Are Physicians Choosing Wisely When Imaging for Distant Metastases in Early-Stage Breast Cancer?


Key Points

  • A review of medical records for 200 patients with early-stage breast cancer treated at a large Canadian academic cancer center found that 75% of the patients underwent imaging for distant metastases not in keeping with ASCO recommendations.
  • None of the patients with stage I or II disease had metastatic disease detected by imaging.
  • Strategies beyond mere publication of recommendations are needed if they are to implemented in practice. 

Patients with early-stage breast cancer still undergo imaging for distant metastases despite evidence-based local, national, and international guidelines, and a recommendation from ASCO to avoid such imaging, according to a retrospective review of staging imaging for distant metastases in patients with primary early-stage breast cancer treated at a large Canadian academic cancer center. The findings by Simos et al were published in the Journal of Oncology Practice.

Demetrios Simos, MD, of Ottawa Hospital Cancer Center, and colleagues reviewed 200 patient medical records, 100 from patients treated before and 100 from patients treated after the 2012 publication of ASCO’s Top Five recommendations for choosing wisely in oncology. One of the recommendations was to avoid routine use of staging imaging in patients with early-stage breast cancer and no clinical findings to suggest metastatic disease.

“ASCO recommended against the routine use of staging imaging in asymptomatic patients with early-stage disease, arguing that this practice has never been shown to extend survival, is costly, and in some cases may lead to harm, because false-positive results from such tests may necessitate invasive procedures and overtreatment, all of which can impair quality of life,” the authors wrote. They also noted that the ASCO recommendation “is in keeping with the spirit of the published guidelines.”

Not in the Spirit of the Guidelines

The mean age of patients was 60 years, 57% of tumors were self-detected, 89% were pathologic stage I or II disease, and 11% stage III. Overall, 169 patients (84.5%) had at least one imaging test (mean = 3.6 tests per imaged patient). Of the 608 total imaging tests, 500 (82.2%) “were initial imaging tests assessing the most common metastatic sites for breast cancer (ie, skeleton, thorax, and abdomen), whereas the remaining 108 tests (17.8%) were confirmatory imaging tests,” the investigators stated.

Confirmatory imaging to clarify indeterminate initial imaging was performed in 51 (30.2%) of the 169 women undergoing imaging. None of the patients with stage I or II disease had metastatic disease detected by imaging. Metastatic disease was ultimately detected by imaging in two women, both with pathologic N3 (stage IIIC) disease, one with lung metastases and the other with liver metastases detected by postoperative computed tomography.

“Overall, 77% (154 of 200) and 75% (150 of 200) of the patients reviewed in our study underwent imaging for distant metastases not in keeping with the spirit of the provincial guidelines and ASCO recommendations, respectively,” the researchers reported. The frequency of imaging did not change after the ASCO Top Five recommendations were published.

Additional Knowledge Translation Strategies Needed

“Generally, the majority of patients with stage I or II disease underwent excessive imaging relative to these recommendations, and almost all patients with stage III disease underwent imaging of the skeleton, abdomen, and thorax, as recommended,” the investigators observed. Factors associated with undergoing more staging imaging than recommended include ductal histology, lower stage disease, and a community vs academic hospital.

The lack of demonstrated benefit and the potential for harm from imaging for metastatic disease in asymptomatic mean that such imaging “should be avoided,” the authors concluded. “If guideline recommendations are to be implemented in practice, clearly additional knowledge translation strategies are needed beyond the simple publication of guideline documents.”

Dr. Simos is the corresponding author for the Journal of Oncology Practice article.

The study was supported by fellowship funding from the Canadian Association of Medical Oncologists and Canadian Institute of Health Research.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.