Breast Cancer Screening in Patients With Newly Diagnosed Lung and Colorectal Cancer: A Population-Based Study of Utilization

Abstract

Purpose To assess breast cancer screening utilization in Medicare beneficiaries with colorectal and lung cancer versus cancer-free controls. Methods Female fee-for-service Medicare beneficiaries who were ≥67 years old and diagnosed with lung or colorectal cancer between 2000 and 2011 and who reported to a Surveillance, Epidemiology, and End Results (SEER) registry (case group) were followed for 2 years after their diagnoses, unless death, a diagnosis of breast cancer, or the end of 2013 came first. A similar number of cancer-free controls were individually matched to cases by age, race, registry region, and follow-up time. Screening utilization was defined as the percentage of women with ≥1 screening mammogram during follow-up. Results Overall, 104,164 cases (48% colorectal, 52% lung; 30% advanced cancer) and 104,164 controls were included. Among women with lung or colorectal cancer, 22% underwent ≥1 screening mammogram versus 26% of controls (odds ratio [OR] 0.80; 95% confidence interval [CI] 0.78–0.82). Stratified by cancer type, 28% of colorectal cancer cases versus 29% of controls (OR 0.98; 95% CI 0.95–1.01) and 17% of lung cancer cases versus 23% of controls (OR 0.63; 95% CI 0.60–0.65) received ≥1 mammogram. When stratified by stage, 8% with advanced cancer versus 18% of controls (OR 0.33; 95% CI 0.31–0.35) and 30% with early-stage cancer versus 30% of controls (OR 1; 95% CI 0.97–1.02) underwent ≥1 mammogram. Conclusion Screening mammography utilization rates are similar between Medicare beneficiaries with early-stage cancer versus controls. Although the majority of patients with advanced-stage cancer appropriately do not pursue screening mammography, a small number (8%) continue with screening.

Downstream Breast Imaging Following Screening Mammography in Medicare Patients with Advanced Cancer: A Population-Based Study

“…Predictors of undergoing at least one screening mammogram were previously reported in these patients with advanced colorectal and lung cancer. 11,16 In the current study, we found that younger age and colorectal cancer (compared to lung cancer) were associated with higher rates of undergoing more than one screening mammography in patients with advanced cancer. This is likely because the majority of breast cancer screening guideline recommendations are based on patient age (currently up to age 75 years), as well as a higher probability of survival in younger patients and in advanced colorectal cancer patients compared to those with lung cancer within the same amount of follow-up time.…”

“…In prior work, we showed that screening mammography utilization rates in patients with advanced colorectal and lung cancer are significantly lower than cancer-free matched controls (8% vs. 18%). 4 In addition, as advanced cancer patients age, utilization rates of screening mammography decline. 11 Indeed, our findings confirm that the rate of multiple screening mammography decreases as patients age.…”

“…Advanced cancer was defined as SEER-derived American Joint Committee on Cancer 15 stage IV colorectal cancer or IIIB-IV lung cancer, which both generally have an overall 5-year survival of less than 20%. 5,16 We limited our study to advanced cancer patients, since screening mammography and its downstream diagnostic tests are considered an inappropriate use of health resources in this overall short-life-expectancy population. We excluded patients in whom colorectal or lung cancer was not their primary cancer, as well as those with an unknown month of cancer diagnosis, a diagnosis reported only from autopsy or death certificate, a date of death before date of diagnosis, or a death or breast cancer diagnosis within the first 3 months after the colorectal or lung cancer diagnosis.…”

“…Despite this, a small percentage of women with short life expectancy still undergo screening mammography, [4][5][6] which may result in additional downstream breast imaging tests and procedures. Both are a potentially wasteful use of health care resources, [7][8][9] and may cause additional psychological stress in the patient and/or their family members and caregivers 10 from either false-positive results or identification of early breast cancers that would never lead to adverse outcomes (overdiagnosis).…”

“…We previously reported rates of screening mammography and its predictors in Medicare beneficiaries aged 67 years and older with advanced colorectal or lung cancer. 4,11 The purpose of the current study was to examine and describe the utilization of downstream diagnostic breast imaging tests following screening mammography in female fee-for-service Medicare beneficiaries aged 65 years or older with advanced colorectal and lung cancer. We further explored predictors of downstream diagnostic breast imaging as well as the frequency that such patients underwent screening mammography more than once.…”