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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 Group | Image/Procedure Type | Frequency (%) |
| Total Patients | | 114 (100) |
| Patients with post-op work-up performed | | 50 (43.9) |
| Bone Scan | 44 (38.6) |
| CT Chest & Abdomen +/- Pelvis | 47 (41.2) |
| PET | 4 (3.5) |
| Abdominal US | 1 (0.9) |
| Patients with subsequent follow-up studies performed | | 13 (11.4) |
| PET | 2 (1.8) |
| CT | 8 (7.0) |
| Bone Scan | 1 (0.9) |
| MRI | 1 (0.9) |
| Thyroid US | 2 (1.8) |
| Thyroid Fine Needle Aspiration | 2 (1.8) |
| Interventional Radiology Guided Biopsy | 3 (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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