Diagnostic workup of early-stage breast cancer: can we choose more wisely?

Abstract

Current international guidelines, including the Choosing Wisely Initiative, recommends against the routine use of systemic imaging studies or tumor markers in early-stage breast cancer. Accumulating data suggests that adherence to these guidelines is low. We aimed to investigate the execution of unnecessary diagnostic tests among Israeli breast cancer patients and identify factors associated with their performance. A retrospective analysis was conducted involvinga database of early breast cancer patients treated at Tel Aviv Sourasky Medical Center. A survey was distributed among Israeli surgeons and oncologists specializing in breast cancer treatment. The study includedearly breast cancer patients (n = 178), who haveno indication for completingsystemic evaluation. Nearly half of the patients (76, 42%) were referred to 128 unjustified diagnostic studies, with the most common referral comprisinga PET-CT (n = 39 30.5%). As expected, none of the tests led to any change in either disease staging or alteration in clinical management. Variables associated with systemic evaluation included younger age (61.8% for < 50years vs 38.9% for > 50years, p = 0.02), diagnosis by palpable masscompared to screening mammography (26.9% vs 52.9% p = 0.043, respectively) and higher tumor grade(33.7% vs 52.2% p = 0.02, respectively). In concordance withthe findings of the database, the physicians' survey revealed low adherence to guidelines and a role of the treating physicians' subjective feelings. Doctors were more likely to recommend unnecessary studies whenpresented with a clinical case as an image, than to an informative question. Our data indicatea high rate of non-adherence to guidelines, physiciansrecommending extensive systemic evaluation for women with early breast cancer. These deviations from the guidelines are associated with subjective factors, some of them beingphysician-dependent. Initiatives aimed at improving adherence to guidelines, and specifically to guidelines recommending "doing less" should therefore include not just knowledge-based education but also encourage conversation about what is appropriate and necessary.