Abstract P4-11-29: Evaluating potential overuse of surveillance care in cancer survivors
Authors: Sheng Jennifer Y , Snyder Claire F , Smith Katherine C , DeSanto Jennifer , Mayonado Nancy , Rall Susan , White Sharon , Blackford Amanda L , Johnston Fabian M , Joyner Robert L , Mischtschuk Joan , Peairs Kimberly S , Thorner Elissa , Tran Phuoc T , Wolff Antonio C , Choi Youngjee 
Published: March 2022

Abstract
Background: From a randomized, controlled trial of survivorship care plan (SCP) delivery, we examined whether cancer-related tests not specified in participants’ SCPs, but conducted after SCP receipt, were appropriate or consistent with overuse (CWO). Methods: Survivors of Stage I-III breast, colorectal, or prostate cancer were recruited from an urban-academic and a rural-community health system and randomized to 1 of 3 arms for SCP delivery: mailed, delivered in a one-time transition visit, or delivered in a transition visit with a 6-month follow-up visit. Tests completed during the 18 months after SCP receipt were classified as CWO if they were (1) not included SCP recommendations and (2) included on a predetermined list of “not recommended surveillance” informed by practice guidelines. Tests ordered for non-cancer related evaluation or delivered during hospitalization were excluded. One research staff member abstracted, and a second reviewed, the medical record, including the ordering provider’s reason. Two physicians then reviewed the ordered test and abstracted reason. If a test was not advised for surveillance from any national guideline (e.g. tumor markers in breast cancer), it was deemed CWO. When the reason for testing was unclear, a medical oncologist performed additional chart review to adjudicate whether the test was CWO. A second physician adjudicated 15% of tests to ensure agreement. We performed a descriptive analysis of tests ordered outside of SCP recommendations and rates of testing CWO and patients with testing CWO. We used a negative binomial regression model to determine if testing CWO differed across study arms. Results: Among 316 cancer survivors (137 breast, 67 colorectal, and 112 prostate), 282 tests ordered in 111 study participants were initially identified as potential overuse, of which 142 were excluded as non-cancer and/or hospitalization related, leaving 140 cancer-related tests for adjudication of possible overuse. Of the 140 tests, 78 were tumor markers (all at the community site) and classified as CWO. The remaining 62 imaging tests required additional chart review, of which 42 tests were deemed appropriate (33 academic, 9 community) and 20 CWO (8 academic, 12 community). Rationales considered appropriate included new concerning clinical/radiographic findings, new symptoms concerning for recurrence, breast reconstruction after surgery, and follow-up for high risk breast cancer surveillance. Rationales CWO included routine cancer surveillance, chronic symptoms, elevated tumor markers (that should not have been checked) and not fulfilling high risk breast cancer surveillance criteria. Including tumor markers, 90 tests were CWO at the community site and 8 at the academic site. The majority of testing CWO were breast cancer-related at both sites (95% overall). On a patient level, 28 patients (9%) across sites received at least 1 test CWO (Table 1). Across sites, breast cancer patients most frequently had at least 1 test CWO (17%); the least amount of overuse (&lt;1%) occurred in prostate cancer patients across the two sites. Exploratory analysis of overuse test frequency by study arm showed no significant difference (p=0.65). Conclusions: Overuse testing in cancer survivors was present at both academic and community cancer centers. Tumor markers in breast cancer survivors were most prevalent, and limited to the community site. These results support the importance of provider education and practice pattern evaluation in cancer survivorship.
Table 1.Participants with Tests Consistent with Overuse by Recruitment Site and Cancer TypeAcademic siteCommunity siteAll sitesBreast N=72Colorectal N=46Prostate N=46Breast N=65Colorectal N=21Prostate N=66316Any overuse- no. (%)None68 (94.4)42 (91.3)46 (100)46 (70.7)21 (100)65 (98.4)288 (91.1)Some4 (5.5)4 (8.6)0 (0)19 (29.2)0 (0)1 (1.5)28 (8.9)
Citation Format: Jennifer Y Sheng, Claire F Snyder, Katherine C Smith, Jennifer DeSanto, Nancy Mayonado, Susan Rall, Sharon White, Amanda L Blackford, Fabian M Johnston, Robert L Joyner, Joan Mischtschuk, Kimberly S Peairs, Elissa Thorner, Phuoc T Tran, Antonio C Wolff, Youngjee Choi. Evaluating potential overuse of surveillance care in cancer survivors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-29.