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Quality and Efficiency of Staging Tests in Breast Cancer Patients

Key findings

Overall, the number of early stage breast cancer patients who receive imaging for staging to detect metastases is declining. This pattern follows the desired direction for quality and efficiency of staging tests in breast cancer, but there is still work to be done to reduce this testing.

Why is this important to Ontarians?

  • Most women with a new diagnosis of breast cancer present with early stage disease (stages 1 and 2).[1] In early stage breast cancer, the disease is limited to the breast tissue. This is in contrast to late stage breast cancer, where the disease has spread to other organs and tissues. These tumour deposits are known as metastases.
  • Baseline imaging tests to detect metastases include bone scans, liver ultrasonography and computed tomography (CT).[2] [3]
  • Most practice guidelines do not recommend imaging for early stage (stages 1 and 2) breast cancer patients who have no symptoms of metastatic disease.[4] [5] Reasons include extremely low detection rates,[6] and likelihood of incidental findings that have no clinical significance but that may lead to unnecessary further testing and needless anxiety for patients. In general, this extra imaging does not improve patient care and may be detrimental, delaying treatment while the patient undergoes testing and contributing to healthcare costs without clinical benefits.

See Quality & Efficiency of Staging Tests in Breast Cancer Patients Methodology for technical information.

Report date: January 2019

Data sources: Ontario Cancer Registry (OCR), Ontario Registered Persons Database (RPDB), Canadian Institute for Health Information’s Discharge Abstract Database (CIHI-DAD), Canadian Institute for Health Information’s National Ambulatory Care Reporting System (CIHI-NACRS), Ontario Health Insurance Plan (OHIP)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Data Table 1. Percentage of breast cancer patients receiving at least 1 imaging test for distant metastasis, 2013 to 2017
  2013 2014 2015 2016 2017
Stage I 58.8 56.7 50.8 46.8 46.7
Stage II 86.4 86 83.1 80.2 80
Stage I + II 71.7 70.3 65.7 61.6 61.8

Report date: January 2019

Data sources: Ontario Cancer Registry (OCR), Ontario Registered Persons Database (RPDB), Canadian Institute for Health Information’s Discharge Abstract Database (CIHI-DAD), Canadian Institute for Health Information’s National Ambulatory Care Reporting System (CIHI-NACRS), Ontario Health Insurance Plan (OHIP)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Results

  • In 2017, we continued to see steady declines in the percentages of stage 1 and stage 2 breast cancer patients receiving at least 1 imaging test for distant metastases (47% and 80%, respectively).
  • As in previous years, more stage 2 breast cancer patients received an imaging test than stage 1 patients. This may be due, in part, to variations in guideline recommendations. Current Cancer Care Ontario guidance indicates bone scanning for stage 2 patients,[3] but Choosing Wisely® does not recommend this test.[2]
  • The overall pattern of staging tests in breast cancer patients for both stage 1 and 2 are also on the decline, although there was a slight increase (0.2%) from 2016 to 2017.

For more information

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References

1. Cancer Care Ontario. Ontario breast screening program: 2011 report [Internet]. Toronto: Cancer Care Ontario: 2011 [cited 2018 Feb 14]. Available from: https://www.cancercareontario.ca/sites/ccocancercare/files/assets/OBSPAnnualReport2011.pdf.

2. Schnipper LE, et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol. 2012; 14(30):1715–1724.

3. Cancer Care Ontario. Baseline staging tests in primary breast cancer [Internet]. Toronto: Cancer Care Ontario; 2011 [cited 2018 Feb 14]. Available from: https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/1096.

4. Houssami N, Miglioretti DL. Breast cancer screening: an examination of scientific evidence. Elsevier Inc.; 2016.

5. Breast Screening Guidelines Summary [Internet]. Toronto: Cancer Care Ontario [cited 2017 Jan 26]. Available from: https://www.cancercareontario.ca/en/guidelines-advice/cancer-continuum/screening/breast-screening-guidelines-summary

6. Canadian Partnership Against Cancer. Report from the evaluation indicators working group: guidelines for monitoring breast cancer screening program performance. 3rd Ed. Toronto: Canadian Partnership Against Cancer; 2013.