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

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.