Baseline radiological staging in primary breast cancer: impact of educational interventions on adherence to published guidelines

Characteristics and impact of interventions to support healthcare providers' compliance with guideline recommendations for breast cancer: a systematic literature review

BACKGROUND

Breast cancer clinical practice guidelines (CPGs) offer evidence-based recommendations to improve quality of healthcare for patients. Suboptimal compliance with breast cancer guideline recommendations remains frequent, and has been associated with a decreased survival. The aim of this systematic review was to characterize and determine the impact of available interventions to support healthcare providers' compliance with CPGs recommendations in breast cancer healthcare.

METHODS

We searched for systematic reviews and primary studies in PubMed and Embase (from inception to May 2021). We included experimental and observational studies reporting on the use of interventions to support compliance with breast cancer CPGs. Eligibility assessment, data extraction and critical appraisal was conducted by one reviewer, and cross-checked by a second reviewer. Using the same approach, we synthesized the characteristics and the effects of the interventions by type of intervention (according to the EPOC taxonomy), and applied the GRADE framework to assess the certainty of evidence.

RESULTS

We identified 35 primary studies reporting on 24 different interventions. Most frequently described interventions consisted in computerized decision support systems (12 studies); educational interventions (seven), audit and feedback (two), and multifaceted interventions (nine). There is low quality evidence that educational interventions targeted to healthcare professionals may improve compliance with recommendations concerning breast cancer screening, diagnosis and treatment. There is moderate quality evidence that reminder systems for healthcare professionals improve compliance with recommendations concerning breast cancer screening. There is low quality evidence that multifaceted interventions may improve compliance with recommendations concerning breast cancer screening. The effectiveness of the remaining types of interventions identified have not been evaluated with appropriate study designs for such purpose. There is very limited data on the costs of implementing these interventions.

CONCLUSIONS

Different types of interventions to support compliance with breast cancer CPGs recommendations are available, and most of them show positive effects. More robust trials are needed to strengthen the available evidence base concerning their efficacy. Gathering data on the costs of implementing the proposed interventions is needed to inform decisions about their widespread implementation.

TRIAL REGISTRATION

CRD42018092884 (PROSPERO).

Clinicopathologic Features Predictive of Distant Metastasis in Patients Diagnosed With Invasive Breast Cancer

PURPOSE

National Comprehensive Cancer Network and European Society for Medical Oncology guidelines suggest screening for distant metastasis (M1) in symptomatic patients or those with locally advanced breast cancer. These guidelines are based on studies that often used pathologic staging for analysis. Physician variability in screening for M1 has also resulted in overuse of diagnostic tests. We sought to identify clinicopathologic features at diagnosis that could guide testing for metastatic disease.

METHODS

Patients diagnosed with invasive breast cancer between January 2014 and December 2015 were identified from our institutional database. Demographic and clinical variables were collected, including receptor profiles and clinical TNM staging. Rates of upstaging for each clinical stage and rates of concordance of pathologic and clinical staging were analyzed. Univariate analysis and multivariate regression analysis (P < .05) identified predictors of upstaging to stage IV disease.

RESULTS

A total of 370 patients met the inclusion criteria. Seventy patients (18.9%) had metastatic disease at diagnosis. The rate of upstaging for stages I, IIA, IIB, and III were 0%, 5.6%, 18.8%, and 36.6%, respectively. Advancing clinical stage, tumor size, and nodal status resulted in a significantly higher rate (P < .001) of upstaging to M1 disease. Age and hormone receptor status were not associated with upstaging to stage IV disease. Clinical stages I-III were concordant with pathologic staging in 65(42.8%) of 152 patients (kappa’s index, 0.197; P < .000).

CONCLUSION

Advancing clinical stage, tumor size, and nodal status at diagnosis were predictive of upstaging to M1 disease in patients with breast cancer. Distant metastatic workup should be considered in patients with clinical stage IIB disease or higher.

The use of imaging in endometrial cancer prior to potential surgery: Are guidelines being followed?

OBJECTIVES

Clinical practice guidelines recommend against routine preoperative axial imaging studies (CT/MRI) for endometrial cancer, except for cases of locally advanced disease or aggressive histologies. This study utilized population-based data to evaluate the use of preoperative imaging and factors associated with its use.

METHODS

A population-based cohort of women diagnosed with endometrial cancer from 2006 to 2016 were identified from the Ontario Cancer Registry in Ontario, Canada. Patients were excluded if they had: hysterectomy prior to the date of diagnosis, non-epithelial histology or a prior cancer diagnosis within 5 years. Preoperative imaging (CT or MRI) rates were calculated over time. Predictive factors for preoperative imaging use were determined using multi-variable regression analysis.

RESULTS

17,718 cases were eligible for analysis. From 2006 to 2016, the proportion of patients receiving preoperative imaging increased from 22.2% to 39.3%. In a subgroup of patients with low-risk disease (stage 1, endometrioid adenocarcinoma), imaging increased from 16.3% to 29.5%. Multivariate analysis showed an association between preoperative imaging and advanced stage, advanced grade, non-endometrioid morphology, surgery with a gynecologic oncologist, surgery at a teaching hospital and a later year of diagnosis. From 2006 to 2016, the yearly incidence of endometrial cancer increased from 22.3/100,000 to 36.1/100,000, representing a mean annual increase of 3.6% per year.

CONCLUSIONS

Endometrial cancer incidence and the use of preoperative imaging are increasing. Factors most associated with preoperative imaging are high-risk features. However, preoperative imaging is still being performed in low-risk patients, indicating non-adherence to guidelines, which has implications for constrained healthcare resources.

Audit of routine preoperative blood test requests for patients undergoing elective breast surgery: Less is more

In 2016, the National Institute for Health and Care Excellence updated guidelines on preoperative blood tests for elective surgery; with failure of adherence having implications for both patients and healthcare providers. A local audit was performed on 919 patients undergoing elective breast surgery that determined compliance and the financial implications of performing inappropriate preoperative blood tests against the National Institute for Health and Care Excellence guideline. Initial findings of an unacceptable quantity of inappropriate blood tests led to the education of the pre-assessment clinic staff regarding the guidelines along with the development of a poster to guide the ordering of appropriate tests. A re-audit of 451 patients assessed impact of interventions which resulted in a significant reduction in the number of blood tests requested with a 71% reduction in financial expenditure. The blood tests considered inappropriate in both the initial and re-audit did not add any relevant clinical information and abnormal results did not alter the clinical course of the patient.

Adherence to guidelines for baseline staging in newly diagnosed localized breast cancer

RATIONALE, AIMS, AND OBJECTIVES

Different health agencies in Canada including Cancer Care Ontario (CCO) have developed guidelines for the baseline staging of newly diagnosed breast cancer patients but adherence to them is unknown. We sought to investigate adherence to CCO staging guidelines in a single cancer center in addition to the factors that influence this adherence.

METHOD

A retrospective chart review was conducted on 212 newly diagnosed breast cancer patients between 2015 and 2017. Baseline patient demographic and disease characteristics as well as radiologic staging studies and subsequent treatments were recorded. The group of patients in whom the guidelines were observed was compared to the group of patients in whom the guidelines were not followed.

RESULTS

Staging guidelines were not followed in 46.7% of the patients in the cohort (99 of 212 patients). In most cases, deviations from the guidelines consisted of performing more than the recommended baseline screening, most commonly in the form of a computerized tomography (CT) scan or a bone scan and chest x-ray (CXR)/ ultrasound (US) of the liver. Less commonly, a recommended staging evaluation was omitted or the suggested timing of the staging procedure (i.e., pre-operatively versus post-operatively) was not followed. Higher stage and grade of the disease and subsequent chemotherapy administration were associated with higher guideline non-adherence.

CONCLUSIONS

Low adherence to staging guidelines for newly diagnosed breast cancer according to CCO is shown in a community cancer center. Incorporation of arising prognostic factors to staging procedure determination may increase acceptance and adherence to guidelines in the future.

Cost implications of unwarranted imaging for distant metastasis in women with early-stage breast cancer in Ontario

INTRODUCTION

Despite the publication of multiple evidence-based guidelines recommending against routine imaging for distant metastasis in patients with early-stage (i/ii) breast cancer, such imaging is frequently performed. The present retrospective cohort study was conducted to estimate the cost of unnecessary imaging tests in women with stage i and ii breast cancer diagnosed between 1 January 2007 and 31 December 2012 in Ontario.

METHODS

We obtained patient-level demographic and tumour data from a large provincial dataset. The total cost of unwarranted imaging tests (in 2015 Canadian dollars) was considered to be equal to the sum of imaging costs incurred between 2007 and 2012 and was stratified by disease stage, imaging modality, and body site.

RESULTS

Of the 26,547 identified patients with early-stage breast cancer, 22,811 (85.9%) underwent at least 1 imaging test, with an average of 3.7 tests per patient (3.2 for stage i patients and 4.0 for stage ii patients) over 5 years. At least 1 imaging test was performed in 79.6% of stage i and 92.7% of stage ii patients. During a 5-year period, the cost of unwarranted imaging in patients with early-stage breast cancer ranged from CA$4,418,139 to CA$6,865,856, depending on guideline recommendations.

CONCLUSIONS

Our study highlights the substantial cost of excess imaging that could be saved and re-allocated to patient care if evidence-based guidelines are followed. Future studies should assess strategies to ensure that evidence-based guidelines are followed and to increase awareness of the cost implications of nonadherence to guidelines.

Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study

BACKGROUND

Practice guidelines recommend that imaging to detect metastatic disease not be performed in the majority of patients with early-stage breast cancer who are asymptomatic. We aimed to determine whether practice patterns in Ontario conform with these recommendations.

METHODS

We used provincial registry data to identify a population-based cohort of Ontario women in whom early-stage, operable breast cancer was diagnosed between 2007 and 2012. We then determined whether imaging of the skeleton, thorax, and abdomen or pelvis had been performed within 3 months of tissue diagnosis. We calculated rates of confirmatory imaging of the same body site.

RESULTS

Of 26,547 patients with early-stage disease, 22,811 (85.9%) had at least one imaging test, and a total of 83,249 imaging tests were performed (mean of 3.7 imaging tests per patient imaged). Among patients with pathologic stage I and II disease, imaging was performed in 79.6% (10,921/13,724) and 92.7% (11,882/12,823) of cases, respectively. Of all imaging tests, 19,784 (23.8%) were classified as confirmatory investigations. Imaging was more likely for patients who were younger, had greater comorbidity, had tumours of higher grade or stage or had undergone preoperative breast ultrasonography, mastectomy or surgery in the community setting.

INTERPRETATION

Despite recommendations from multiple international guidelines, most Ontario women with early-stage breast cancer underwent imaging to detect distant metastases. Inappropriate imaging in asymptomatic patients with early-stage disease is costly and may lead to harm. The use of population datasets will allow investigators to evaluate whether or not strategies to implement practice guidelines lead to meaningful and sustained change in physician practice.

Use of imaging for staging of early-stage breast cancer in two integrated health care systems: adherence with a choosing wisely recommendation

PURPOSE

Advanced imaging is commonly used for staging of early-stage breast cancer, despite recommendations against this practice. The objective of this study was to evaluate and compare use of imaging for staging of breast cancer in two integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was routine or used for diagnostic purposes.

METHODS

We identified patients with stages 0 to IIB breast cancer diagnosed between 2010 and 2012. Using KP and IH electronic health records, we identified use of computed tomography, positron emission tomography, or bone scintigraphy 30 days before diagnosis to 30 days postsurgery. We performed chart abstraction on a random sample of patients who received a presurgical imaging test to identify indication.

RESULTS

For the sample of 10,010 patients, mean age at diagnosis was 60 years (range, 22 to 99 years); with 21% stage 0, 47% stage I, and 32% stage II. Overall, 15% of patients (n = 1,480) received at least one imaging test during the staging window, 15% at KP and 14% at IH (P = .5). Eight percent of patients received imaging before surgery, and 7% postsurgery. We found significant intraregional variation in imaging use. Chart abstraction (n = 129, 16% of patients who received presurgical imaging) revealed that 48% of presurgical imaging was diagnostic.

CONCLUSION

Use of imaging for staging of low-risk breast cancer was similar in both systems, and slightly lower than has been reported in the literature. Approximately half of imaging tests were ordered in response to a sign or symptom.

Imaging for metastatic disease in patients with newly diagnosed breast cancer: are doctor's perceptions in keeping with the guidelines?

RATIONALE, AIMS AND OBJECTIVES

Despite multiple guidelines advocating against routine radiological evaluation for metastases in women with early stage breast cancer, imaging is still frequently overused. The objective of this study was to assess doctor's views on imaging guidelines, and an attempt to establish why personal and local clinical practice patterns regarding imaging may differ from current guidelines.

METHODS

Canadian doctors who treat breast cancer were invited by email to complete an online survey developed by members of the research team.

RESULTS

Responses were received from 173 physicians (26% response rate). Most (82%) indicated awareness of at least one published imaging guideline. Sixty per cent indicated that they had read the recommendations of the 2012 American Society of Clinical Oncology 'Top 5' list for choosing wisely in oncology imaging and, of those, 81% agreed with it. However, most indicated that this recommendation has not influenced them to order less imaging. Over 95% of doctors identified suspicious history, physical examination findings and inflammatory breast cancer as important factors for performing imaging. The majority did not feel that patient demand, fear of litigation or ease of access to imaging influenced their ordering for imaging.

CONCLUSIONS

The majority of breast cancer doctors are aware of and generally agree that guidelines pertaining to staging imaging for early breast cancer are reflective of evidence. Despite this, adherence is variable and factors such as local practice patterns and disease biology may play a role. Alternative strategies, beyond simply publishing recommendations, are therefore required if there is to be a sustained change in doctor behaviour.

Are Physicians Choosing Wisely When Imaging for Distant Metastases in Women With Operable Breast Cancer?

PURPOSE

In 2012, the American Society of Clinical Oncology (ASCO) published its inaugural Top Five recommendations for "choosing wisely" in oncology. One recommendation was to avoid imaging for metastatic disease in asymptomatic patients with early-stage breast cancer. We assessed whether local practice is in keeping with provincial practice guidelines and whether publication of the ASCO recommendations had any significant impact on this.

METHODS

A retrospective review of staging imaging for distant metastases was performed in patients with primary operable (early-stage) breast cancer seen at a large Canadian academic cancer center.

RESULTS

A total of 200 patient medical records were reviewed: 100 patients from 2011 (pre-ASCO Top Five), and 100 after September 2012 (post-ASCO Top Five). Baseline patient and tumor characteristics were similar in both groups. Overall, 169 patients (84.5%) underwent at least one imaging test (mean, 3.6 tests per imaged patient); 154 patients (77.0%) underwent imaging that was not in keeping with the spirit of the local guideline recommendations. The frequency of imaging did not change after publication of the ASCO recommendations. Furthermore, imaging to clarify indeterminate initial imaging was required in 51 (30.2%) of 169 patients. None of the confirmatory imaging results ultimately revealed metastatic disease.

CONCLUSION

Despite the presence of local imaging guidelines, patients with early-stage breast cancer still undergo imaging for distant metastases. There was no reduction in imaging after publication of the ASCO Top Five recommendations. Broader knowledge translation strategies beyond publication are needed if recommendations are to be implemented into routine clinical practice.

Appropriateness of imaging for lung cancer staging in a national cohort

PURPOSE

Optimizing evidence-based care to improve quality is a critical priority in the United States. We sought to examine adherence to imaging guideline recommendations for staging in patients with locally advanced lung cancer in a national cohort.

METHODS

We identified 3,808 patients with stage IIB, IIIA, or IIIB lung cancer by using the national Department of Veterans Affairs (VA) Central Cancer Registry (2004-2007) and linked these patients to VA and Medicare databases to examine receipt of guideline-recommended imaging based on National Comprehensive Cancer Network and American College of Radiology Appropriateness Criteria. Our primary outcomes were receipt of guideline-recommended brain imaging and positron emission tomography (PET) imaging. We also examined rates of overuse defined as combined use of bone scintigraphy (BS) and PET, which current guidelines recommend against. All imaging was assessed during the period 180 days before and 180 days after diagnosis.

RESULTS

Nearly 75% of patients received recommended brain imaging, and 60% received recommended PET imaging. Overuse of BS and PET occurred in 25% of patients. More advanced clinical stage and later year of diagnosis were the only clinical or demographic factors associated with higher rates of guideline-recommended imaging after adjusting for covariates. We observed considerable regional variation in recommended PET imaging and overuse of combined BS and PET.

CONCLUSION

Receipt of guideline-recommended imaging is not universal. PET appears to be underused overall, whereas BS demonstrates continued overuse. Wide regional variation suggests that these findings could be the result of local practice patterns, which may be amenable to provider education efforts such as Choosing Wisely.

Patient perceptions and expectations regarding imaging for metastatic disease in early stage breast cancer

Purpose

The probability of detecting radiologically evident metastatic disease in asymptomatic women with newly diagnosed operable breast cancer is low. Despite the recommendations of most practice guidelines imaging is still frequently performed. Relatively little is known about what patients believe is important when it comes to radiologic staging.

Methods

Patients with early stage breast cancer who had completed their definitive breast surgery were surveyed about their personal experiences, perceptions, and expectations on the issue of perioperative imaging for distant metastatic disease.

Results

Over a 3 month period, 245 women with primary operable breast cancer completed the questionnaire (87.0% response rate) and 80.8% indicated having had at least one imaging test for distant metastatic disease. These were either of the thorax (72.2%), abdomen (55.9%) or skeleton (65.3%) with a total of 701 imaging tests (average of 3.5 tests per patient imaged) performed. Overall, 57.1% indicated that they would want imaging done if the chance of detecting metastases was ≤10%. Although 80.0% of patients indicated that, “doing whatever their doctor recommended” was important to them, 70.4% also noted that they would be uncomfortable if their physician did not order imaging, even if this was in keeping with practice guidelines.

Conclusions

Most patients with early stage breast cancer recall having imaging tests for distant metastases. Given the choice, most would prefer having imaging performed, even if this is not in line with current guidelines. If patient expectations are, in part, driving excessive imaging, new strategies addressing this are required.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-3-176) contains supplementary material, which is available to authorized users.

Staging Investigations in Breast Cancer: Collective Opinion of UK Breast Surgeons

Introduction. Certain clinicopathological factors are associated with a higher likelihood of distant metastases in primary breast cancer. However, there remains inconsistency in which patients undergo formal staging for distant metastasis and the most appropriate investigation(s). Aims. To identify UK surgeon preferences and practice with regard to staging investigations for distant metastases. Methods. A survey was disseminated to members of the Association of Breast Surgery by e-mail regarding surgeon/breast unit demographics, use of staging investigations, and local policy on pre/postoperative staging investigations. Several patient scenarios were also presented. Results. 123 of 474 (25.9%) recipients completed the survey. Investigations routinely employed for patients diagnosed with early breast cancer included serological/haematological tests (72% respondents), axillary ultrasound (67%), liver ultrasound (2%), chest radiograph (36%), and computed tomography (CT) (1%). Three areas contributed to decisions to undertake staging by CT scan: tumour size, axillary nodal status, and plan for chemotherapy. There was widespread variation as to criteria for CT staging based on tumour size and nodal status, as well as the choice of staging investigation for the clinical scenarios presented. Conclusions. There remains variation in the use of staging investigations for distant disease in early breastcancer despite available guidelines.

Is knowledge translation adequate? A quality assurance study of staging investigations in early stage breast cancer patients

After primary surgery, patients diagnosed with early stage breast cancer undergo radiological investigations based on pathologic stage of disease to rule out distant metastases. Published guidelines can aid clinicians in determining which tests are appropriate based on stage of disease. We wished to assess the consistency of radiological staging in an academic community oncology setting with standard guidelines and to determine the overall impact of non-adherence to these guidelines. A retrospective cohort study was conducted for new breast cancer patients seen at a single institution between January 2009 and April 2010. Patients were included if initial diagnosis and primary surgery was at this institution. Pathologic stage and radiological tests completed were recorded. A literature review was performed and the results were compared with those from this study to determine overall adherence rates. Subsequently, a cost analysis was performed to determine the financial impact at this centre. 231 patients met eligibility criteria for inclusion in this study. A large proportion of patients were over-staged with 129 patients (55%) undergoing unnecessary investigations according to guidelines. Specifically, 59% of stage I patients and 58% of stage II patients were over-investigated. Distant metastases at the time of diagnosis were found in three patients, all of whom had stage III disease (1.3%). The literature reviewed revealed similar non-adherence rates in other centres. The estimated cost of such non-adherence is in the range of $78 (CDN) per new early stage breast cancer patient seen at this centre. This oncology centre has a low adherence to practice guidelines for staging investigations in breast cancer patients, with 55% of patients undergoing unnecessary tests. Very few patients had metastases at diagnosis, and all had pathological stage III disease. Efforts may need to focus on improving knowledge translation across clinical oncology settings to increase guideline adherence.

Prevalence of overt metastases in locally advanced breast cancer

AIMS

Locally advanced breast cancer (LABC) represents a wide spectrum of clinical presentations and poses significant clinical challenges for both patients and their physicians. Before starting neoadjuvant therapy, most patients undergo staging investigations, including a radioisotope bone scan, liver ultrasound and chest X-ray as per our provincial guidelines. The aim of this study was to document the prevalence of metastatic disease using standard baseline radiological staging in patients with LABC.

MATERIALS AND METHODS

A retrospective chart review was carried out for LABC patients at two large Canadian centres between 2003 and 2006. Data on tumour characteristics and baseline staging tests were collected. Information on any confirmatory imaging (bone X-ray, computed tomography, magnetic resonance imaging, positron emission tomography) undertaken due to the presence of suspicious baseline tests or due to worrying symptoms was also obtained. The prevalence of metastatic disease after each baseline imaging technique was analysed, as was the frequency of discordance between baseline staging tests and confirmatory imaging where applicable.

RESULTS

In total, 144 patients with LABC were assessed. After initial staging investigations, 15 patients (10.4%) were diagnosed as having overt metastatic disease. Confirmatory imaging was carried out on 19 patients (13.2%); five (3.5%) for unexplained symptoms and 14 (9.7%) due to equivocal baseline imaging. These additional investigations isolated a further four subjects with metastatic disease, bringing the overall prevalence of overt metastases to 13.2%.

CONCLUSIONS

Given that the rate of systemic relapse in patients with LABC is very high, current baseline staging investigations probably underestimate the true incidence of metastases. This study has shown that further confirmatory imaging can be helpful, especially in symptomatic patients, as it seems that negative baseline tests in these patients can be falsely reassuring. Accurate staging of patients with LABC has many advantages and, therefore, further research is needed to define the role of newer imaging modalities.