P5-12-05: (In-)Efficiencies in the Preoperative Imaging Evaluation of the Medicare Breast Cancer Patient.
Authors: Bleicher RJ , Ruth K , Sigurdson ER , Evers K , Wong Y-N , Boraas M , Egleston BL 
Published: June 2012

Abstract
Introduction: Breast cancer evaluation requires a combination of physical examination and imaging for preoperative diagnosis and assessment of surgical treatment options. While imaging remains a critical component of that assessment, the burden of patient (pt) return visits for imaging is unknown.
Methods: Medicare claims linked to Surveillance Epidemiology End Results data were reviewed for women developing breast cancer between 1992 and 2005. The preoperative interval was defined as the period from the first physician encounter for a breast-related diagnosis until therapeutic surgery. Pts without ≥6 mos of data prior to that interval, those having DCIS or Stage IV disease, and those having preoperative chemotherapy or radiotherapy were excluded. Imaging modality counts exclude image-guidance claims for biopsies.
Results: Among 353,265 Medicare pts developing breast cancer between 1992 and 2005, 67,751 women &gt;65 y of age had invasive, nonmetastatic breast cancer, and simultaneous breast surgery (lumpectomy or mastectomy) with lymph node staging. Median age was 75 y and preoperative interval length was 27 d. In the 6 mos before the preoperative interval, mammograms (MMGs), breast ultrasounds (USs), and breast MRIs were performed exclusive of the preoperative interval in 34,192 (50.5%), 16,936 (25.0%), and 180 (0.3%) pts respectively, while during the preoperative interval, MMGs, USs, and MRIs were performed in an additional 30,414 (44.9%), 17,983 (26.5%), and 1,409 (2.1%) respective pts. Imaging was performed on ≥2 separate dates during the preoperative interval in 4.9% of pts in 1992, rising to 19.4% in 2005 (trend, p&lt;0.0001). During that interval, there were ≥2 encounter dates for MMGs in 7.0% of pts, rising from 3.9% in 1992 to 8.8% in 2005 (trend, p&lt;0.0001); for US, 3.6% overall, rising from 0.2% in 1992 to 6.6% in 2005 (trend, p&lt;0.0001). Multiple MRI encounters were rare, occurring in 0.2% overall, and increasing to 0.6% in 2005 (trend, p&lt;0.0001), while single MRI use increased from &lt;0.1% in 1994 to 8.3% in 2005 (trend, p&lt;0.0001). In the preoperative interval, use of more than one imaging modality on any given date increased from 4.3% in 1992, to 27.1% in 2005. Among those with imaging, there was low correlation between number of imaging dates and number of modalities on any given date (rs= 0.13, p&lt;0.0001). MMGs accounted for 71.9% of the days where one modality was performed alone, but MRI was performed alone 94.1% of the time. The total number of imaging dates in the preoperative interval was inversely related to age (p&lt;0.0001). Differences in the mean number of imaging dates by race and stage were minor and all &lt;0.3 days.
Conclusion: Preoperative Medicare breast imaging claims on multiple dates have been increasing substantially since 1992, suggesting that the patient's time burden for such evaluation is increasing. This trend is present despite the fact that multiple imaging modalities are being performed more frequently on the same date. Efforts to further consolidate preoperative breast imaging visits to lower that burden should be undertaken where possible in the Medicare population, for whom advanced age, in itself, may provide its own challenges.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-12-05.