High Rate of Tumor Marker Assessment in Older Early-Stage Breast Cancer Survivors
Current guidelines discourage tumor marker assessment in surveillance of nonmetastatic breast cancer. In a study reported in the Journal of Clinical Oncology, Ramsey et al found that > 40% of Medicare patients with early-stage breast cancer had at least one tumor marker assessment and that medical costs were increased by 29% in women undergoing such testing.
Study Details
The study involved linked Surveillance, Epidemiology, and End Results (SEER)-Medicare records for patients diagnosed with early-stage breast cancer between 2001 and 2007. Use of tumor markers (carcinoembryonic antigen [CEA], CA 15-3, CA27.29) within 2 years after diagnosis and use of imaging (ultrasound, computed tomography, magnetic resonance imaging, positron emission tomography, bone scan) and biopsy between 3 months and 2 years after diagnosis were identified by billing codes.
Frequency of Testing
Of 39,650 eligible patients, 16,653 (42%) received at least one tumor marker assessment. Those undergoing assessment received an average of 5.7 tests (2.3 CEA tests and 3.4 CA 15-3/CA 27.29 tests) over 2 years. The frequency of testing increased from 38% in 2001 to 46% in 2007.
Factors Associated With Testing
Factors significantly associated with testing included younger age at diagnosis (median, 74.8 vs 76.1 years, P < .01), diagnosis year, stage at diagnosis (odds ratios [ORs] = 1.48 for stage II and 2.19 for stage III vs stage I), race/ethnicity (OR = 0.84 for African American vs white), SEER geographic region, and urban/rural status.
Compared with patients in San Francisco (referent), patients from Connecticut (OR = 2.14), Seattle (OR = 1.75), Atlanta (OR = 1.36), Los Angeles (OR = 7.72), greater California (OR = 2.55), Kentucky (OR = 1.17), and New Jersey (OR = 3.49) were significantly more likely and those from Iowa (OR = 0.36), San Jose (OR = 0.56), and rural Georgia (OR = 0.28) were significantly less likely to have testing. Compared with patients from large metropolitan areas with population > 1 million, patients from rural areas (OR = 1.30) were more likely and those from smaller metropolitan (OR = 0.88), large urban (OR = 0.80), and small urban areas (OR = 0.75) were less likely to have testing.
Additional Procedures
Patients undergoing testing were significantly more likely to receive chemotherapy (23.8% vs 10.9%, P < .001), undergo advanced imaging (62.2% vs47.3%, P < .001), and undergo biopsy (8.0% vs 6.9%, P < .001). Patients undergoing testing had a greater number imaging procedures (2.5 vs2.0, P < .001) but not biopsy procedures (1.09 vs 1.11, P > .05).
Cost
The total Medicare cost of care was increased by 29.4% (P < .001) in women undergoing tumor marker assessment after adjustment for demographic and clinical factors. Cost was increased by 34.7% in months 3 to 12 and by 28.4% in months 13 to 24 after diagnosis.
The investigators concluded: “Breast cancer tumor markers are frequently used among women with early-stage disease and are associated with an increase in both diagnostic procedures and total cost of care. A better understanding of factors driving the use of and the potential benefits and harms of surveillance-based tumor marker testing is needed.”
Scott D. Ramsey, MD, PhD, of Fred Hutchinson Cancer Research Center, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by the National Cancer Institute. For full disclosures of the study authors, visit jco.ascopubs.org.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
