Study examines association of inappropriate prostate, breast cancer imaging

An association of high rates of inappropriate imaging for prostate cancer and breast cancer identified in a study of Medicare beneficiaries suggests that, at the regional level, regional culture and infrastructure could contribute to inappropriate imaging, something policymakers should want to consider as they seek to improve the quality of care and reduce health care spending, according to a study published online by JAMA Oncology.

Researchers have estimated that 30 percent of resources spent on health care in the United States does not improve the health of patients. Choosing Wisely is a national effort to encourage the appropriate use of health care resources. As part of that effort, the American Society of Clinical Oncology released a Top 5 list of tests and procedures that could be used less without compromising care and among them were decreasing imaging to stage patients with low-risk prostate and breast cancers, according to background information in the study.

Danil V. Makarov, M.D., M.H.S., of the New York University School of Medicine, and coauthors used a Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to identify patients with low-risk prostate or breast cancer based on Choosing Wisely definitions. Because prostate and breast cancers affect different patient populations and are often treated by different specialists, there should not be an association between their imaging. But a correlation between regional rates of prostate and breast cancer imaging suggests that regional imaging behaviors share common determinants, according to the authors.

The authors identified 9,219 men with prostate cancer and 30,398 women with breast cancer living in 84 hospital referral regions (HRRs). They found high rates of inappropriate imaging for both prostate cancer (44.4 percent) and breast cancer (41.8 percent). At the HRR-level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates, according to the results. At the patient level, for example, a man with low-risk prostate cancer had higher odds of undergoing inappropriate imaging if he lived in an HRR with higher inappropriate breast cancer imaging.

"Our findings suggest that practice patterns may be a function of local propensities for health care utilization. This is a novel finding with great relevance to cancer policy. As patients with prostate cancer and breast cancer are a nonoverlapping cohort treated by nonoverlapping specialists, an association of inappropriate imaging between them suggests that regional culture and infrastructure contribute to health care utilization patterns across disease. ... Further research should be conducted to determine the causes of regional patterns of inappropriate imaging. Such research, including an evaluation of the clinicians and institutions performing these tests, might help optimize policy interventions aimed at improving the quality and lowering the cost of health care without decreasing access to care for those who need it," the study concludes.

In a related editorial, Samuel Swisher-McClure, M.D., M.S.H.P., and Justin Bekelman, M.D., of the University of Pennsylvania, Philadelphia, write: "As our understanding of explanatory factors driving regional patterns of health care continues to evolve, interventions designed to educate, enhance awareness, and support shared medical decision-making between patients and physicians are most appropriate. The Choosing Wisely campaign is a laudable example, and it will be critical for continued research to examine temporal trends in patterns of care following its implementation to assess the potential effects. Payment policies that reward high-value care and discourage low-value care are also promising. However, as concluded by the recent IOM [Institute of Medicine] report, smaller-level variation exists within individual HRRs, and so payment policies applied uniformly across geographic regions may be unjust and risk adversely affecting patient outcomes by reducing overall care utilization regardless of appropriateness."