to or they're not being a good doctor if they don't do everything they possibly can do. And this is really a shift in the focus to say, well, let's do what matters for the patients. Let's do what is important and what is proven to improve outcomes and not just test for the sake of testing.

Lisa Garvin: And I would assume, I don't know if your study covered this, that there are probably millions, and perhaps billions, of dollars spent on unnecessary testing.

Dr. Carlos Barcenas: Our plan for the paper is to include cost. We don't have that information for the poster, yet, but that will be there, hopefully, so we have to stay tuned for that information.

Lisa Garvin: Now, what can women as patients -- they have just been diagnosed or they have a suspicion of cancer -- what advice would you give them as regards to staging their disease?

Dr. Carlos Barcenas: I think it's, you always think that knowledge is power and if they understand what are the guidelines and what has to be done and what not has to be done. I think that's important. You know, but sometimes patients rely on what their oncologist tells them. If their oncologist says you need something, well, most of them will say yes, or, you know, and so I think it is important for them to understand that there is some guidelines and that they can always ask why are we doing this, why are we not doing this, and the oncologist may explain to them the reasons why he ordered something or not ordered something.

Lisa Garvin: Do you see in the future, perhaps, campaigns on the level of like mammogram campaigns, where you are actually going out and saying, you know, this is what we suggest?

Dr. Sharon Giordano:  To some extent, that's what ASCO's doing right now, is, you know, going out in a very public way, saying these are the tests that we should and should not be doing. And NCCN has also done that, very publically put in their guidelines not just how we treat breast cancer, but how you work up an initial diagnosis of breast cancer. So, I think you're right. I think this is really a communication message to get out there.

Lisa Garvin: So, Dr. Barcenas, how do you see this playing out in the future?

Dr. Carlos Barcenas: I would see this playing out, if the campaign is successful, we may see decrease in these percentages of overuse, and that is something that we will, may monitor over time. And that's what I hope happens, is that we have a better use of our resources that add value to the patient and that's our hope with all this.

Lisa Garvin: Dr. Giordano, any final words?

Dr. Sharon Giordano:  Oh, I completely second those thoughts. I think our overall mission is, again, to provide the best quality care and the best value care for our patients so that that's why we want to bring attention to these types of findings.

Lisa Garvin: So, more care doesn't necessarily translate into better care?

Dr. Sharon Giordano:  No. Often, it's not.

Lisa Garvin: Great. Thank you both very much.

Dr. Sharon Giordano:  Thank you.

Dr. Carlos Barcenas: Thank you.

Lisa Garvin:   If you have questions about anything you have heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789 or online at Thank you for listening to this episode of Cancer Newsline. Tune in for the next Podcast in our series.

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