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. 2020 Jun;17(6):755-764.
doi: 10.1016/j.jacr.2019.12.020. Epub 2020 Jan 28.

Facility Variability in Examination Indication Among Women With Prior Breast Cancer: Implications and the Need for Standardization

Diana S M Buist  1 , Laura Ichikawa  2 , Karen J Wernli  2 , Christoph I Lee  3 , Louise M Henderson  4 , Karla Kerlikowske  5 , Erin J A Bowles  2 , Diana L Miglioretti  6 , Jennifer Specht  7 , Garth H Rauscher  8 , Brian L Sprague  9 , Tracy Onega  10 , Janie M Lee  3
Affiliations

Facility Variability in Examination Indication Among Women With Prior Breast Cancer: Implications and the Need for Standardization

Diana S M Buist et al. J Am Coll Radiol. 2020 Jun.

Abstract

Objective: We sought to identify and characterize examinations in women with a personal history of breast cancer likely performed for asymptomatic surveillance.

Methods: We included surveillance mammograms (1997-2017) in asymptomatic women with a personal history of breast cancer diagnosed at age ≥18 years (1996-2016) from 103 Breast Cancer Surveillance Consortium facilities. We examined facility-level variability in examination indication. We modeled the relative risk (RR) and 95% confidence intervals (CIs) at the examination level of a (1) nonscreening indication and (2) surveillance interval ≤9 months using Poisson regression with fixed effects for facility, stage, diagnosis age, surgery, examination year, and time since diagnosis.

Results: Among 244,855 surveillance mammograms, 69.5% were coded with a screening indication, 12.7% short-interval follow-up, and 15.3% as evaluation of a breast problem. Within a facility, the proportion of examinations with a screening indication ranged from 6% to 100% (median 86%, interquartile range 79%-92%). Facilities varied the most for examinations in the first 5 years after diagnosis, with 39.4% of surveillance mammograms having a nonscreening indication. Within a facility, breast conserving surgery compared with mastectomy (RR = 1.64; 95% CI = 1.60-1.68) and less time since diagnosis (1 year versus 5 years; RR = 1.69; 95% CI = 1.66-1.72; 3 years versus 5 years = 1.20; 95% CI = 1.18-1.23) were strongly associated with a nonscreening indication with similar results for ≤9-month surveillance interval. Screening indication and >9-month surveillance intervals were more common in more recent years.

Conclusion: Variability in surveillance indications across facilities in the United States supports including indications beyond screening in studies evaluating surveillance mammography effectiveness and demonstrates the need for standardization.

Keywords: Breast Cancer Surveillance Consortium; Breast cancer screening; breast cancer surveillance; breast carcinoma; mammography indication.

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Figures

Figure 1.
Figure 1.
Distribution surveillance mammograms examination indications in women with a personal history of breast cancer* for 103 BCSC facilities† *Diagnosed age ≥18 years in 1996 or later AJCC stage 0-III †Each bar represents a single facility. All facilities have ≥3 consecutive years of data, ≥100 surveillance mammograms. 244,855 surveillance mammograms occurring at ≥6-months after cancer diagnosis SIFU: Short interval follow-up
Figure 2.
Figure 2.
Facility-level distribution of surveillance mammograms by indication by year since diagnosis, stratified by facilities that use and do not use Diagnostic Not-Otherwise-Specified (NOS)* *Each dot represents a facility’s proportion of each indication among exams within each yearly interval post-diagnosis. Boxes contain interquartile range and whiskers are 1.5 times the IQR.
Figure 3.
Figure 3.
Distribution of surveillance mammograms by exam year* by year since diagnosis stratified by indication and stratified by facilities that use and do not use Diagnostic Not-Otherwise-Specified (NOS) *Colored lines represent the proportion of each indication among total exams within each yearly interval post-diagnosis stratified by exam year.
Figure 4.
Figure 4.
Distribution of time since last exam (up to 21 months) by current indication for exam
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