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Metastatic Evaluations in Asymptomatic, Sentinel Node Positive Breast Cancer Patients: An Analysis of Utility and Cost
*Andrew Pellet, *Mujde Erten, Ted James
University of Vermont/Fletcher Allen Health Care, Burlington, VT

Objective: National guidelines recommend obtaining staging imaging in early-stage breast cancer only if there is suspicion for distant metastasis based on the patient’s history and/or physical exam. Despite this, there is tremendous variability in performing metastatic work-ups for asymptomatic patients following a positive sentinel node (SN+).We seek to identify the implications on utility and cost of performing metastatic evaluations in asymptomatic SN+ patients.
Design: Retrospective chart review
Setting: Tertiary Academic Medical Center, 4/2009-4/2013, four surgeons performing breast surgery with Medical & Radiation Oncology involved in multidisciplinary clinical decision-making
Patients: 114 asymptomatic female patients with early-stage breast cancer who were clinically node negative but found to have pathologically positive sentinel node(s) following surgery.
Main Outcome Measures: Type and frequency of post-operative staging evaluations, incidence of subsequent imaging/interventions prompted by findings from initial evaluations, frequency of identified distant metastasis or other malignant pathology. Estimated cost of evaluations using institutional cost data.
Results: 50 of 114 patients underwent a metastatic workup not driven by symptomatology. Details displayed in figure.
Post-operative Metastatic Work-up Patterns
Patient GroupImage/Procedure TypeFrequency (%)
Total Patients114 (100)
Patients with post-op work-up performed50 (43.9)
Bone Scan44 (38.6)
CT Chest & Abdomen +/- Pelvis47 (41.2)
PET4 (3.5)
Abdominal US1 (0.9)
Patients with subsequent follow-up studies performed13 (11.4)
PET2 (1.8)
CT8 (7.0)
Bone Scan1 (0.9)
MRI1 (0.9)
Thyroid US2 (1.8)
Thyroid Fine Needle Aspiration2 (1.8)
Interventional Radiology Guided Biopsy3 (2.6)

No metastatic breast cancer was identified. Two patients had non-breast malignancies identified by these studies. The added cost of the first round diagnostic imaging studies was $90,819. The total cost of 19 follow-up studies was $19,207.
Conclusions: Practice patterns for post-operative metastatic work-up of asymptomatic SN+breast cancer patients vary substantially. Utility of these studies was low, costly and in approximately 1/3 of patients resulted in further testing/interventions. Standardizing practice through implementation of evidence-based clinical pathways may help increase quality while decreasing unnecessary cost.

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