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Routine clinical follow-up for distant metastatic disease among women with early stage breast cancer is of uncertain clinical benefit. In order to evaluate current practice patterns, we administered a mailed survey to a stratified random sample of physician members of the American Society of Clinical Oncology (ASCO) (N = 435). The survey assessed the frequency and motivation for ordering follow-up medical tests in asymptomatic postmenopausal women with stage I or II breast cancer. The response rate was 55%, distributed as 39% radiation oncologists, 32% medical oncologists, and 29% surgeons. In the first year after treatment, physicians performed, on average, one physical examination every 3 months, one blood panel (CBC, alkaline phosphatase and liver function tests) every 4 months, and one chest radiograph every 9 months. In addition, 38% of the respondents ordered CEA and 21% ordered CA 15-3 levels, 28% ordered bone scans, and less than 4% ordered CT scans, bone surveys, or bone marrow biopsies in the first year after treatment. A logistic regression analysis controlling for physician age, gender, sub-specialty, practice type, years of experience, number of breast cancer patients treated annually, geographic region, and community size, showed that surgeons were less likely to order blood tests (p < 0.001) and tumor markers (p < 0.0029) than medical oncologists in years 3 and 5 of follow-up. Compared to physicians practicing in the northeast, those from the midwest were less likely to order chest radiographs in year 3 of follow-up (p = 0.0028). Other provider characteristics had no significant effect on test ordering behavior. The results of this survey suggest that relatively uniform practice patterns in regard to the follow-up of postmenopausal women with early stage breast cancer exist among ASCO physicians.

Routine surveillance for distant metastases in women with early stage breast cancer has limited clinical utility and can result in large medical care costs. In order to estimate breast cancer surveillance costs, we used the results of a survey administered to a random sample of physician members of the American Society of Clinical Oncology. The survey measured the frequency in which radiographic and laboratory tests are ordered for postmenopausal women with stage I or II breast cancer after the completion of surgery and radiation or adjuvant chemotherapy if indicated. There were 209 completed surveys representing a response rate of 48%. The volume of tests ordered was expressed in terms of Medicare's relative value units (RVUs) and 1993 cost equivalents. The mean total RVUs over 5 years post-diagnosis was 43.8 (interquartile range 30.1-54.2) which represents a cost of $1369 using the 1993 Medicare conversion factor of $31.249. A cumulative logistic regression model categorized RVUs according to intensity of care (minimal, average, and intensive). While medical oncologists compared to surgeons and radiation oncologists, and physicians practicing in the Northeast and Midwest, compared to those practicing in the South and West, were more likely to adopt an intensive practice style, these differences were not statistically significant (p = 0.1). None of the other provider characteristics evaluated, including gender, prior experience, and practice type, had a significant effect on physician practice in a multivariate model. The data showed a wide variation among providers in surveillance practice patterns that was largely unexplained by physician demographics. These results are consistent with the physician practice style hypothesis which suggests that wide variations in treatment patterns result from uncertainty regarding effectiveness of care.

This study estimates the costs of clinical follow-up for women with early stage breast cancer and evaluates the effects of patient and provider characteristics on follow-up intensity. Claims data were cumulated from 1/1/89 through 4/30/93 for a comprehensive set of follow-up tests (office visits, radiologic, and laboratory) ordered for 222 women diagnosed at a university hospital between 1/1/89 and 12/31/91. Aggregated measures of the volume and costs of follow-up over 6 month intervals were expressed in terms of Medicare's 1993 relative value units (RVUs) and their 1993 cost equivalents. Excluding the first 6 months, women received on average, 11.7 RVUs of follow-up in the first year (equivalent to a cost of $362), and 9.5 RVUs in the second year ($297). In the first year, chest x-rays, clinical chemistry tests, automated hemograms, and bone scans, accounted for 36% of the cost of follow-up, while computerized tomographic scans and magnetic resonance imaging studies accounted for 30%. Multiple regression analysis of the first year data showed that women who received radiation and/or were followed by oncology, were more likely to receive intensive follow-up. Age, race, socioeconomic status, insurance, stage, and treatment did not impact follow-up. Costs of follow-up for breast cancer are substantial, though much lower than suggested by others. Additionally, wide variations in practice are largely unexplained by patient and/or provider characteristics. In light of recent evidence questioning the benefit of intensive surveillance, this study supports the need for an accepted set of follow-up guidelines for breast cancer.

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