NCCN Study Reveals Non-Compliance to Breast Surveillance in Half of Breast Cancer Survivors

A 2018 study published in the Journal of the National Comprehensive Cancer Network revealed that half of breast cancer survivors are not receiving recommended breast surveillance. The number not adhering to recommendations is alarming since early detection of recurrence is critical to better outcomes.

Recommendations for Breast Cancer Survivors

ASCO (The American Society of Clinical Oncology), the American Cancer Society (ACS), and the NCCN (National Comprehensive Cancer Network) all recommend that breast cancer survivors who have residual breast tissue have a mammogram a year after the mammogram that culminated in their diagnosis of breast cancer. The timing should be a minimum of six months after post-surgical radiation. After that, annual mammograms are recommended for all breast cancer survivors with residual breast tissue.

Studies show that early detection of asymptomatic recurrences by mammography finds new disease at an earlier stage resulting in increased survival.

Details of the Study

Kathryn Ruddy, MD, MPH, led the study. She is the Director of Cancer Survivorship for the Mayo Department of Oncology. Dr. Ruddy is also a member of the NCCN Panel for Survivorship.

The study identified women who were either privately insured or Medicare Advantage beneficiaries. The study only included women with non-metastatic disease who had residual breast tissue following breast cancer surgery during a 10-year time frame from January 2005 until May 2015. The researchers looked at five consecutive 13-month periods. A total of 27,212 patients were studied for a median of 2.9 years after their surgery date.

The data was collected from OptumLabs Data Warehouse, an extensive database that contains administrative claims from private insurers and Medicare Advantage members from all 50 states, all ages, all races, and all ethnic groups. Independent variables included region, age, sex, race, ethnicity, treatment (lumpectomy, lumpectomy with radiation, mastectomy, and mastectomy with radiation) and if the patient received chemotherapy. The data extracted included if they visited an oncologist or PCP in the prior year and prior comorbidities. The study used a 13-month time frame since scheduling might prevent a strict 12-month schedule.

The Findings

All of the breast cancer survivors had healthcare insurance, but even when having insurance, many women did not have annual recommended surveillance mammograms as the years passed after their diagnosis.

The key findings include:

• 13 percent of women did not have a mammogram within a year after their surgery.
• At 5 years after surgery, 19 percent had not had a surveillance mammogram within the past year.
• Only 50 percent of the study group had annual mammograms each of the 5 years.

It is disturbing to see the lack of consistent surveillance imaging in such a large population of high-risk women. Breast cancer survivors are at higher risk than the general population for both recurrences and new breast cancers.

The study revealed that African-American breast cancer survivors are the least likely to receive surveillance mammograms on the recommended schedule, even when they have insurance. The mortality rate from breast cancer is higher among African-American women, possibly because recurrences are not found at their earliest stage when increased survival rates are more likely. Researchers point out that decreased access to genetic testing for African-American women might also contribute to the higher mortality rate. Another researcher found that 86 percent of African-American women being treated at a large Detroit medical center had comorbidities compared to 65.7 percent of Caucasian women. Socioeconomic conditions, lack of transportation, and different attitudes towards healthcare may also be contributing factors among African-American breast cancer survivors.

Improving Breast Cancer Survivor Surveillance Rates

With 3.5 million breast cancer survivors in the United States, clinicians need to create more awareness among their breast cancer survivors for the ongoing need for annual mammography screening. Radiologists can play a crucial role in creating more awareness among both primary care physicians and women’s care practices to help ensure better adherence to breast surveillance recommendations for their breast cancer survivor patients.

New mobile apps and text alerts along with enhancement of identifying at-risk patients who go beyond 13 months between mammography appointments should help compliance with an annual mammogram screening program.