Early-stage breast cancer patients routinely undergo diagnostic examinations they don't need, according to a Houston study, the latest to show that overtesting lies at the heart of U.S. health care.
The study, conducted by M.D. Anderson Cancer Center researchers and presented this week at a breast cancer conference in San Antonio, found more than a third of Stage 1 breast cancer patients get tests, mostly imaging, that national guidelines recommend against.
"People need to know that this really is a problem," said Dr. Carlos Barcenas, an M.D. Anderson professor of breast oncology and the study's first author. "There is no evidence that suggests these tests improve outcomes in early-stage breast cancer patients, and they drive up cost, pose potential safety risks and cause patients' anxiety because there are often false positives."
The study did not investigate the reasons for such overtesting, but Barcenas and Dr. Sharon Giordano, the study's principal investigator, cited doctors' natural inclination to be as thorough as possible, patient demand, a fee-for-service system that rewards testing, and habit.
The study comes amid a growing consensus that Americans are overtested and overtreated for cancer. In recent years, numerous advisory groups began recommending against routine screening for breast, prostate and ovarian cancers because studies show such testing doesn't save lives.
The M.D. Anderson team looked at a "Top Five List" of tests the American Society of Clinical Oncology 11/2 years ago identified as unnecessary and overused in early-stage patients - positron emission tomography, (PET) scans, computed tomography (CT) scans, nuclear medicine bone scans and those that measure tumor markers. The list was made as part of an American Board of Internal Medicine campaign - "Choose Wisely" - to reduce the amount of unneeded diagnostic tests.
The M.D. Anderson researchers analyzed claims of more than 42,000 breast cancer patients between 2005 and 2010, using a national employer-based database. The women, from 20 to 64 years of age, had undergone a mastectomy or lumpectomy and the cancer had not spread beyond their breasts.
The study found that 37 percent of such patients had undergone at least one of the tests - specifically, 4.5 percent had gotten a PET scan, 13 percent a CT scan, 10.3 percent a bone scan and 18 percent a tumor marker test. Barcenas said the tumor marker amount was the most baffling, given that such tests are used only for the surveillance of metastatic cancer.
"Without question, this data demonstrates overuse of imaging in this setting," said Dr. Gary Lyman, director of Comparative Effectiveness and Outcomes Research at Duke University School of Medicine and co-author of the cancer society manuscript that published the top five unnecessary tests list.
Little change over time
The study found little change in the ordering of such tests in the years studied. Thirty-six percent of patients underwent one of the tests in 2005, 35 percent in 2010.
The study also found women with the highest odds of having undergone one of the tests lived in the South (Texas' region) and were younger than 35.
Patients in HMOs were less likely to have gotten one of the tests than patients in PPOs, the study found. Barcenas said that was likely because HMOs are more restrictive.
The study has not yet been published. Barcenas said the team is still working on the financial cost of the unnecessary tests and will include that when they submit the study for publication.
"The take-home message is that I don't think people would want to spend their free time at the doctor on these tests if they were aware they're not in their best interest," said Giordano, chair of health services research at M.D. Anderson. "These are tests that expose women to radiation, cost time and money without benefitting the patient and sometimes lead to follow-up tests that cause pain, bleeding, infections."